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Importance: Stroke treatment is exquisitely time sensitive. The door-in-door-out (DIDO) time, defined as the total time spent in the emergency department (ED) at a transferring hospital, is an important quality metric for the care of acute stroke. However, little is known about the contributions of specific process steps to delays and disparities in DIDO time., Objective: To quantify process steps and their association with DIDO times at transferring hospitals among patients with acute ischemic stroke (AIS)., Design, Setting, and Participants: This retrospective cohort study analyzed patients in the American Heart Association Get With the Guidelines-Stroke registry with AIS presenting between January 1, 2019, to December 31, 2021, and transferred from the presenting hospital ED to another acute care hospital for evaluation of thrombolytics, endovascular therapy, or postthrombolytic care. Data were analyzed from July 8 to October 13, 2023., Exposures: Intervals of ED care of ischemic stroke: door-to-imaging and imaging-to-door times., Main Outcomes and Measures: The primary outcome was DIDO time. Multivariate generalized estimating equations regression models were performed to compare contributions of interval process times to explain variation in DIDO time, controlling for patient- and hospital-level characteristics., Results: Among 28 887 patients (50.5% male; mean [SD] age, 68.3 [14.8] years; 5.5% Hispanic, 14.7% non-Hispanic Black, and 73.2% non-Hispanic White), mean (SD) DIDO time was 171.4 (149.5) minutes, mean (SD) door-to-imaging time was 18.3 (34.1) minutes, and mean (SD) imaging-to-door time was 153.1 (141.5) minutes. In the model adjusting for door-to-imaging time, the following were associated with longer DIDO time: age 80 years or older (compared with 18-59 years; 5.97 [95% CI, 1.02-10.92] minutes), female sex (5.21 [95% CI, 1.55-8.87] minutes), and non-Hispanic Black race (compared with non-Hispanic White 10.09 [95% CI, 4.21-15.96] minutes). In the model including imaging-to-door time as a covariate, disparities in DIDO by age and female sex became nonsignificant, and the disparity by Black race was attenuated (2.32 [95% CI, 1.09-3.56] minutes)., Conclusions and Relevance: In this national cohort study of interhospital transfer of patients with AIS, delays in DIDO time by Black race, older age (≥80 years), and female sex were largely explained by the imaging-to-door period, suggesting that future systems interventions should target this interval to reduce these disparities. While existing guidelines and care resources heavily focus on reducing door-to-imaging times, further attention is warranted to reduce imaging-to-door times in the management of patients with AIS who require interhospital transfer.

Background: Musculoskeletal (MSK) conditions affect over 20.3 million people in the UK, presenting a substantial economic impact on health and social services. Physiotherapy can alleviate MSK conditions, especially if delivered in the acute or sub-acute period. However, patients often present after significant waiting times., Objectives: Our analysis examined how waiting times and the number of treatments influenced physiotherapy outcomes for MSK conditions., Design: Retrospective analysis of the Data for Impact, Physio First dataset., Methods: Logistic regression models assessed the effects of symptom duration, treatment frequency, and other variables on pain, Patient-Specific Functional Scores (PSFSs), and Goal Achievement (GA)., Results: Analysis of 15,624 patient records showed that patients treated within two weeks of symptom onset were more likely to have favourable outcomes in pain (odds ratio [OR] = 2.01, 95% Confidence Interval [95% CI] = 1.65-2.45), PSFS (OR = 1.80, 95% CI = 1.55-2.08), and GA (OR = 1.74, 95% CI = 1.51-2.01) compared to those treated after longer durations. Receiving four or more treatment sessions significantly improved outcomes compared with only one session (pain: OR = 4.64, PSFS: OR = 5.72, GA: OR = 1.94, all p's < 0.001), with no additional benefits beyond four sessions. Younger age was associated with better outcomes (approximately OR = 0.99 per year age difference). Other findings included better outcomes in males and in those with fewer previous episodes of the condition., Conclusions: Shorter waiting times, a greater number of treatments, and younger patient age are associated with better physiotherapy outcomes for MSK conditions., (© 2024 The Author(s). Musculoskeletal Care published by John Wiley & Sons Ltd.)

The purpose of this study was to assess changes in time to optimal therapy (TTOT) for bacteremia due to select organisms after implementation of the BioFire® FilmArray® blood culture identification panels at two community teaching hospitals. TTOT (days) was similar in Pre-BCID compared to BCID1 and BCID2 [(2.48 vs. 2.65, p=0.10); (2.48 vs. 2.37, p=0.27)]. There were no significant differences in time to effective antimicrobial therapy between groups. However, there were significantly more therapy changes and appropriate carbapenem use within 24 hours of the Gram stain result for gram-negative organisms in the BCID2 arm compared to the Pre-BCID arm. Additionally, a significant reduction in the duration of vancomycin for gram-positive organisms was noted in the BCID2 arm compared to the Pre-BCID arm. These findings suggest that the incorporation of the BCID2 panel resulted in changes in prescribing practices, leading to more appropriate antimicrobial utilization in a subset of patients., Competing Interests: Declaration of competing interest The authors declare there is no conflict of interests., (Copyright © 2024. Published by Elsevier Inc.)

Objectives: The quality of care for patients may be partly determined by the time they are admitted to the hospital. This study was conducted to explore the effect of admission time and describe the pattern and magnitude of weekly variation in the quality of patient care., Study Design: A retrospective observational study., Methods: Data were collected from the Medical Care Quality Management and Control System for Specific (Single) Diseases in China. A total of 238,122 patients treated for acute ischemic stroke between January 2015 and December 2017 were included. The primary outcomes were completion of the ten process indicators and in-hospital death., Results: The quality of in-hospital care varied according to hospital arrival time. We identified several patterns of variation across the days of the week. In the first pattern, the quality of four indicators, such as stroke physicians within 15 min, was lowest for arrivals between 08:00 and 11:59, increased throughout the day, and peaked for arrivals between 20:00 and 23:59 or 00:00 and 03:59. In the second pattern, the quality of four indicators, such as the application of antiplatelet therapy within 48 h, was not significantly different between days and weeks. There was no difference in in-hospital mortality between the different admission times., Conclusions: The effect of admission time on the quality of in-hospital care of patients with acute ischemic stroke showed several diurnal patterns. Detecting the times when quality is relatively low may lead to quality improvements in health care. Quality improvement should also focus on reducing diurnal temporal variation., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: To determine whether there is a difference in antibiotic administration time and prognosis in afebrile sepsis patients compared to febrile sepsis patients., Methods: This was retrospective multicenter observational study. Data collected from three referral hospitals. Data were collected from May 2014 through February 2016 under the SEPSIS-2 criteria and from March 2016 to April 2020 under the newly released SEPSIS-3 criteria. Patients were divided into two groups based on body temperature: afebrile (<37.3 °C) and febrile (≥37.3 °C). The relationship between initial body temperature and 28-day mortality were analyzed using multivariable logistic regression. The subgroup analysis was conducted on patients with complete Hour-1 bundle performance records., Results: We included 4293 patients in this study. Initial body temperatures in 28-day survivors were significantly higher than in 28-day non-survivors (37.5 °C ± 1.2 °C versus 37.1 °C ± 1.2 °C, p < 0.01). Multivariable logistic regression analysis was performed in afebrile and febrile sepsis patients. Adjusted odds ratio of afebrile sepsis patients for 28-day mortality was 1.76 (95% Confidence interval 1.46-2.12). As a result of performing the Hour-1 bundle, the number of patients who received antibiotics within 1 h was smaller in the afebrile sepsis patients (323/2076, 15.6%) than in the febrile sepsis patients (395/2156, 18.3%) (p = 0.02). In the subgroup analysis of patients with complete Hour-1 bundle performance records adjusted odds ratio of afebrile sepsis patients for 28-day mortality was 1.68 (95% Confidence interval 1.34-2.11). The febrile sepsis patients received antibiotics faster than the afebrile sepsis patients (175.5 ± 207.9 versus 209.3 ± 277.9, p < 0.01)., Conclusions: Afebrile sepsis patients were associated with higher 28-day mortality compared to their febrile counterparts and were delayed in receiving antibiotics. This underscores the need for improved early detection and treatment strategies for the afebrile sepsis patients., Competing Interests: Declaration of competing interest The authors have no potential conflicts of interest to disclose., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Boarding time in the Emergency Department (ED) is an area of concern for all patients and potentially more problematic for the hip fracture population. Identifying patient outcomes impacted by ED boarding and improving emergent care to reduce surgical delay for this patient population is a recognized opportunity. The objective of this study is to examine the impact of ED boarding in relation to patient outcomes in the surgical hip fracture population., Methods: This is a retrospective study of hip fracture patients who presented at the ED of a Level 1 trauma center between January 2020 and December 2021. Patients were categorized into four quartiles based on boarding time. Study outcomes-hospital length of stay, time to surgery, visit to ICU post-operative, total blood products, in-hospital complications, discharge disposition, in-hospital mortality, and 30-day readmission-were compared among these four quartiles., Results: The outcome endpoints were comparable among the four quartiles except for time to surgery. Time to surgery significantly differed among the quartiles, increasing from 20.39 to 29.03 h (p < 0.001) from the first to fourth quartile., Conclusion: In contrast to the existing literature, ED boarding in our study was not associated with adverse outcomes except for time to surgery. By expediting the time to surgery in accordance with established guidelines, adverse outcomes were mitigated even when our patients boarded for a longer duration. System processes including a 24/7 trauma nurse practitioner model, availability of in-house orthopedic surgeons, and timely cardiac evaluation need to be considered in relation to time to surgery, in turn impacting ED boarding and patient outcomes., Competing Interests: Declaration of competing interest None of the authors have any potential conflicts of interest. The authors have no financial disclosures. Study findings have not been presented., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: A comprehensive review of the literature on the time between the onset of symptoms and the first episode of care and its effects on important worker outcomes in compensated musculoskeletal conditions is currently lacking. This scoping review aimed to summarize the factors associated with time to service and describe outcomes in workers with workers' compensation accepted claims for musculoskeletal conditions., Methods: We used the JBI guidelines for scoping reviews and reported following the PRISMA-ScR protocol. We included peer-reviewed articles published in English that measured the timing of health service initiation. We conducted searches in six databases, including Medline (Ovid), Embase (Ovid), PsycINFO, Cinahl Plus (EBSCOhost), Scopus, and the Web of Science. Peer-reviewed articles published up to November 01, 2022 were included. The evidence was summarized using a narrative synthesis., Results: Out of the 3502 studies identified, 31 were included. Eight studies reported the factors associated with time to service. Male workers, availability of return to work programmes, physically demanding occupations, and greater injury severity were associated with a shorter time to service, whereas female workers, a high number of employees in the workplace, and having legal representation were associated with a longer time to service. The relationship between time service and worker outcomes was observed in 25 studies, with early access to physical therapy and biopsychosocial interventions indicating favourable outcomes. Conversely, early opioids, and MRI in the absence of severe underlying conditions were associated with a longer duration of disability, higher claim costs, and increased healthcare utilization., Conclusion: Existing evidence suggests that the time to service for individuals with compensated musculoskeletal conditions was found to be associated with several characteristics. The relationship between time to service and worker outcomes was consistently indicated in the majority of the studies. This review highlights the need to consider patient-centred treatments and develop strategies to decrease early services with negative effects and increase access to early services with better outcomes., (© 2024. The Author(s).)

Introduction: An increasing proportion of congenital choledochal malformation (CCM) are being detected on antenatal ultrasound. However, the actual timing of its surgical correction remains controversial with some series showing an excess of complications the earlier the operation. The aim of this study was to characterize the pathophysiological aspects of this cohort from the perspective of age at surgery in order to inform a more rational basis for clinical decision-making., Methods: We analysed a prospective database of CCM acquired over a 26-year period (Jan. 1997 to Dec. 2022) for patient demography; details of pre- and post-natal imaging; age at surgical intervention; operative complications (Clavien-Dindo classification) and outcome. Data are quoted as median (IQR). All comparisons are non-parametric. A P value of 0.05 was accepted as significant., Results: There were 58 (72% female) children with an antenatally-detected CCM from a total of 265 (21.8%) in the series. These were classified as Type 1C (n = 47; 81%), type 4C (n = 3; 5%) and Type 5 (n = 8; 14%). There were no Type 1F lesions in this cohort. Median age at surgery was 113 (IQR 57-198) days. Postnatal cyst (US) size varied from 12 to 130 mm but there was little evidence of a relationship between this and post-natal liver biochemistry (e.g. bilirubin r S  = 0.01, P = 0.44; AST r S  = 0.14, P = 0.19). Choledochal pressure measurements (n = 46) showed resting pressures of 12 (9-21) mmHg with no significant correlation with age (P = 0.4) or aspartate aminotransferase (P = 0.2) or γ-glutamyl transferase (P = 0.06). The cohort was divided into 2 groups (Early and Late) based on the median age at surgery (all open) (113 days). Biliary obstruction was more common in the Early group (10 vs. 2; P = 0.01). Two perforations occurred, both in the Early group. With a deliberate policy of regular ultrasound-based follow-up we have seen no anastomotic complications (leak, stenosis, persistent intrahepatic biliary dilatation or stones) or post-operative cholangitis in any child [median follow-up 3.42 (1.30-8.05) years]., Conclusions: This is one of the largest series documenting the outcomes of antenatally-detected CCMs, certainly in Europe and North America. Such lesions are invariably cystic in nature, and either Types 1C, 4C or 5. The absence of complications using a policy of early intervention (where possible) in experienced hepatobiliary units was shown., Evidence Level: II., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Small renal masses (SRMs) have been shown to have low malignant potential. Active surveillance (AS), typically characterized by regular follow-up and delayed nephrectomy if necessary, is recommended as an option for frail patients with SRMs. Nevertheless, the impact of tumor size on survival in T1a RCC patients undergoing delayed nephrectomy for SRMs remains unclear., Methods: Patients diagnosed with non-metastatic T1a RCC who underwent nephrectomy were identified from the Surveillance, Epidemiology, and End Results (SEER) database and divided into immediate (< 6 months) and delayed nephrectomy (≥ 6 months) groups based on the duration from diagnosis to nephrectomy. After propensity score matching (PSM), overall survival (OS) and cancer-specific survival (CSS) were estimated by K-M curves and compared with log-rank test., Results: A total of 27,502 patients were enrolled, of whom 26,915 (97.9%) received immediate nephrectomy and 587 (2.1%) received delayed nephrectomy. After PSM, 1174 patients who underwent immediate nephrectomy and 587 patients who underwent delayed nephrectomy were included. With a median delay of 7 months, delayed nephrectomy resulted in non-inferior OS for RCC tumors sized 0.1-2.0 cm (HR = 1.12, p = 0.636). However, for RCC tumors sized 2.1-3.0 cm (HR = 1.60, p = 0.008) and 3.1-4.0 cm (HR = 1.89, p < 0.001), delayed nephrectomy showed inferior OS compared to immediate nephrectomy. Delayed nephrectomy did not result in significantly worse CSS than immediate nephrectomy in all tumor size subgroups (all p > 0.05), however this may be due to sample size limiting statistical power., Conclusion: Based on the SEER database, we found that with a median delay of 7 months, 2 cm may be an appropriate cut-off point of delayed nephrectomy for patients diagnosed with non-metastatic T1a RCC., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Arriving during "off hours" to the hospital can put patients at greater risk of complications or mortality given lesser staff. Our goal was to investigate this in trauma patients with an Injury Severity Score (ISS) of >15. We hypothesized that the patients admitted late at night and/or during the weekend, would have worse outcomes, delays to the operating room (OR), and longer lengths of stay (LOS) compared to those who arrive on a weekday during the day., Methods: We performed a retrospective study from 8/1/2019 to 8/1/2022 of all trauma patients with an ISS >15 at our Level 1 Trauma Center. Patients <18 years, dead on arrival, or transferred out were excluded. Univariate and multivariable analysis were performed comparing weekday vs weekend arrivals, day vs night shift arrivals, and with patients grouped as weekday day, weekday night, weekend day, and weekend night. The primary outcome was mortality., Results: 953 patients met inclusion criteria. The patients that arrived on the weekend and at night were significantly younger than their counterparts. A significantly greater percentage of Black patients arrived during night shift. Mortality, hospital LOS, and ICU LOS did not differ based on day or time of arrival., Conclusion: Contrary to our hypothesis, our study did not find a significant difference in outcomes when evaluating based on a patient's time of arrival. This gives credence that our mature trauma center can provide the same level of care despite the time of a severely injured patient's time of arrival., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: Optimal time to enucleation following marsupialization of large odontogenic mandibular cysts is undefined. We aim to assess volume reduction throughout follow-up, to indicate optimal time to enucleation. Secondary objectives include the identification of factors influencing cyst reduction., Study Design: We retrospectively enrolled 15 patients with mandibular cysts of different histological types treated with marsupialization at our center between 2018 and 2022. Cyst volume was assessed with cone-beam computed tomography (CBCT) and a semi-automatic segmentation algorithm, at baseline and between 6 and 8 months post marsupialization., Results: The overall mean cyst volume reduction percent (VR%) was 57.7 % or 0.2 % per day. VR% at 8 months was significantly higher than those assessed at 6 and 7 months (67.1% vs 47.1 %, p = 0.003). Time to CBCT was the only independent variable influencing cyst VR%., Conclusion: Our study proves that the optimal time to enucleation for mandibular cyst is 8 months, independent of histological cyst type, patient age, baseline cyst volume and the number of pre-operative residual bone walls., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

Purpose: Delays to biopsy and surgery after lung nodule detection can impact survival from lung cancer. The aim of this study was to identify factors associated with delay in a lung cancer screening (LCS) program., Materials and Methods: We evaluated patients in an LCS program from May 2015 through October 2021 with a malignant lung nodule classified as lung CT screening reporting and data system (Lung-RADS) 4B/4X. A cutoff of more than 30 days between screening computed tomography (CT) and first tissue sampling and a cutoff of more than 60 days between screening CT and surgery were considered delayed. We evaluated the relationship between delays to first tissue sampling and surgery and patient sex, age, race, smoking status, median income by zip code, language, Lung-RADS category, and site of surgery (academic vs community hospital)., Results: A total of 185 lung cancers met the inclusion criteria, of which 150 underwent surgical resection. The median time from LCS CT to first tissue sampling was 42 days, and the median time from CT to surgery was 52 days. 127 (69%) patients experienced a first tissue sampling delay and 60 (40%) had a surgical delay. In multivariable analysis, active smoking status was associated with delay to first tissue sampling (odds ratio: 3.0, CI: 1.4-6.6, P = 0.005). Only performing enhanced diagnostic CT of the chest before surgery was associated with delayed lung cancer surgery (odds ratio: 30, CI: 3.6-252, P = 0.02). There was no statistically significant difference in delays with patients' sex, age, race, language, or Lung-RADS category., Conclusion: Delays to first tissue sampling and surgery in a LCS program were associated with current smoking and performing diagnostic CT before surgery., Competing Interests: M.M.H. was supported by the National Cancer Institute (R01CA260889). The remaining authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Surgical treatment of Hirschsprung's disease (HSCR) in Sweden was centralized to two tertiary pediatric surgery centers 1st of July 2018. Although complex surgical care in adults seems to benefit from centralization there is little evidence to support centralization of pediatric surgical care. The aim of this study was to assess centralization of HSCR in Sweden, with special consideration to preoperative management and outcomes in this group of patients., Methods: This study retrospectively analyzed data of patients with HSCR that had undergone or were planned to undergo pull-through at our center, from 1st of July 2013 to 30th of June 2023. Patients managed from 1st of July 2013 to 30th of June 2018 were compared with patients managed from 1st of July 2018 to 30th of June 2023 regarding diagnostic procedures, preoperative treatment, complications and time to definitive surgery., Results: Thirty-six patients were managed during the first five-year period compared to 57 during the second period. There was an increased number of patients referred from other Swedish regions to our center following the centralization. Time from diagnosis to pull-through increased from 33 to 55 days after centralization. There were no significant differences in pre-operative management or complications, general or related to stoma., Conclusions: Despite increasing patient volumes and longer time from diagnosis to pull through, centralization of care for HSCR does not seem to change the preoperative management and risk of complications. With access to support from the specialist center, transanal irrigations remain a safe mode of at home management until surgery, regardless of distance to index hospital., Level of Evidence: Level III., Competing Interests: Conflicts of interest None to declare., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Early appropriate antimicrobial therapy plays a critical role for patients with Staphylococcus aureus bloodstream infection (SAB). We aim to determine the optimal time-window for appropriate antimicrobial therapy and evaluate the effects of delayed therapy on adverse clinical outcomes (in-hospital mortality, sepsis, and septic shock) in children with SAB by propensity score matching (PSM) analysis. Receiver-operating characteristic was used to determine the cut-off point of the time to appropriate therapy (TTAT), the patients were divided into timely and delayed appropriate antimicrobial therapy (delayed therapy) groups accordingly. The PSM was used to balance the characteristics between the two groups, controlling the effects of potential confounders. Kaplan-Meier methods and Cox proportional hazards regression were applied to the matched groups to analyze the association between delayed therapy and clinical outcomes. Inverse probability of treatment weighting and propensity score covariate adjustment were also performed to investigate the sensitivity of the results under different propensity score-based approaches. In total, 247 patients were included in this study. The optimal cut-off point of TTAT was identified as 6.4 h, with 85.0% sensitivity and 69.2% specificity (AUC 0.803, 95% confidence interval 0.702-0.904). Eighty-seven (35.22%) of the 247 patients who received delayed therapy (TTAT ≥ 6.4 h) had higher in-hospital mortality (19.54% vs 1.88%, p < 0.001), higher incidences of sepsis (44.83% vs 15.00%, p < 0.001) and septic shock (32.18% vs 6.25%, p < 0.001) when compared to timely therapy (TTAT < 6.4 h) patients. After PSM analysis, a total of 134 episodes (67 in each of the two matched groups) were further analyzed. No statistically significant difference was observed in in-hospital mortality between delayed and timely -therapy groups (log-rank test, P = 0.157). Patients with delayed therapy had a higher incidence of sepsis or septic shock than those with timely therapy (log-rank test, P = 0.009; P = 0.018, respectively). Compared to the timely-therapy group, the hazard ratio and 95% confidence interval in delayed-therapy group were 2.512 (1.227-5.144, P = 0.012) for sepsis, 3.109 (1.166-8.290, P = 0.023) for septic shock.    Conclusion: Appropriate therapy delayed 6.4 h may increase the incidence of sepsis and septic shock, with similar in-hospital mortality in patients with SAB. What is Known: • Staphylococcus aureus (S. aureus) is a major cause of bloodstream infections in children. Undoubtedly, early antimicrobial application plays a critical role in the treatment of children with Staphylococcus aureus bloodstream infections (SAB). • However, rapid, and aggressive administration of antimicrobials may lead to the overuse of these drugs and the emergence of multidrug-resistant microorganisms. Therefore, it is crucial to determine the optimal time-window for appropriate antimicrobial administration in children with SAB. Unfortunately, the optimal time-window for appropriate antimicrobial administration in children with SAB remains unclear. What is New: • Determining the optimal time-window for appropriate antimicrobial administration in patients with matched data variables is particularly important. The Propensity score matching (PSM) analysis effectively controls for confounding factors to a considerable extent when assessing the impact of treatment, thereby approximating the effects observed in randomized controlled trials. • To our knowledge, this is the first study using PSM method to assess the effects of delayed appropriate antimicrobial therapy on adverse outcomes in children with SAB. In low-risk populations with SAB, a delay of 6.4 h in appropriate therapy might increase the occurrence rate for sepsis and septic shock; however, no correlation has been found between this delay and an increased risk for hospital mortality., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background and Purpose: A mobile stroke unit (MSU) reduces delays in stroke treatment by allowing thrombolysis on board and avoiding secondary transports. Due to the beneficial effect in comparison to conventional emergency medical services, current guidelines recommend regional evaluation of MSU implementation., Methods: In a descriptive study, current pathways of patients requiring a secondary transport for mechanical thrombectomy were reconstructed from individual patient records within a Danish (n = 122) and an adjacent German region (n = 80). Relevant timestamps included arrival times (on site, primary hospital, thrombectomy centre) as well as the initiation of acute therapy. An optimal MSU location for each region was determined. The resulting time saving was translated into averted disability-adjusted life years (DALYs)., Results: For each region, the optimal MSU location required a median driving time of 35 min to a stroke patient. Time savings in the German region (median [Q1; Q3]) were 7 min (-15; 31) for thrombolysis and 35 min (15; 61) for thrombectomy. In the Danish region, the corresponding time savings were 20 min (8; 30) and 43 min (25; 66). Assuming 28 thrombectomy cases and 52 thrombolysis cases this would translate to 9.4 averted DALYs per year justifying an annual net MSU budget of $0.8M purchasing power parity dollars (PPP-$) in the German region. In the Danish region, the MSU would avert 17.7 DALYs, justifying an annual net budget of PPP-$1.7M., Conclusion: The effects of an MSU can be calculated from individual patient pathways and reflect differences in the hospital infrastructure between Denmark and Germany., (© 2024 The Authors. European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.)

Background: Lung transplant is a therapeutic option for patients with progressive interstitial lung disease (ILD)., Objectives: The objective of this study was to determine whether time from ILD diagnosis to referral to a transplant center influences the probability of being included in the transplant waiting list., Methods: We performed a retrospective cohort study including all ILD patients evaluated as lung transplantation (LT) candidates at a lung transplant center between 01/01/2017 and 31/12/2022. The primary endpoint was the probability of being included in the lung transplant waiting list according to the time elapsed from diagnosis to referral to the transplant center., Results: A total of 843 lung transplant requests were received, of which 367 (43.5%) were associated with ILD. Thirteen patients were excluded because they did not attend the first visit, whereas another 11 were excluded because some information was missing. As a result, our final sample was composed of 343 patients. The median time from diagnosis to referral was 29.4 (10.9 - 61.1) months. The overall probability of inclusion in the waiting list was 29.7%. By time from diagnosis to referral, the probability of inclusion in the waiting list was 48.1% for the patients referred 〈 6 months from diagnosis; 27.5% for patients referred 6 to 24 months from diagnosis; and 25.8% for patients referred 〉 24 months from diagnosis (p = 0.007)., Conclusions: Early referral to a lung transplant center seemed to increase the probability of being included in the lung transplant waiting list. Further research is needed in this topic., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Rural residency has been associated with lower reperfusion treatment rates for acute ischemic stroke in many countries. We aimed to explore urban-rural differences in IV thrombolysis rates in a small country with universal health care, and short transport times to stroke units., Patients and Methods: In this nationwide cohort study, adult ischemic stroke patients registered in the Danish Stroke Registry (DSR) between 2015 and 2020 were included. The exposure was defined by residence rurality. Data from the DSR, Statistics Denmark, and the Danish Health Data Authority, were linked on the individual level using the Civil Registration Number. Adjusted treatment rates were calculated by balancing baseline characteristics using inverse probability of treatment weights., Results: Among the included 56,175 patients, prehospital delays were shortest for patients residing in capital municipalities (median 4.7 h), and longest for large town residents (median 7.1 h). Large town residents were predominantly admitted directly to a comprehensive stroke center (98.5%), whereas 30.9% of capital residents were admitted to a hospital with no reperfusion therapy available (non-RT unit). Treatment rates were similar among all non-rural residents (18.5%-18.7%), but slightly lower among rural residents (17.2% [95% CI 16.5-17.8]). After adjusting for age, sex, immigrant status, and educational attainment, rural residents reached treatment rates comparable to capital and large town residents at 18.5% (95% CI 17.7-19.4)., Discussion and Conclusion: While treatment rates varied minimally by urban-rural residency, substantial differences in median prehospital delay and admission to non-RT units underscored marked urban-rural differences in potential obstacles to reperfusion therapies., Competing Interests: Declaration of conflicting interestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: CS: Supported by research grants from Novo Nordisk Foundation and Health Research Foundation of Central Denmark Region. SB, AB, MS, JN, PC, SJ TP and GA declare no conflict of interest.

Late presentation for kidney replacement therapy (KRT) is an important cause of avoidable morbidity and mortality. Here, we evaluated the effect of a complex intervention of graphical estimated glomerular filtration rate (eGFR) surveillance across 15% of the United Kingdom population on the rate of late presentation using data routinely collected by the United Kingdom Renal Registry. A stepped wedge cluster randomized trial was established across 19 sites with eGFR graphs generated from all routine blood tests (community and hospital) across the population served by each site. Graphs were reviewed by trained laboratory or clinical staff and high-risk graphs reported to family doctors. Due to delays outside the control of clinicians and researchers few laboratories activated the intervention in their randomly assigned time period, so the trial was converted to a quasi-experimental design. We studied 6,100 kidney failure events at 20 laboratories served by 17 main kidney units. A total of 63,981 graphs were sent out. After adjustment for calendar time there was no significant reduction in the rate of presentation during the intervention period. Therefore, implementation of eGFR graph surveillance did not reduce the rate of late presentation for KRT after adjustment for secular trends. Thus, graphical surveillance is an intervention aimed at reducing late presentation, but more evidence is required before adoption of this strategy can be recommended., (Copyright © 2024 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.)

Background: The causes for delays during the COVID19 pandemic and their impact on head and neck cancer (HNC) diagnosis and staging are not well described., Methods: Two cohorts were defined a priori for review and analysis-a Pre-Pandemic cohort (June 1 to December 31, 2019) and a Pandemic cohort (June 1 to December 31, 2020). Delays were categorized as COVID-19 related or not, and as clinician, patient, or policy related., Results: A total of 638 HNC patients were identified including 327 in the Pre-Pandemic Cohort and 311 in the Pandemic Cohort. Patients in the Pandemic cohort had more N2-N3 category (41% vs. 33%, p = 0.03), T3-T4 category (63% vs. 50%, p = 0.002), and stage III-IV (71% vs. 58%, p < 0.001) disease. Several intervals in the diagnosis to treatment pathway were significantly longer in the pandemic cohort as compared to the Pre-Pandemic cohort. Among the pandemic cohort, 146 (47%) experienced a delay, with 112 related to the COVID-19 pandemic; 80 (71%) were clinician related, 15 (13%) were patient related, and 17 (15%) were policy related., Conclusions: Patients in the Pandemic cohort had higher stage disease at diagnosis and longer intervals along the diagnostic pathway, with COVID-19 related clinician factors being the most common cause of delay., (© 2024 The Authors. Head & Neck published by Wiley Periodicals LLC.)

Background: Rhythm control is a cornerstone of atrial fibrillation (AF) management. Shorter time between diagnosis of AF and receipt of catheter ablation is associated with greater rates of therapy success. Previous work considered diagnosis-to-ablation time as a binary or categorical variable and did not consider the unique risk profile of patients after a referral for ablation was made., Objective: The purpose of this study was to comprehensively assess the impact of diagnosis-to-ablation and referral-to-ablation time on postprocedural outcomes at a population level., Methods: This observational cohort study included patients who received catheter ablation to treat AF in Ontario, Canada. Patient demographics, medical comorbidities, AF diagnosis date, ablation referral date, and ablation date were collected. The primary outcomes of interest included a composite of death and hospitalization/emergency department visit for AF, heart failure, or ischemic stroke. Multivariable Cox models assessed the impact of diagnosis-to-ablation and referral-to-ablation times on the primary outcome., Results: Our cohort included 7472 patients who received ablation for de novo AF between April 1, 2016, and March 31, 2022. Median [interquartile range] diagnosis-to-ablation time was 718 [399-1274] days and median referral-to-ablation time was 221 [117-363] days. Overall, 911 patients (12.2%) had the composite endpoint within 1 year of ablation. Increasing diagnosis-to-ablation time was associated with a greater incidence for the primary outcome (hazard ratio [HR]1.02; 95% confidence interval [CI] 1.01-1.02 per month). Increasing referral-to-ablation time did not impact the primary outcome (HR 1.00; 95% CI 0.98-1.01 per month)., Conclusion: Delays between AF diagnosis and ablation referral may contribute to adverse postprocedural outcomes and provide an opportunity for health system quality improvements., Competing Interests: Disclosures The authors have no conflicts to disclose., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Introduction: Substantial evidence exists for the superiority of emergency over delayed cholecystectomy for gallstone disease during primary admission. Despite this, emergency surgery rates in the UK remain low compared with other developed countries, with great variation in care across the nation. We aimed to describe the local paradigm shift towards emergency surgery and investigate outcomes., Methods: This is a prospective observational study examining patients enrolled onto an emergency cholecystectomy pathway, following the hospital's subscription to the Royal College of Surgeons of England's Cholecystectomy Quality Improvement Collaborative (Chole-QuIC), between 1 December 2021 and 31 January 2023. Multivariate logistical regression models were used to identify patient and hospital factors associated with postoperative outcomes., Results: Of the 307 suitable acute admissions, 261 (85%) had an emergency cholecystectomy, compared with 5% preceding the Chole-QuIC interventions. Waiting time dropped from 67 to 5 days. A total of 208 (79.7%) patients were primary presentations, 92 (35.2%) were classed Tokyo grade 2 and 142 (54.4%) were obese. A total of 23 (8.8%) patients underwent preoperative endoscopic retrograde cholangiopancreatography, and 26 (10%) patients had a subtotal cholecystectomy. Favourable outcomes (Clavien Dindo ≥3) were observed in first presentations (odds ratio (OR) 0.35; p =0.042) and for operation times within 7 days (OR 0.32; p =0.037), with worse outcomes in BMI ≥35 (OR 3.32; p =0.005) and operation time >7 days (OR 3.11; p =0.037)., Conclusion: A paradigm shift towards emergency cholecystectomy benefits both the patient and the service. Positive outcomes are apparent for early operation in patients presenting for the first time and recurrent attendees, with early operation (<7 days) providing the most favourable outcome in a select patient group.

Optimal timing of revascularization for patients who presented with non-ST segment elevation myocardial infarction (NSTEMI) and severe left ventricular (LV) dysfunction is unclear. A total of 386 NSTEMI patients with severe LV dysfunction from the nationwide, multicenter, and prospective Korea Acute Myocardial Infarction Registry V (KAMIR-V) were enrolled. Severe LV dysfunction was defined as LV ejection fraction ≤ 35%. Patients with cardiogenic shock were excluded. Patients were stratified into two groups: PCI within 24 hours (early invasive group) and PCI over 24 hours (selective invasive group). Primary endpoint was major adverse cardiac and cerebrovascular events (MACCE) including all-cause death, non-fatal MI, repeat revascularization, and stroke at 12 months after index procedure. Early invasive group showed higher incidence of in-hospital death (9.4% vs 3.3%, P = .036) and cardiogenic shock (11.5% vs 4.6%, P = .030) after PCI. Early invasive group also showed higher maximum troponin I level during admission (27.7 ± 44.8 ng/mL vs 14.9 ± 24.6 ng/mL, P = .001), compared with the selective invasive group. Early invasive group had an increased risk of 12-month MACCE, compared with selective invasive group (25.6% vs 17.1%; adjusted HR = 2.10, 95% CI 1.17-3.77, P = .006). Among NSTEMI patients with severe LV dysfunction, the early invasive strategy did not improve the clinical outcomes. This data supports that an individualized approach may benefit high-risk NSTEMI patients rather than a routine invasive approach., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

The aim of this study is to reduce door-to-wire time for ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention through multidisciplinary collaboration. Patients over the age of 18who visited the Foshan Sanshui District People's Hospital between 2018 and 2019 and were diagnosed with STEMI were included in this study. Analyses were performed with patients segregated into a pre-intervention interim period (2018) and a post-intervention period (2019) based on the date of admission. Intervention measures for reducing door to wire time were fully implemented towards the end of the interim period. There were no significant differences in the baseline characteristics of the 2 groups. Median door to puncture time was reduced from 57.5 minutes in the interim period to 46.0 minutes (P < .001) in the post-intervention period. Similarly, median door to wire time was shortened from 88.0 minutes to 63.5 minutes (P < .001). During the interim period, 24% of patients had a door to wire time of <60 minutes, compared to 40.67% of patients in the post-intervention period (P = .002). Multidisciplinary collaboration is an important strategy to reduce door to wire time for patients with STEMI, and may be implemented in suitable centers to improve patient care., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: To investigate the association between the time from onset to initial treatment and changes in visual acuity or the number of treatments in patients with branch retinal vein occlusion (BVO)., Design: Retrospective., Methods: Thirty-nine eyes of 39 consecutive patients with untreated acute-phase BVO who visited the University of Tokyo Hospital and were followed up for at least one year were included. The patients were initially treated with anti-vascular endothelial growth factor (VEGF) therapy and additional pro re nata therapy within six months of onset. The patients were classified according to the time from disease onset to the first treatment (group A: 28 days or less, group B: over 28 days)., Results: The mean (SD) age was 73 ± 8 years, and 19 patients were male. The mean (SD) time to the first treatment was 31.6 ± 17.9 days. The mean (SD) logMAR visual acuity at first treatment was 0.37 ± 0.30. After 12 months of treatment, the mean (SD) logMAR change was - 0.15 ± 0.23, and the mean number (SD) of treatments was 3.1 ± 1.7. No significant association was observed between the timing of treatment initiation and changes in logMAR visual acuity. Patients in group A and central macular thickness at the initial visit were independently associated with the greater number of treatments at one year (p = 0.03 and p = 0.01, respectively)., Conclusions: At one year, the time between onset and the start of anti-VEGF therapy for BVO was not associated with subsequent visual acuity changes. Meanwhile, it may have significant association with the number of treatments., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Background and Objectives: Following the outbreak of COVID-19, a set of restrictions, health advice, and limitations were put in place to reduce the spread of the virus. These restrictions, together with fear and anxiety of the population, limited people's access to public services such as health care services. Cancer patients during this era are a significant concern due to being at high risk for COVID-19 infection and also being exposed to delays in their diagnosis, treatment, and follow-ups. Delays in the treatment of cancer could lead to a poorer prognosis. In this study, we attempted to determine the magnitude of delays in chemotherapy and factors associated with delays during the COVID-19 pandemic., Method: All patients diagnosed with colorectal, lung, gastric cancer, and lymphoma who had chemotherapy at teaching hospitals of Iran University of Medical Sciences (IUMS) between February 20, 2020, and March 20, 2022, were included. Age, gender, cancer type, having metastatic cancer, and date of each chemotherapy session were included for each patient individually. Every session with delays longer than two days was recorded. A three to six-day delay was considered a moderate delay, and a seven-day or longer delay was considered a severe delay in receiving each chemotherapy session. Additionally, each patient's total number of delays in the entire course was calculated. Logistic regression was used to examine the impact of pandemic waves on delays. On the other hand, Poisson regression was used to evaluate the number of delays in the entire course of chemotherapy., Results: The research findings indicated an association between the male gender and having metastasis with a higher likelihood of a moderate delay in the treatment regimen. Regarding cancer type, colorectal cancer was associated with higher rates of moderate delays (IRR = 1.88, P < 0.001), but gastric (IRR = 0.75, P = 0.001) and lung cancer (IRR = 0.59, P = 0.002) were associated with reduced rates of severe and moderate delays, respectively. Compared to the COVID-19 pandemic plateau periods, the first (OR = 2.08, P < 0.001), third, and fifth waves of the pandemic were associated with increased delays., Conclusion: We found an association between the male gender, colorectal cancer, metastatic disease and higher rates of moderate delays. The initial COVID-19 pandemic wave was associated with increased severe delays in the chemotherapy course. According to the findings of this study, male cancer patients and those with metastatic cancer are at risk of poorer prognosis due to lower adherence to treatment. These findings can assist policymakers in developing targeted strategies to lessen the delay rates in the more vulnerable population., (© 2024. The Author(s).)

Objectives: To analyze factors associated with delayed initiation of breast cancer treatment at an oncology referral center in Juiz de Fora, Minas Gerais state, between 2010 and 2019., Methods: This was a cohort study using data from the Hospital-based Cancer Registry. The probability of not starting treatment within 60 days, in accordance with Brazilian law, was estimated using Kaplan-Meier, method and its association with the factors studied was assessed using the Cox model, presenting hazard ratios (HR) and respective 95% confidence intervals (95%CI)., Results: Among the 911 participants, the probability of delayed treatment initiation was 18.8% (95%CI 16.4;21.5). Those who underwent treatment at a health service other than the one where the cancer was diagnosed had a significantly higher risk (HR: 3.49; 95%CI 3.00;4.07)., Conclusion: Receiving a diagnosis and treatment at the same institution may help reduce waiting time to initiate cancer treatment., Main Results: The probability of study participants not initiating treatment within 60 days was 18.8%. Undergoing treatment at a healthcare service other than the one where the diagnosis was made was the main factor associated with delay., Implications for Services: Organizing healthcare services based on strategies that optimize referral flows and avoid transitions of care, can be crucial in reducing the time to initiation of breast cancer treatment., Perspectives: It is essential to improve the workflows at the different stages of health care to ensure timely initiation of oncological treatment.

Introduction: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing hemorrhage control intervention, but its inevitable effect on time to operating room (OR) has not been assessed. The aim of our study is to assess the impact of undergoing REBOA before surgery (RBS) on time to definitive hemorrhage control surgery., Methods: In this retrospective analysis of 2017-2021 ACS-TQIP database, all adult (≥18 years) patients who underwent emergency hemorrhage control laparotomy (≤4 hours of admission) and received early blood products (≤4 hours) were included, and patients with severe head injury (Head-abbreviated injury score > 2) were excluded. Patients were stratified into those who did (RBS) vs those who did not undergo REBOA before surgery (No-RBS). Primary outcome was time to laparotomy. Secondary outcomes were complications and mortality. Multivariable linear and binary logistic regression analyses were performed to identify the independent associations between RBS and outcomes., Results: A total of 32,683 patients who underwent emergency laparotomy were identified (RBS: 342; No-RBS: 32,341). The mean age was 39 (16) years, 78% were male, mean SBP was 107 (34) mmHg, and the median injury severity score was 21 [14-29]. The median time to emergency hemorrhage control surgery was 50 [32-85] minutes. Overall complication rate was 16% and mortality was 19%. On univariate analysis, RBS group had longer time to surgery (RBS 56 [41-89] vs No-RBS 50 [32-85] minutes, P < 0.001). On multivariable analysis, RBS was independently associated with a longer time to hemorrhage control surgery (β + 14.5 [95%CI 7.8-21.3], P < 0.001), higher odds of complications (aOR = 1.72, 95%CI = 1.27-2.34, P < 0.001), and mortality (aOR = 3.42, 95%CI = 2.57-4.55, P < 0.001)., Conclusion: REBOA is independently associated with longer time to OR for hemorrhaging trauma patients with an average delay of 15 minutes. Further research evaluating center-specific REBOA volume and utilization practices, and other pertinent system factors, may help improve both time to REBOA as well as time to definitive hemorrhage control across US trauma centers., Level of Evidence: III., Study Type: Epidemiologic., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Objectives: Patient-centredness of care during wait time before surgery can be improved. In this study we aimed to assess (1) patients' experiences with and preferences regarding wait time before surgery; (2) the impact of wait time on quality of life (QoL) and (3) which factors influence patients' wait time experience., Design, Setting, Participants: We performed an exploratory sequential mixed-methods study among women with gynaecological cancer in two tertiary hospitals. We conducted semistructured interviews and identified aspects of QoL and factors that influenced wait time acceptability through thematic analysis. We developed a questionnaire from this thematic analysis which was completed by 97 women. Descriptive statistics and univariate and multivariate regression analyses were performed., Results: Average ideal wait time was 3.5 weeks (±1.7 weeks), minimum and maximum acceptable wait times were 2.2 and 5.6 weeks. Many patients scored above the threshold of the Hospital Anxiety and Depression Scale for anxiety (48%) or depression (34%), had sleeping problems (56%) or experienced pain (54%). A number of factors were more common in patients who indicated that their wait time had been too long: low education level (OR 7.4, 95% CI 0.5 to 5.0, p=0.007), time to surgery >4 weeks (OR 7.0, 95% CI 0.8 to 4.4, p=0.002) and experienced sleep disturbance (OR 3.27, 95% CI 0.0 to 3.1, p=0.05). If patients expectation of wait time was >4 weeks (OR 0.20, 95% CI -4.0 to -0.5 p=0008) or if patients experienced pain (OR 0.26, 95% CI -3.6 to -0.3, p=0.03), they less frequently indicated that wait time had been too long., Conclusion: To improve patient-centredness of care, healthcare providers should aim to reduce wait time to 3-4 weeks and ensure that patients are well informed about the length of wait time and are aware of high levels of anxiety, depression and pain during this time. Future studies should evaluate what interventions can improve QoL during wait time., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Optimal timing of tracheostomy in severe traumatic brain injury (TBI) is unknown due to lack of clinical trials. We emulated a target trial to estimate the effect of early vs. delayed tracheostomy strategy on functional outcome of patients with severe TBI., Design: Target trial emulation using 1:1 balanced risk-set matching., Setting: North American hospitals participating in the TBI Hypertonic Saline randomized controlled trial of the Resuscitation Outcomes Consortium., Patients: The prematching population consisted of patients with TBI and admission Glasgow Coma Scale less than or equal to 8, who were alive and on mechanical ventilation on the fourth day following trial enrollment, and stayed in the ICU for at least 5 days. Patients with absolute indication for tracheostomy and patients who died during the first 28 days with a decision to withdraw care were excluded., Interventions: We matched patients who received tracheostomy at a certain timepoint (early group) with patients who had not received tracheostomy at the same timepoint but were at-risk of tracheostomy in the future (delayed group). The primary outcome was a poor 6-month functional outcome, defined as Glasgow Outcome Scale-Extended less than or equal to 4., Measurements and Main Results: Out of 1282 patients available for analysis, 275 comprised the prematching population, with 75 pairs being created postmatching. Median time of tracheostomy differed significantly in the early vs. the delayed group (7.0 d [6.0-10.0 d] vs. 12.0 d [9.8-18.3 d]; p < 0.001). Only 40% of patients in the delayed group received tracheostomy. There was no statistically significant difference between groups regarding poor 6-month functional outcome (early: 68.0% vs. delayed: 72.0%; p = 0.593)., Conclusions: In a target trial emulation, early as opposed to delayed tracheostomy strategy was not associated with differences in 6-month functional outcome following severe TBI. Considering the limitations of target trial emulations, delaying tracheostomy through a "watchful waiting" approach may be appropriate., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Aim: This audit describes variation in the time from referral to starting disease modifying drug (DMARD) for people with newly diagnosed seropositive rheumatoid arthritis (RA), how frequently this was within the recommended 6 weeks and whether regional, service-level or patient-level factors were associated with this variation., Method: Rheumatologists submitted data on new patients with a new diagnosis of rheumatoid factor and/or cyclic-citrullinated peptide antibody positive RA. The association between visit funding, ethnicity, socio-economic deprivation, rurality, local specialist staffing levels and the time to DMARD treatment was assessed using Cox proportional-hazard models., Results: Data were collected on 355 patients over 12 months. Overall, 64.8% of patients commenced DMARD treatment within 6 weeks of referral and this was associated with rheumatologist FTE per 100,000 population (adjusted HR 2.47, 95%CI 1.27-4.81; p=0.008) and the rurality (Geographic Classification of Health [GCH]) of the patient (for R2 compared to U1 adjusted HR 0.20, 95%CI 0.09-0.43; p<0.001). There was no association between time to DMARD and ethnicity or socio-economic deprivation., Conclusion: There was significant variation in time to DMARD treatment, mainly related to variation in rheumatologist staffing levels and patient rurality. Rheumatologist staffing levels of 1.0 FTE/100,000 population was associated with 80% of patients meeting the recommended 6-week time to DMARD treatment., Competing Interests: The authors declare that they have no conflicts of interest., (© PMA.)

Importance: The China Antihypertensive Trial in Acute Ischemic Stroke II (CATIS-2) suggests that early antihypertensive treatment did not reduce the risk of dependency or death in acute ischemic stroke (AIS), compared with delayed treatment. Single subcortical infarction (SSI) is an important stroke subtype, and the association of antihypertensive timing with clinical outcomes is unclear., Objective: To investigate the association of early vs delayed antihypertensive treatment with clinical outcomes in patients with SSI, stratified by the presence of parent artery disease (PAD) stenosis., Design, Setting, and Participants: This secondary analysis of the CATIS-2 randomized clinical trial included 106 hospitals in China between June 2018 and July 2022. In CATIS-2, patients with AIS within 24 to 48 hours of symptoms onset and elevated systolic blood pressure were eligible. Patients with SSI detected in diffusion-weighted imaging were included in the current post hoc subgroup analysis. Patients were grouped into (1) SSI with PAD stenosis and (2) SSI without PAD stenosis. Statistical analysis was performed from July 2023 to May 2024., Exposures: Early (immediate) vs delayed (starting on day 8) antihypertensive therapy., Main Outcome and Measure: Primary outcome was the combination of functional dependency or death (modified Rankin Scale score ≥3) at 90 days., Results: Among 997 patients with SSI in CATIS-2 (mean [SD] age, 62.4 [9.8] years; 612 [61.4%] men), 116 (11.6%) had SSI with PAD and 881 (88.4%) had SSI without PAD. There was no significant difference in the primary outcome between early and delayed antihypertensive treatment groups among all patients with SSI (8.8% vs 7.1%; OR, 1.25 [95% CI, 0.79-1.99]; P = .34). Among patients with SSI with PAD, early antihypertensive treatment was associated with increased risk of the primary outcome compared with delayed treatment (23.4% vs 7.7%; OR, 3.67 [95% CI, 1.14-11.86]; P = .03); this finding was not observed in patients with SSI without PAD (6.6% vs 7.1%; OR, 0.93 [95% CI, 0.55-1.57]; P = .77). Significant interaction with treatment and presence of PAD stenosis was detected for the primary outcome (P for interaction = .04)., Conclusions and Relevance: In this secondary analysis of a randomized clinical trial, early antihypertensive treatment was associated with an increased risk of functional dependency or death at 90 days among patients with SSI and coexisting PAD stenosis, compared with delayed antihypertensive treatment. Further studies are warranted for individualized BP management in patients with SSI by the presence of PAD., Trial Registration: ClinicalTrials.gov Identifier: NCT03479554.

Importance: Cancer treatment delay is a recognized marker of worse outcomes. Timely treatment may be associated with physician patient-sharing network characteristics, yet this remains understudied., Objective: To examine the associations of surgeon and care team patient-sharing network measures with breast cancer treatment delay., Design, Setting, and Participants: This cross-sectional study of Medicare claims in a US population-based setting was conducted from 2017 to 2020. Eligible participants included patients with breast cancer who received surgery and the subset who went on to receive adjuvant therapy. Patient-sharing networks were constructed for treating physicians. Data were analyzed from September 2023 to February 2024., Exposures: Surgeon linchpin score (a measure of local uniqueness or scarcity) and care density (a measure of physician team familiarity) were assessed. Surgeons were considered linchpins if their linchpin score was in the top 15%. The care density of a patient's physician team was calculated on preoperative teams for surgically-treated patients and postoperative teams for adjuvant therapy-receiving patients., Main Outcomes and Measures: The primary outcomes were surgical and adjuvant delay, which were defined as greater than 60 days between biopsy and surgery and greater than 60 days between surgery and adjuvant therapy, respectively., Results: The study cohort included 56 433 patients (18 004 aged 70-74 years [31.9%]) who were mostly from urban areas (44 931 patients [79.6%]). Among these patients, 8009 (14.2%) experienced surgical delay. Linchpin surgeon status (locally unique surgeon) was not statistically associated with surgical delay; however, patients with high preoperative care density (ie, high team familiarity) had lower odds of surgical delay compared with those with low preoperative care density (odds ratio [OR], 0.58; 95% CI, 0.53-0.63). Of the 29 458 patients who received adjuvant therapy after surgery, 5700 (19.3%) experienced adjuvant delay. Patients with a linchpin surgeon had greater odds of adjuvant delay compared with those with a nonlinchpin surgeon (OR, 1.30; 95% CI, 1.13-1.49). Compared with those with low postoperative care density, there were lower odds of adjuvant delay for patients with high postoperative care density (OR, 0.77; 95% CI, 0.69-0.87) and medium postoperative care density (OR, 0.85; 95% CI, 0.77-0.94)., Conclusions and Relevance: In this cross-sectional study of Medicare claims, network measures capturing physician scarcity and team familiarity were associated with timely treatment. These results may help guide system-level interventions to reduce cancer treatment delays.

Objective: To investigate the effect of hospital working hours on outcomes of patients with acute ischemic stroke 3 months after receiving alteplase intravenous thrombolysis., Methods: A retrospective analysis was performed on 254 individuals with acute ischemic stroke who received alteplase intravenous thrombolysis between January 2018 and December 2020 either during peak hospital working hours (08:00-17:59; Group A) or off-peak hours (18:00-07:59 the following day; Group B). Patients were also categorized according to which of four peak/off-peak-hour periods they received treatment in: Group 1 (08:00-11:59), Group 2 (12:00-17:59), Group 3 (18:00-21:59), Group 4 (22:00-07:59 the following day). Baseline data and 3-month prognosis were compared across groups. Logistic regression analysis was used to investigate the correlation between hospital working hours and 3-month prognosis., Results: There were no significant differences in door-to-needle time, onset-to-needle time, 24-hour National Institutes of Health Stroke Scale (NIHSS) score, 7-day NIHSS score or Modified Rankin Score between Groups 1 to 4 or between Groups A and B. Whether treatment was administered during peak or off-peak hours did not significantly affect 3-month prognosis., Conclusion: At this hospital, differences in the time at which stroke patients were treated were not associated with outcomes., Competing Interests: Declaration of conflicting interestsThe authors declare that there is no conflict of interest.

Background: In Indonesia incidence of colorectal cancer (CRC) remains high. Information about early symptoms that can offer clinicians insights for timely diagnosis, prompt referral and quick treatment decisions is very limited. This study aims to examine the pattern of CRC early symptoms and its association with tumor laterality, age at onset, metastatic status, and symptom-to-treatment initiation (STI) duration and delay., Method: This cross-sectional study recruits 258 patients diagnosed with CRC between November 2022 and October 2023 from two distinct study databases. Patient baseline characteristics were also obtained from medical records and through interviews at baseline. Symptom-to-treatment initiation (STI) duration was defined as the number of days between the date of the symptom's onset and the date of the first treatment's initiation. Relative risk estimation for metastatic disease and the STI delay, based on tumor laterality and the age at onset group, were estimated using a log-binomial regression for each early symptom., Result: Experiencing abdominal mass as an early symptom is significantly associated with metastatic disease, specifically in right-sided CRC cases (relative risk/RR=2.08, 95% confidence interval/CI 1.29-3.37, p=0.003). In all study subjects, the median STI duration was 182 days (2-5,082 days), with more than half of the subjects experiencing an STI delay of >180 days. Experiencing rectal mass as an early symptom is significantly associated with a higher risk of STI delay >180 days in early onset CRC (RR=1.97, 95% CI 1.27-3.06, p=0.003) and left sided-CRC cases (RR=1.54, 95% CI 1.13-2.08, p=0.005). The non-specific early symptom of weight loss is associated with a higher risk of STI delay >180 days in right-sided CRC cases (RR=1.73, 95% CI 1.06-2.84, p=0.029)., Conclusion: The findings underlined the importance of maintaining a high clinical suspicion, particularly in patients with rectal masses and unexplained weight loss, as they might experience STI delay.

Introduction: Breast cancer treatment patterns and quality of care among patients experiencing incarceration are underexplored. This study examined associations between incarceration and breast cancer disease and treatment characteristics., Methods: This retrospective analysis was conducted at a tertiary center in the Southeastern United States that serves as the state's safety-net hospital and primary referral site for the state's prisons. All patients ≥18 years diagnosed with breast cancer between 4/14/2014-12/30/2020 were included. Incarceration status was determined through electronic health record review. Linear regression was used to estimate the association of incarceration with time to treatment. Unadjusted overall survival (OS) was estimated using the Kaplan-Meier method with log-rank tests to compare groups., Results: Of the 4329 patients included, 30 (0.7%) were incarcerated at the time of diagnosis or treatment (DI) and 4299 (99.3%) had no incarceration history (NI). Compared to patients who were NI, patients who were DI were younger (p < 0.001), more likely to be unmarried (p < 0.001), and more likely to have family history of breast cancer (p = 0.02). Patients who were DI had an increased time from diagnosis to neoadjuvant chemotherapy (+47.2 days on average, 95% CI 3.9-90.5, p = 0.03) and from diagnosis to surgery (+20 days on average, 95% CI 6.5-33.5, p = 0.02) compared to NI patients. No difference in OS was observed (log-rank p = 0.70)., Conclusions: Patients who are incarcerated experienced significant delays in breast cancer care. While no differences in mortality were appreciated, these findings are concerning, as they indicate poorer care coordination for patients who are incarcerated. Further research is necessary to understand the full scope of these disparities and elucidate factors that contribute to them., (© 2024 The Author(s). Cancer Medicine published by John Wiley & Sons Ltd.)

Purpose: Longer time between breast cancer (BC) diagnosis and treatment initiation is associated with poorer survival, and this may be a factor behind disparities in global survival rates. We assessed time to BC treatment in the Kathmandu Valley, Nepal, including factors associated with longer waiting times and their impact on survival., Methods: We conducted a retrospective population-based study of BC cases recorded in the Kathmandu Valley Population-Based Cancer Registry between 2018 and 2019. Fieldwork survey through telephone was undertaken to collect additional sociodemographic and clinical information. Logistic regression was performed to identify factors associated with longer time to treatment, and Kaplan-Meier and Cox proportional hazard regression was used to examine survival time and evaluate the association between longer time to treatment and survival., Results: Among the 385 patients with BC, one third waited >4 weeks from diagnosis to initial treatment. Lower education was associated with longer time to treatment (adjusted odds ratio, 1.63 [95% CI, 1.03 to 2.60]). The overall 3-year survival rate was 88.6% and survival was not associated with time to treatment ( P = .50). However, advanced stage at diagnosis was associated with poorer survival (adjusted hazard ratio, 4.09 [95% CI, 1.27 to 13.23]). There was some indication that longer time to treatment was associated with poorer survival for advanced-stage patients, but data quality limited that analysis., Conclusion: In the Kathmandu Valley, Nepal, women with a lower education tend to wait longer from BC diagnosis to treatment. Patients with advanced-stage BC had poorer survival, and longer waiting time may be associated with poorer survival for women diagnosed with advanced-stage disease.

Background: Various factors contribute to the development of mortality and morbidity in hip fracture surgeries. This study aims to investigate the effects of modifiable factors such as the type of anesthesia, anesthesia management, surgical method, and timing of surgery on 30-day mortality rates, intensive care unit admissions, and complications., Methods: A total of 400 patients who underwent hip fracture surgery between January 2021 and December 2023 at a Training and Research Hospital were retrospectively analyzed. Patients were divided into two groups: those followed in the ward, named Group 1 (n=304), and those in the intensive care unit, named Group 2 (n=96). Recorded data included demographic characteristics, American Society of Anesthesiologists (ASA) physical status scores, types of comorbidities, anesthesia type, surgical method, surgical delay time, duration of surgery, blood transfusion requirements, and complications., Results: Patients in Group 2 had higher mean age, comorbidity, and mortality rates compared to Group 1 (p<0.001). In terms of types of comorbidities, the rate of intensive care unit admission was higher in patients with coronary artery disease and chronic renal failure (p<0.001). Mean surgical delay and length of hospital stay were also higher in Group 2 (p<0.001). In multivariate logistic regression analysis, age (p<0.001, Odds Ratio [OR]=1.91, Confidence Interval [CI]=1.046-1.137), ASA score (p<0.001, OR=3.872, CI=1.913-7.838), duration of surgical delay (p<0.001, OR=2.029, CI=1.365-3.017), surgical method (p=0.003, OR=2.003, C=1.258-3.188), and length of hospital stay (p=0.006, OR=1.147, CI=1.04-1.266) were determined as predictive factors for 30-day mortality., Conclusion: This study found that age, ASA classification, length of hospital stay, surgical method, and surgical delay were predictive factors for both morbidity and mortality. Among these, surgical delay time appears to be a modifiable parameter when all factors are considered.

Background: Data regarding the management of adnexal torsion (AT) during the coronavirus disease 2019 (COVID-19) pandemic are scarce., Objectives: To study the effects of actions to limit the spread of COVID-19 on AT management., Methods: We conducted a retrospective cohort study of all women who underwent laparoscopy for suspected AT between March 2011 and February 2021. We compared the COVID-19 pandemic period, (15 March 2020-2 August 2021, group A) to a parallel period (2019-2020, group B), and a 9-year period preceding the pandemic (March 2011-February 2020, group C)., Results: We performed 97 laparoscopies in group A, 82 in group B, and 635 in group C. The proportion of women presenting following in vitro fertilization treatment was lower (odds ratio [OR] 0.22, 95% confidence interval ]95%CI] (0.06-0.86), P < 0.023). Time from admission to decision to operate was shorter (2.7 vs. 3.9 hours, P = 0.028) in group A than group B. Time from admission to surgery was shorter (9.1 vs. 12.5 hours, P = 0.005) and the rate of surgically confirmed AT was lower (59 [60.8%] vs. 455 [71.7%], P = 0.030, OR 0.61, 95%CI 0.39-0.95) in group A than group C. Among surgically confirmed AT cases only, mean time from admission to decision was shorter in group A than group B (2.6 vs. 4.6 hours, P = 0.014)., Conclusions: We identified differences in time from admission to clinical decision and from admission to surgery among women with suspected AT during the COVID-19 pandemic.

Background: Lung cancer (LC) remains the leading cause of cancer-related mortality globally, necessitating timely diagnosis and treatment to improve patient outcomes. This study aimed to evaluate the timeliness of care for LC patients at a public hospital in Almería, Spain, assess adherence to guidelines, and explore associations between timeliness and survival., Methods: A retrospective cohort study was conducted, reviewing medical records of LC patients diagnosed between 2019 and 2021. Quality indicators, adapted from prevailing guidelines, facilitated the assessment of care timeliness, with a focus on diagnostic and treatment wait times. Cox regression modeling was employed to explore survival associations, adjusting for covariates including age, performance status, stage, histology, and treatment modalities., Results: Of 539 patients included, most (79.84 %) had initial specialist contact within 7 days, and 82.25 % received diagnosis within 30 days. However, delays were observed in treatment initiation, with surgery experiencing the longest median wait time (78 days). Survival analysis showed no significant difference between shorter and longer diagnostic (HR: 0.87, 95 % CI: 0.62-1.24) or treatment intervals (HR: 1.14, 95 % CI: 0.83-1.58). Multivariate analysis identified age, performance status, stage, histology, and treatment as prognostic factors., Conclusion: This study highlights the importance of timely diagnosis and treatment in improving lung cancer outcomes. Despite achieving diagnostic targets, treatment delays were common, particularly for surgical interventions. These findings underscore the need for enhanced coordination and efficient care pathways to minimize delays, ultimately improving survival rates and quality of life for lung cancer patients. Addressing these issues is crucial for optimizing lung cancer care delivery in the future., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Pre-hospital delay is the major cause of stroke treatment delay, and behavioral intention is considered to be the most direct predictor of behavior. Therefore, to effectively reduce stroke pre-hospital delay, it is essential to further understand the relationship between stroke pre-hospital delay intention (SPDBI) and its social-psychological influencing factors, namely personality traits, social support and coping style., Aim: This study aims at examining the relationships among personality traits, coping style, social support, and SPDBI., Methods: A cross-sectional, self-administered questionnaire was distributed to 845 residents. The content of the questionnaire included demographic information, the knowledge of "Stroke 120", Ten-Item Personality Inventory-Chinese version, Simplified Coping Style Questionnaire, Perceived Social Support Scale and SPDBI Scale. Path analysis was used to investigate the relationship among SPDBI and its psychosocial influencing factors., Results: The final path model showed a good fit to the data (χ 2 /df = 2.981, RMSEA = 0.048, GFI = 0.936, CFI = 0.941). Extroversion (β = 0.106), positive coping (β = -0.110), negative coping (β = 0.150) and the knowledge of "Stroke 120" (β = -0.152) had only direct effects on SPDBI. While agreeableness (β = 0.113), openness (β = -0.121) and social support (β = -0.118) had direct effects on SPDBI, they also had indirect effects (β = -0.009; -0.022; -0.049) on SPDBI though positive coping., Conclusions: Adequate social support and positive coping of health threat may reduce residents' SPDBI. Meanwhile, the interventions to reduce SPDBI should take personality differences into consideration., Competing Interests: Declaration of competing interest There is no competing financial interest in the research. The intention of the research did not reflect the official policy or position of any organization or any government., (Copyright © 2024. Published by Elsevier Inc.)

Background: Globally, fall-related injuries are a substantial problem, and 80% of fatal falls occur in low-income and middle-income countries. We aimed to measure time from injury to hip-fracture surgery in people aged 50 years or older living in low-income and middle-income regions, as well as to measure the proportion of patients with surgical stabilisation of their hip fracture within 72 h of admission to hospital and to identify risk factors associated with surgical delay., Methods: For this secondary analysis, we analysed data collected from Africa, Latin America, China, India, and Asia (excluding China and India) for the International Orthopaedic Multicentre Study in Fracture Care (INORMUS) between March 29, 2014, and June 15, 2022. Patients from INORMUS were included in this analysis if they were aged 50 years or older and had an isolated, primary hip fracture sustained from a ground-level fall. Staff at participating hospitals identified patients with musculoskeletal injury and referred them for assessment of eligibility. We report time from injury to surgery as three distinct time periods: time from injury to hospital admission, time from admission to surgery, and a total time from injury to surgery. Date and time of injury were self-reported by patients at the time of study recruitment. If time to hospital admission after injury exceeded 24 h, patients reported the primary reason for delayed admission. Reasons for surgery, no surgery, and surgical delay were reported by the treating team. For patients undergoing surgery, multivariable regression analyses were used to identify risk factors for surgical delay., Findings: 4486 adults aged 50 years or older with an isolated, primary hip fracture were enrolled in INORMUS from 55 hospitals in 24 countries. Countries were grouped into five regions: Africa (418 [9·3%] of 4486), Latin America (558 [12·4%]), China (1680 [37·4%]), India (1059 [23·6%]) and Asia (excluding China and India; 771 [17·2%]). Of 4486 patients, 3805 (84·8%) received surgery. The rate of surgery was similar in all regions except in Africa, where only 193 (46·3%) of 418 patients had surgery. Overall, 2791 (62·2%) of 4486 patients were admitted to hospital within 24 h of injury. However, 1019 (22·7%) of 4486 patients had delayed hospital admission of 72 h or more from injury. The two most common reasons for delayed admission of more than 24 h were transfer from another hospital (522 [36·2%] of 1441) and delayed care-seeking because patients thought the injury would heal on its own (480 [33·3%]). Once admitted to hospital, 1451 (38·1%) of 3805 patients who received surgery did so within 72 h (median 4·0 days [IQR 1·7-6·0]). Regional variation was seen in the proportion of patients receiving surgery within 72 h of hospital admission (92 [17·9%] of 514 in Latin America, 53 [27·5%] of 193 in Africa, 454 [30·9%] of 1471 in China, 318 [44·4%] of 716 in Asia [excluding China and India], and 534 [58·6%] of 911 in India). Of all 3805 patients who received operative treatment, 2353 (61·8%) waited 72 h or more from hospital admission. From time of injury, the proportion of patients who were surgically stabilised within 72 h was 889 (23·4%) of 3805 (50 [9·7%] of 517 in Latin America, 31 [16·1%] of 193 in Africa, 277 [18·8%] of 1471 in China, 189 [26·4%] of 716 in Asia [excluding China and India], and 342 [37·5%] of 911 in India)., Interpretation: Access to surgery within 72 h of hospital admission was poor, with factors that affected time to surgery varying by region. Data are necessary to understand existing pathways of hip-fracture care to inform the local development of quality-improvement initiatives., Funding: The National Health and Medical Research Council of Australia, the Canadian Institutes of Health Research, McMaster Surgical Associates, Hamilton Health Sciences, and the US National Institutes of Health., Competing Interests: Declaration of interests MB receives financial support from McMaster Surgical Associates and the Canadian Orthopaedic Association; grant support from Smith and Nephew, Huxley Health, Sonex, the US Department of Defense, the Canadian Institutes of Health Research, the US National Institutes of Health via the Institute of Arthritis and Musculoskeletal and Skin Diseases, Physician Services, and the Patient-Centered Outcomes Research Institute. PJD receives grant funding from Abbott Diagnostics, Roche Diagnostics, and Siemans; is a consultant to Abbott Canada, Renibus, Roche Canada, and Trimedic; is a speaker for Velocity Canada; is a member of a data safety monitoring board for the Pulmonary Embolism Prevention after Hip and Knee Replacement (PEPPER) study; is President of the Society for Perioperative Research and Care; and has been provided with medical devices for studies by CloudDX and Phillips Healthcare. RI is supported by an Australian National Health and Medical Research Council senior research fellowship. EA receives an Australian Government Research Training Programme scholarship, grant funding from the UK National Institute of Health and Care Research (NIHR 203194), and has previously received grant funding from the Australian Government Department of Health and Aged Care. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Approximately 20 % of femoral fragility fracture patients take anticoagulants, typically warfarin or Direct Oral AntiCoagulant (DOAC). These can impact timing of surgery affecting patient survival. Due to several possible approaches and numerous factors to consider in the preoperative workup of anticoagulated patients, potential for variations in clinical practice exist. Some hospitals employ dedicated anticoagulation management protocols to address this issue, and to improve time to surgery. This study aimed to determine the proportion of hospitals with such protocols, compare protocol guidance between hospitals, and evaluate the effectiveness of protocols in facilitating prompt surgery., Methods: Data was prospectively collected through a collaborative, multicentre approach involving hospitals across the UK. Femoral fragility fracture patients aged ≥60 years and admitted to hospital between 1 st May to 31 st July 2023 were included. Information from dedicated anticoagulation management protocols were collated on several domains relating to perioperative care including administration of reversal agents and instructions on timing of surgery as well as others. Logistic regression was used to evaluate effects of dedicated protocols on time to surgery., Results: Dedicated protocols for management of patients taking warfarin and DOACs were present at 41 (52.6 %) and 43 (55.1 %) hospitals respectively. For patients taking warfarin, 39/41 (95.1 %) protocols specified the dose of vitamin k and the most common was 5 milligrams intravenously (n=21). INR threshold values for proceeding to surgery varied between protocols; 1.5 (n=28), 1.8 (n=6), and 2 (n=6). For patients taking DOACs, 35/43 (81.4 %) and 8/43 (18.6 %) protocols advised timing of surgery based on renal function and absolute time from last dose respectively. Analysis of 10,197 patients from 78 hospitals showed fewer patients taking DOACs received surgery within 36 h of admission at hospitals with a dedicated protocol compared to those without (adjusted OR 0.73, 95% CI 0.54-0.99, p=0.040), while there were no differences among patients taking warfarin (adjusted OR 1.64, 95% CI 0.75-3.57, p=0.219)., Conclusions: Around half of hospitals employed a dedicated anticoagulation management protocol for femoral fragility fracture patients, and substantial variation was observed in guidance between protocols. Dedicated protocols currently being used at hospitals were ineffective at improving the defined targets for time to surgery., Competing Interests: Declaration of competing interest WE is the Surgical lead of the National Hip Fracture Database of England and Wales. The other authors declare no conflicts of interest., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

High risk perception (HRP) is fundamental for adequate health behavior. However, its impact on rapid access to cardiac care after the onset of acute myocardial infarction (AMI) is not known. Conflicting evidence exists about sources that promote HRP. Data on sociodemographic and clinical characteristics of 588 AMI patients who participated in the Munich Examination of Delay in Patients Experiencing Acute Myocardial Infarction (MEDEA) study were collected at the bedside. Adjusted multivariate logistic regression models identified factors associated with HRP. Only 13.4% (n = 79) of patients had a favorable HRP level. The HRP patients did not differ from those with low risk perception (LRP) in terms of sex, age, other sociodemographic features, and somatic risk factors. Among the univariate contributors to HRP were prodromal chest pain (p = 0.0004), symptom mismatch during AMI (p < 0.0001), depression (p = 0.01), and anxiety (p = 0.005). However, family history of AMI, a previous AMI, and knowledge of AMI remained significant in the multivariate regression model. Median delay time to reach a hospital-based emergency facility after the onset of AMI was 127 min (interquartile range [IQR]: 83-43, p = 0.02) in HRP patients and 216 min (IQR: 106-721) in LRP patients. An increasing risk perception score was associated with a corresponding stepwise decline in median delay time (p > 0.004). Self-perceived AMI risk is associated in a dose-response relationship with the time needed to reach coronary care emergency facilities. Recurrent AMI, family history of AMI, and sufficient knowledge of MI contribute to risk perception, whereas somatic risk factors do not., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Introduction: Expeditious initiation of biologic therapy is important in patients with inflammatory bowel disease (IBD). However, initiation of biologics in the outpatient setting may be delayed by various clinical, social, and financial variables., Aim: To evaluate the delay in initiation of an advanced therapy in IBD and to identify factors that contributed to this delay., Methods: This was a multi-center retrospective study. Outpatients who were initiated on a biologic therapy from 3/1/2019 to 9/30/20 were eligible for the study. Univariate and multivariate linear regression analyses were performed to identify variables associated with a delay in biologic treatment initiation. Delay was defined as the days from decision date (prescription placement) to first infusion or delivery of medication., Results: In total 411 patients (Crohn's disease, n = 276; ulcerative colitis, n = 129) were included in the analysis. The median [interquartile range-(IQR)] delay for all drugs was 20 [12-37] days (infliximab, 19 [13-33] days; adalimumab, 10 [5-26] days; vedolizumab, 21 [14-42] days; and ustekinumab, 21 [14-42] days). Multivariate linear regression analysis identified that the most important variables associated with delays in biologic treatment initiation was self-identification as Black, longer distance from treatment site, and lack of initial insurance coverage approval., Conclusion: There may be a significant delay in biologic treatment initiation in patients with IBD. The most important variables associated with this delay included self-identification as Black, longer distance from site, and lack of initial insurance coverage approval., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Aim: In cases of out-of-hospital cardiac arrests (OHCA) occurring at home, Japanese emergency medical services personnel decide whether to provide treatment on the scene or during transport based on their judgment. This study aimed to evaluate the association between the timing of advanced life support (ALS) (i.e., endotracheal intubation [ETI] or adrenaline administration) for OHCA at home and prognosis., Method: This retrospective cohort study used data from the Japan Utstein Registry and emergency transport data collected from patients who underwent pre-hospital ETI (n = 6806) and received adrenaline (n = 22,636) between 2016 and 2019. The timing of ETI or adrenaline administration was determined as "on the scene" or "in the ambulance." Multiple logistic regression analysis was used to estimate the association among the timing of ALS implementation, pre-hospital return of spontaneous circulation (ROSC), and survival at 1 month., Result: ETI on the scene was significantly positively associated with pre-hospital ROSC (adjusted odds ratio [AOR], 1.81; 95% confidence interval [CI], 1.57-2.09) and survival at 1 month (AOR, 1.81; 95% CI, 1.47-2.23). Adrenaline administration on the scene was significantly positively associated with pre-hospital ROSC (AOR, 2.51; 95% CI, 2.33-2.70) and survival at 1 month (AOR, 2.13; 95% CI, 1.89-2.40)., Conclusion: Our analysis suggests performing ALS on the scene was associated with pre-hospital ROSC and survival at 1 month. Further efforts are needed to increase the rate of ALS implementation on the scene by emergency life-saving technicians., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Our analysis was designed to characterize the demographics and disparities between the diagnosis of pancreas cancer during emergency presentation (EP) and the outpatient setting (OP) and to see the impact of our institutions pancreatic multidisciplinary clinic (PMDC) on these disparities., Methods: Institutional review board-approved retrospective review of our institutional cancer registry and PMDC databases identified patients diagnosed/treated for pancreatic ductal adenocarcinoma between 2014 and 2022. Chi-square tests were used for categorical variables, and one-way ANOVA with a Bonferroni correction was used for continuous variables. Statistical significance was set at p < 0.05., Results: A total of 286 patients met inclusion criteria. Eighty-nine patients (31.1%) were underrepresented minorities (URM). Fifty-seven (64.0%) URMs presented during an EP versus 100 (50.8%) non-URMs (p = 0.037). Forty-one (46.1%) URMs were reviewed at PMDC versus 71 (36.0%) non-URMs (p = 0.10). No differences in clinical and pathologic stage between the cohorts (p = 0.28) were present. URMs took 22 days longer on average to receive treatment (66.5 days vs. 44.8 days, p = 0.003) in the EP cohort and 18 days longer in OP cohort (58.0 days vs. 40.5 days, p < 0.001) compared with non-URMs. Pancreatic Multidisciplinary Clinic enrollment in EP cohort eliminated the difference in time to treatment between cohorts (48.3 days vs. 37.0 days; p = 0.151)., Results: Underrepresented minorities were more likely to be diagnosed via EP and showed delayed times to treatment compared with non-URM counterparts. Our PMDC alleviated some of these observed disparities. Future studies are required to elucidate the specific factors that resulted in these findings and to identify solutions., (© 2024. The Author(s).)

Background and Objectives: The SARS-COVID-19 pandemic significantly limited healthcare access. We sought to evaluate whether California's lockdown in March 2020 affected staging and time to treatment of pancreatic ductal adenocarcinoma (PDAC). We hypothesized that patients diagnosed after the lockdown would have longer time to treatment and higher stage at presentation., Methods: We retrospectively identified and categorized 1294 patients presenting to five University of California healthcare systems with a new diagnosis of PDAC into "pre-lockdown" and "post-lockdown" groups based on timing of pathologic diagnosis., Results: In the 12 months pre-lockdown, 835 patients were diagnosed with PDAC, and 459 patients in the 6 months post-lockdown. Demographics, staging, and treatment type were similar between eras. There was a decreased male:female ratio post- versus pre-lockdown (0.97 vs. 1.25; p = 0.03). Time from symptom onset to first treatment was significantly increased among females post-lockdown (p = 0.001). However, overall time from diagnosis to first treatment was shorter in the post-lockdown era (median 23 vs. 26 days, p < 0.001)., Conclusions: The COVID-19 lockdown did not significantly delay initial presentation, diagnosis, or treatment of newly diagnosed PDAC patients. Time from diagnosis to first treatment was shorter post-lockdown. Reduced healthcare utilization for minor complaints and increased telehealth utilization may have contributed., (© 2024 The Author(s). Journal of Surgical Oncology published by Wiley Periodicals LLC.)

Background and Objectives: Recent evidence suggests earlier tracheostomy is associated with fewer complications in patients with complete cervical spinal cord injury (SCI). This study aims to evaluate the influence of spine surgical approach on the association between tracheostomy timing and in-hospital adverse events treating patients with complete cervical SCI., Methods: This retrospective cohort study was performed using Trauma Quality Improvement Program data from 2017 to 2020. All patients with acute complete (American Spinal Injury Association-A) cervical SCI who underwent tracheostomy and spine surgery were included. Tracheostomy timing was dichotomized to early (within 1 week after surgery) and delayed (more than 1 week after surgery). Primary outcome was the occurrence of major in-hospital complications. Secondary outcomes included occurrences of immobility-related complications, surgical-site infection, hospital and intensive care unit length of stay, and time on mechanical ventilation., Results: The study included 1592 patients across 358 trauma centers. Mean time to tracheostomy from surgery was 8.6 days. A total of 495 patients underwent anterior approach, 670 underwent posterior approach, and 427 underwent combined anterior and posterior approach. Patients who underwent anterior approach were significantly more likely to have delayed tracheostomy compared with posterior approach (53% vs 40%, P < .001). Early tracheotomy significantly reduced major in-hospital complications (odds ratio 0.67, 95% CI 0.53-0.84) and immobility complications (odds ratio = 0.78, 95% CI 0.6-1.0). Those undergoing early tracheostomy spent 6.0 (95% CI -8.47 to -3.43) fewer days in hospital, 5.7 (95% CI -7.8 to -3.7) fewer days in the intensive care unit, and 5.9 (95% CI -8.2 to -3.7) fewer days ventilated. Surgical approach had no significant negative effect on the association between tracheostomy timing and the outcomes of interest., Conclusion: Earlier tracheostomy for patients with cervical SCI is associated with reduced complications, length of stay, and ventilation time. This relationship appears independent of the surgical approach. These findings emphasize that tracheostomy need not be delayed because of the SCI treatment approach., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Introduction: The incidence of infection in open tibial shaft injuries varies with the severity of the injury with rates ranging from roughly 2% for Gustilo-Anderson type I to nearly 43% for type IIIB fractures. As with all fractures, timely antibiotics administration in the emergency department (ED) is an essential component of fracture management and infection prevention. This study identifies factors associated with the expedient administration of antibiotics for open tibial shaft fractures., Methods: This retrospective study identified patients treated for open tibial shaft fractures at an academic level 1 trauma center between 2015 and 2021. Open fractures were identified by reviewing patient charts. We used chart reviews to gather demographics, fracture characteristics, postoperative outcomes, trauma activation, and time to antibiotic order, delivery, and operating room. Univariate analysis was used to compare patients who received antibiotics within 1 h of ED presentation to those who did not. Multivariate analysis was performed to investigate factors associated with faster delivery of antibiotics., Results: Among 70 ED patients with open tibial shaft fractures, 39 (56%) received early administration of antibiotics. Arrival at the ED via emergency medical service (EMS) as opposed to walking in (98% vs. 74%, p = 0.01) and trauma activation (90% vs. 52%, p < 0.001) were significantly more common in the early administration group than the late group. The early group had shorter intervals between antibiotic order and delivery (0.02 h vs. 0.35 h, p = 0.007). Multivariate analysis suggested that trauma activation, EMS arrival, and arrival during non-overnight shifts were independent predictors of a shorter time to antibiotic administration (odds ratios 11.9, 30.7, and 5.4, p = 0.001, 0.016, and 0.013, respectively)., Discussion: Earlier antibiotic delivery is associated with non-overnight arrival at the ED, arrival via EMS, and a coordinated trauma activation. Our findings indicate that in cases where administering antibiotics is critical to achieving positive outcomes, it is advisable to initiate a coordinated trauma response. Furthermore, hospital personnel should be attentive to the need for rapid administration of antibiotics to patients with open fractures who arrive via walk-in or during late-night hours., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The COVID-19 pandemic placed a significant burden on healthcare resources, limiting care to emergent and essential services only. The objective of this study was to describe the effect of the COVID-19 pandemic on the diagnosis and progression of oral cancer lesions in Montreal, Canada. A retrospective analysis of health records was performed. Patients presenting for a new oncology consultation for an oral lesion suspicious for cancer between March 2018 and March 2022, within the Department of Oral and Maxillofacial Surgery of the McGill University Health Center, were included. Data was collected on sociodemographic characteristics, oral cancer risk behaviors of study participants, oral cancer delays, tumor characteristics, and clinical management. A total of 190 patients were included, 91 patients from the pre-pandemic period and 99 from the pandemic period. The demographic characteristics of the patients in the two periods were comparable. There was no significant difference in the patient, professional, or treatment delay between the two periods. There was a non-significant increase in pathologic tumor size during the pandemic, but the pathologic staging and postoperative outcomes were comparable to those of the pre-pandemic cohort. The results indicate that emergent care pathways for oral cancer treatment were efficiently maintained despite the pandemic shutdown of services., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)