Assessing the Response of Biomarkers to Anti-Inflammatory Medications in PIMS-TS by Longitudinal Multilevel Modeling: Real-World Data from a UK Tertiary Center.

Background: Pediatric inflammatory multisystem syndrome temporarily associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (PIMS-TS) is an acute complication of previous SARS-CoV-2 exposure. The relationship between inflammatory markers and anti-inflammatory medication in PIMS-TS is unknown. We retrospectively investigated the relationship between demographics, biomarkers, treatment, and length of stay (LOS) in this novel disease. Methods: We reviewed the case notes and blood tests of all patients who met the Royal College of Paediatrics and Child Health diagnostic criteria for PIMS-TS at a large tertiary center in the United Kingdom. Biomarker trajectories were modeled using log linear mixed effects, and factors affecting LOS in hospital were evaluated using multiple regression. Results: Between March 2020 and May 2022, a total of 56 patients attended Sheffield Children's Hospital with PIMS-TS, 70% male. Mean age was 7.4 ± 3.7 years and mean LOS 8.7 ± 4.5 days with 50% requiring intensive care and 20% requiring inotropes. Older males had shorter LOS than younger males (P = 0.04), not seen in females. Treatment included intravenous glucocorticoids in 93%, intravenous immunoglobulins (IVIG) in 77%, Anakinra in 11%, and infliximab in 1.8%. Biomarkers correlated poorly with trajectories that peaked at different times. C-reactive protein peaked first after median 1.3 days postadmission; while LFT's and neutrophils peaked after 3 days. Age had a large effect on some biomarkers, with older children having larger troponin and ferritin, and lower lymphocytes and platelets. Cumulative dose of glucocorticoids and IVIG had a statistically significant effect on some biomarkers, but effect size was small. Conclusions: The heterogenous nature of PIMS-TS highlights the importance of a multidisciplinary approach. Worse inflammatory markers in older children within our cohort may be an indication of a different disease process occurring at different ages. Future work to investigate the association between age and troponin and ferritin in hyperinflammatory states is warranted.

Dual-Energy, Dual-Exposure PA and Lateral Chest Radiograph: Not Your Father's Chest X-Ray.

In the last two decades, our military and federal health care facilities have transitioned from traditional X-rays exposing film screen systems, developed much like photographic film, to an entirely digital detection system that affords computer processing of images and digital image and report distribution. While health care providers are well aware of the practicality of these advancements, they may not be aware of the improved diagnostic capabilities afforded by these new methods. In this report, we outline how application of physical principles of X-rays, with digital detectors and computer data manipulation, can present images demonstrating chest and heart diseases that were previously not readily visible by traditional film screen systems. More recently, dual-energy, dual-exposure systems have been implemented. This commentary is to educate the medical community so that they may better understand not only the written report but the information on the images being provided, along with potential pitfalls to avoid. Specifically, we demonstrate improved detection of pulmonary nodules and coronary atherosclerosis with the dual-energy technique.

Panel sequencing links rare, likely damaging gene variants with distinct clinical phenotypes and outcomes in juvenile-onset SLE.

OBJECTIVES: Juvenile-onset systemic lupus erythematosus (jSLE) affects 15-20% of lupus patients. Clinical heterogeneity between racial groups, age groups and individual patients suggests variable pathophysiology. This study aimed to identify highly penetrant damaging mutations in genes associated with SLE/SLE-like disease in a large national cohort (UK JSLE Cohort Study) and compare demographic, clinical and laboratory features in patient sub-cohorts with 'genetic' SLE vs remaining SLE patients. METHODS: Based on a sequencing panel designed in 2018, target enrichment and next-generation sequencing were performed in 348 patients to identify damaging gene variants. Findings were integrated with demographic, clinical and treatment related datasets. RESULTS: Damaging gene variants were identified in ∼3.5% of jSLE patients. When compared with the remaining cohort, 'genetic' SLE affected younger children and more Black African/Caribbean patients. 'Genetic' SLE patients exhibited less organ involvement and damage, and neuropsychiatric involvement developed over time. Less aggressive first line treatment was chosen in 'genetic' SLE patients, but more second and third line agents were used. 'Genetic' SLE associated with anti-dsDNA antibody positivity at diagnosis and reduced ANA, anti-LA and anti-Sm antibody positivity at last visit. CONCLUSION: Approximately 3.5% of jSLE patients present damaging gene variants associated with younger age at onset, and distinct clinical features. As less commonly observed after treatment induction, in 'genetic' SLE, autoantibody positivity may be the result of tissue damage and explain reduced immune complex-mediated renal and haematological involvement. Routine sequencing could allow for patient stratification, risk assessment and target-directed treatment, thereby increasing efficacy and reducing toxicity.

Psychological/social factors associated with transfer readiness in young people with juvenile idiopathic arthritis.

The aim of this study is to investigate the relationships between psychological/social factors and transfer readiness from paediatric to adult rheumatology services in pre- and post-transfer young people (YP) with juvenile idiopathic arthritis (JIA). Participants completed questionnaires measuring a broad range of psychological/social factors (generalised anxiety, pain-specific anxiety, pain-related thoughts, depression, prosocial behaviours, problem behaviours, arthritis-related quality of life (QoL), social support, family functioning) and transfer readiness (transfer-related knowledge and skills, health-related self-efficacy). JIA disease activity was measured on the same day as the questionnaires. This study received all relevant ethical and regulatory approvals, and informed consent was received from or on behalf of all participants. In total, 40 pre-transfer YP with JIA aged 10-16 years (M = 13.54 years, 26 females) and their parents/guardians participated at Sheffield Children's NHS Foundation Trust, and 40 post-transfer YP with JIA aged 16-24 years (M = 20.16 years, 26 females) participated at Sheffield Teaching Hospitals NHS Foundation Trust. For both pre- and post-transfer YP, greater transfer readiness was associated with lower generalised anxiety levels, lower pain-specific anxiety levels, fewer pain-related thoughts, lower depression levels, fewer problem behaviours, better arthritis-related QoL, better social support, and better family functioning. Greater transfer readiness was also associated with less JIA disease activity for post-transfer YP only. A broad range of psychological/social factors were associated with transfer readiness in pre- and post-transfer YP with JIA. This highlights the importance of assessing and addressing YP's psychological/social well-being during their transition to adult services. Key Points • A wide range of psychological and social factors may be associated with how ready young people with juvenile idiopathic arthritis feel to move from paediatric to adult rheumatology services. • Transition outcomes may be improved by comprehensively assessing and addressing young people's psychological and social well-being.

Real world treatment of juvenile-onset systemic lupus erythematosus: Data from the UK JSLE cohort study.

BACKGROUND: In the absence of clinical trials evidence, Juvenile-onset Systemic Lupus Erythematosus (JSLE) treatment plans vary. AIM: To explore 'real world' treatment utilising longitudinal UK JSLE Cohort Study data. METHODS: Data collected between 07/2009-05/2020 was used to explore the choice/sequence of immunomodulating drugs from diagnosis. Multivariate logistic regression determined how organ-domain involvement (pBILAG-2004) impacted treatment choice. RESULT: 349 patients met inclusion criteria, median follow-up 4-years (IQR:2,6). Mycophenolate mofetil (MMF) was most commonly used for the majority of organ-domains, and significantly associated with renal involvement (OR:1.99, 95% CI:1.65-2.41, pc < 0.01). Analyses assessing the sequence of immunomodulators focused on 197/349 patients (meeting relevant inclusion/exclusion criteria). 10/197 (5%) solely recieved hydroxychloroquine/prednisolone, 62/197 (31%) received a single-immunomodulator, 69/197 (36%) received two, and 36/197 patients (28%) received ≥three immunomodulators. The most common first and second line immunomodulator was MMF. Rituximab was the most common third-line immunomodulator. CONCLUSIONS: Most UK JSLE patients required ≥two immunomodulators, with MMF used most commonly.

Not Just Down and Out: Oculomotor Nerve Pathologic Spectrum.

The purpose of this article is to understand the complex pathologic spectrum of oculomotor nerve palsy. We review the detailed anatomy and function of the oculomotor nerve and demonstrate how the location of a lesion can drive the differential diagnosis. Lastly, we review atypical presentations of oculomotor nerve palsy to include oculomotor synkinesis and oculomotor nerve hyperactivity. Radiologists must be aware of the typical and atypical presentations of CN III palsy to accurately localize lesions as well as avoid premature exclusion of CN III pathology.

Attainment of low disease activity and remission targets reduces the risk of severe flare and new damage in childhood lupus.

OBJECTIVES: To assess the achievability and effect of attaining low disease activity (LDA) or remission in childhood-onset SLE (cSLE). METHODS: Attainment of three adult-SLE derived definitions of LDA (LLDAS, LA, Toronto-LDA), and four definitions of remission (clinical-SLEDAI-defined remission on/off treatment, pBILAG-defined remission on/off treatment) was assessed in UK JSLE Cohort Study patients longitudinally. Prentice-Williams-Petersen gap recurrent event models assessed the impact of LDA/remission attainment on severe flare/new damage. RESULTS: LLDAS, LA and Toronto-LDA targets were reached in 67%, 73% and 32% of patients, after a median of 18, 15 or 17 months, respectively. Cumulatively, LLDAS, LA and Toronto-LDA was attained for a median of 23%, 31% and 19% of total follow-up-time, respectively. Remission on-treatment was more common (61% cSLEDAI-defined, 42% pBILAG-defined) than remission off-treatment (31% cSLEDAI-defined, 21% pBILAG-defined). Attainment of all target states, and disease duration (>1 year), significantly reduced the hazard of severe flare (P < 0.001). As cumulative time in each target increased, hazard of severe flare progressively reduced. LLDAS attainment reduced the hazard of severe flare more than LA or Toronto-LDA (P < 0.001). Attainment of LLDAS and all remission definitions led to a statistically comparable reduction in the hazards of severe flare (P > 0.05). Attainment of all targets reduced the hazards of new damage (P < 0.05). CONCLUSIONS: This is the first study demonstrating that adult-SLE-derived definitions of LDA/remission are achievable in cSLE, significantly reducing risk of severe flare/new damage. Of the LDA definitions, LLDAS performed best, leading to a statistically comparable reduction in the hazards of severe flare to attainment of clinical remission.

Juvenile Idiopathic Arthritis: A Review of Novel Diagnostic and Monitoring Technologies.

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease of childhood and is characterized by an often insidious onset and a chronic relapsing-remitting course, once diagnosed. With successive flares of joint inflammation, joint damage accrues, often associated with pain and functional disability. The progressive nature and potential for chronic damage and disability caused by JIA emphasizes the critical need for a prompt and accurate diagnosis. This article provides a review of recent studies related to diagnosis, monitoring and management of JIA and outlines recent novel tools and techniques (infrared thermal imaging, three-dimensional imaging, accelerometry, artificial neural networks and fuzzy logic) which have demonstrated potential value in assessment and monitoring of JIA. The emergence of novel techniques to assist clinicians' assessments for diagnosis and monitoring of JIA has demonstrated promise; however, further research is required to confirm their clinical utility.

Limited sensitivity and specificity of the ACR/EULAR-2019 classification criteria for SLE in JSLE?-observations from the UK JSLE Cohort Study.

OBJECTIVES: This study aimed to test the performance of the new ACR and EULAR criteria, that include ANA positivity as entry criterion, in JSLE. METHODS: Performance of the ACR/EULAR-2019 criteria were compared with Systemic Lupus International Collaborating Clinics (SLICC-2012), using data from children and young people (CYP) in the UK JSLE Cohort Study (n = 482), with the ACR-1997 criteria used as reference standard. An unselected cohort of CYP positive for ANA (n = 129) was used to calculate positive/negative predictive values of the criteria. RESULTS: At both first and last visits, the number of patients fulfilling the different classification criteria varied significantly (P < 0.001). The sensitivity of the SLICC-2012 criteria was higher when compared with that of the ACR/EULAR-2019 criteria at first and last visits (98% vs 94% for first visit, and 98% vs 96% for last visit; P < 0.001), when all available CYP were considered. The ACR/EULAR-2019 criteria were more specific when compared with the SLICC-2012 criteria (77% vs 67% for first visit, and 81% vs 71% for last visit; P < 0.001). Significant differences between the classification criteria were mainly caused by the variation in ANA positivity across ages. In the unselected cohort of ANA-positive CYP, the ACR/EULAR-2019 criteria produced the highest false-positive classification (6/129, 5%). CONCLUSION: In CYP, the ACR/EULAR-2019 criteria are not superior to those of the SLICC-2012 or ACR-1997 criteria. If classification criteria are designed to include CYP and adult populations, paediatric rheumatologists should be included in the consensus and evaluation process, as seemingly minor changes can significantly affect outcomes.

'It is good to have a target in mind': qualitative views of patients and parents informing a treat to target clinical trial in juvenile-onset systemic lupus erythematosus.

OBJECTIVE: We sought to explore patient and parental views on treatment targets, outcome measures and study designs being considered for a future JSLE treat-to-target (T2T) study. METHODS: We conducted topic-guided, semistructured interviews with JSLE patients and parents and analysed the audio recorded interviews using thematic approaches. RESULTS: Patients and parents differed regarding symptoms they felt would be tolerable, representing 'low disease activity'. Patients often classed symptoms that they had previously experienced, were 'invisible' or had minimal disruption on their life as signs of low disease activity. Parents were more accepting of visible signs but were concerned about potential organ involvement and symptom severity. Overall, patients and parents preferred that children were entirely asymptomatic, with no ongoing treatment side effects. They regarded fatigue as particularly challenging, requiring proper monitoring using a fatigue patient-reported outcome measure. Most families felt that reducing corticosteroids would also be a good treatment target. Overall, families liked the concept of T2T, commenting that it could help to improve disease control, help structure treatment and improve communication with clinicians and treatment compliance. They were concerned that T2T might increase the frequency of hospital visits, thus impacting upon schooling, parental employment and finances. Families made suggestions on how to modify the future trial design to mitigate such effects. CONCLUSION: This study provides guidance from patients and parents on T2T targets and study designs. Complementary quantitative studies assessing the achievability and impact of different targets (e.g. lupus low disease activity state or remission) are now warranted to inform an international consensus process to develop treatment targets.

An update on the modern management of paediatric uveitis.

Uveitis in children and young people (CYP) is often painless, chronic and persistent. It is an often silent blinding condition. Uveitis can be isolated or develop as a manifestation of a systemic disease. Due to the symptomless nature, it can present late with advanced ocular comorbidities such as band keratopathy, hypotony, cataracts. Inadequate control of the eye inflammation can result in permanent and severe ocular complications, structural damage and visual loss. One of the most common systemic associations is juvenile idiopathic arthritis where uveitis has a cumulative incidence of approximately 10%-14% (though wide variation in incidence is reported) after 5 years. Appropriately targeted uveitis screening is recommended to continue for at least 7 years in some subgroups. Paediatric uveitis poses multiple diagnostic and therapeutic challenges. Clinical manifestation and disease course may differ significantly from adult-onset uveitis. However, some CYP are still managed by adult specialists alone, without the opportunity for the prompt use of National Health Service England approved therapy. Optimal management of paediatric uveitis requires a multidisciplinary approach involving coordinated working of different specialities and healthcare professionals. This article highlights the evidence-based practice for the contemporary management of paediatric uveitis to readers in different specialities who may come across this condition. It raises awareness of early systemic treatment aiming to achieve early and complete disease inactivity thereby improving the chances of a long-term positive outcome.

Multi-centre national audit of juvenile localised scleroderma: describing current UK practice in disease assessment and management.

OBJECTIVE: To describe current United Kingdom practice in assessment and management of patients with juvenile localised scleroderma (JLS) compared to Paediatric Rheumatology European Society (PRES) scleroderma working party recommendations. METHODS: Patients were included if they were diagnosed with JLS and were under the care of paediatric rheumatology between 04/2015-04/2016. Retrospective data was collected in eleven UK centres using a standardised proforma and collated centrally. RESULTS: 149 patients were included with a median age of 12.5 years. The outcome measures recommended by the PRES scleroderma working party were not utilised widely. The localised scleroderma cutaneous assessment tool was only used in 37.6% of patients. Screening for extracutaneous manifestations did not meet recommendations that patients with head involvement have regular screening for uveitis and baseline magnetic resonance imaging (MRI) brain: only 38.5% of these patients were ever screened for uveitis; 71.2% had a MRI brain. Systemic treatment with disease-modifying anti-rheumatic drugs (DMARDs) or biologics was widely used (96.0%). In keeping with the recommendations, 95.5% of patients were treated with methotrexate as first-line therapy. 82.6% received systemic corticosteroids and 34.2% of patients required two or more DMARDs/biologics, highlighting the significant treatment burden. Second-line treatment was mycophenolate mofetil in 89.5%. CONCLUSION: There is wide variation in assessment and screening of patients with JLS but a consistent approach to systemic treatment within UK paediatric rheumatology. Improved awareness of PRES recommendations is required to ensure standardised care. As recommendations are based on low level evidence and consensus opinion, further studies are needed to better define outcome measures and treatment regimens for JLS.

Correction to: Inter- and intra-observer reliability of contrast-enhanced magnetic resonance imaging parameters in children with suspected juvenile idiopathic arthritis of the hip.

The article "Inter- and intra-observer reliability of contrast-enhanced magnetic resonance imaging parameters in children with suspected juvenile idiopathic arthritis of the hip".

Inter- and intra-observer reliability of contrast-enhanced magnetic resonance imaging parameters in children with suspected juvenile idiopathic arthritis of the hip.

BACKGROUND: Previous work at our institution demonstrated discrepancies between radiologists in interpretation of contrast-enhanced magnetic resonance imaging (MRI) in suspected hip arthritis. OBJECTIVE: To assess inter- and intra-observer reliability of selected MRI parameters (effusion, marrow oedema and synovial thickness and enhancement) used in the diagnosis of juvenile idiopathic arthritis. MATERIALS AND METHODS: A retrospective cohort study was conducted of patients with confirmed or suspected juvenile idiopathic arthritis who underwent hip contrast-enhanced MRI between January 2011 and September 2014. Three pediatric musculoskeletal radiologists independently assessed all scans for effusion, marrow oedema, measurement of synovial thickness, synovial enhancement and subjective assessment of synovium. Categorical variables were analysed using the Cohen κ, and measurement using Bland-Altman plots. RESULTS: Eighty patients were included. Interobserver reliability was moderate for effusion (κ=0.5-0.7), marrow oedema (κ=0.6), subjective synovial assessment (κ=0.4-0.5) and synovial enhancement (κ=0.1-0.5). Intra-observer reliability was highest for marrow oedema (κ=0.6-0.8) and lowest for effusion (κ=0.4-0.7). Intra-observer reliability for synovial enhancement (κ= -0.7-0.8) and subjective synovial assessment (κ=0.4-1.0) ranged from poor to excellent. For synovial thickness, intra- and interobserver Bland-Altman plots were well clustered around the mean suggesting good agreement. CONCLUSION: There were large differences across variables and only moderate agreement between observers. The most reliable parameters were presence of joint effusion and bone marrow oedema and subjective assessment of synovium.

United Kingdom survey of current management of juvenile localized scleroderma.

OBJECTIVES: Juvenile localized scleroderma (JLS) is a rare condition that is often difficult to assess and for which a variety of monitoring tools have been described. We aimed to describe how monitoring tools are used and perceived by clinicians in the UK, to ascertain treatments used for JLS and to provide a description of transition arrangements to adult care. METHODS: An e-survey of UK paediatric rheumatologists and dermatologists managing children and young people (CYP) with JLS was distributed using the national organisations representing these clinician groups. We asked respondents for their views and experience using 15 JLS monitoring tools, about transition services and about treatments used. RESULTS: Thirty-five dermatologists and 13 paediatric rheumatologists responded. Paediatric rheumatologists managed more CYP with JLS than dermatologists (median 16-20 and 3, respectively). Transition arrangements were reported by 43% of dermatologists and 91% of paediatric rheumatologists. Medical photography was the most frequently regularly used monitoring tool (73% respondents). The modified Rodnan skin score was the skin score used most commonly: 33% of paediatric rheumatologists and 3% of dermatologists reported using this tool frequently. Topical treatments and ultraviolet light were used by 49-80% of dermatologists and 0-8% paediatric rheumatologists. Biologic drugs and CYC were used by 0-3% of dermatologists and 31-46% of paediatric rheumatologists. CONCLUSION: How monitoring tools are accessed, used and perceived by paediatric rheumatologists and dermatologists in the UK varies between and within clinician groups, as do treatment prescribing patterns and transition arrangements. These differences will impact on the feasibility of conducting multicentre clinical trials and on standardising clinical care.

Access to care for children and young people diagnosed with localized scleroderma or juvenile SSc in the UK.

OBJECTIVES: To describe pathways of care and referral to paediatric rheumatology from onset of first symptom (noticed by the patient or their family) to diagnosis for children and young people diagnosed with localized scleroderma (LS) or juvenile SSc (jSSc). METHODS: Retrospective case note audit of patients under paediatric rheumatology care who presented during January 2005-January 2010. Data included disease subtype, sex, age at key points in the referral pathway and health care professional (HCP) contact. All patient and HCP data were pseudo-anonymized in accordance with good clinical practice. RESULTS: Data were from eight UK centres that saw 89 cases: 62 females, 26 males; 73 LS, 16 jSSc. Median time from first symptom to first HCP review was 4 (range 0-72) months (LS) and 1 (range 0-50) month (jSSc). Median time from first symptom to paediatric rheumatology review was 15 (range 1-103) months (LS) and 7 (range 0-50) months (jSSc). Median time from first HCP review to first paediatric rheumatology review was 11 (range 0-103) months (LS) and 2 (range 0-10) months. First HCP seen (74%) was usually a general practitioner. The referring HCP to paediatric rheumatology was usually a dermatologist (56%) for LS. Median time from first symptom to diagnosis was 13 (range 1-102) months (LS) and 8 (range 1-50) months (jSSc). CONCLUSION: A prolonged interval occurs from first symptom to definitive diagnosis, which may adversely affect outcome. There is a need to raise awareness of this rare diagnosis and facilitate earlier recognition.

British isles survey of methotrexate monitoring practice during treatment of juvenile idiopathic arthritis.

OBJECTIVES: We surveyed current pediatric rheumatology monitoring practice in methotrexate treatment of juvenile idiopathic arthritis in the British Isles, and experiences of significant side effects during methotrexate monitoring. METHODS: Single-center responses were sought from the current British Society for Pediatric and Adolescent Rheumatology membership, using a web-based survey tool. RESULTS: Thirty-three centers across the British Isles responded. Twenty-eight centers reported following British Society for Pediatric and Adolescent Rheumatology or local guidelines. Thirty-one centers were willing to modify their monitoring practice to individual circumstances. All centers used a full blood count and liver enzymes as monitoring tests. There was variation in frequency at which monitoring tests were performed, both at initiation of methotrexate therapy and once methotrexate therapy was established; 27 centers were willing to change the frequency of monitoring blood tests after a period of stability. Centers reported acting on alanine aminotransferase values ranging from 50 to 500 IU/L. Particular variation existed between smaller and larger centers. Few centers reported any experience of serious side effects, and only 1 cited a case of liver cirrhosis. CONCLUSIONS: Despite specific pediatric guidance for monitoring low-dose methotrexate use in juvenile idiopathic arthritis, variation in practice exists in the British Isles. It may be that blood test monitoring could safely be performed less frequently than currently recommended. To inform future changes to guidance, we suggest establishing a prospective registry for serious side effects.

Impact of geographic barriers on the utilization of mammograms by older rural women.

OBJECTIVES: To examine whether geographic proximity to mammography facilities influences mammogram utilization. DESIGN: Retrospective cohort analysis. SETTING: Rural state. PARTICIPANTS: Female Kansas Medicare beneficiaries aged 65 to 79 (N=117,901). MEASUREMENTS: Using Medicare claims data, we measured county-level mammography rates for beneficiaries in Kansas. We calculated mammography rate differences for beneficiaries according to age, race, distance from permanent and mobile mammography sites, and county characteristics including county mammography service availability. RESULTS: Of 105 counties, 37% had only permanent mammography facilities, 22% had both permanent and mobile sites, 29% had only mobile facilities, and 11% had neither, representing 44%, 44%, 9%, and 3% of the 117,901 beneficiaries, respectively. Of the beneficiaries, 91% lived less than 20 miles from a permanent facility; of the remaining 9%, 67% lived less than 20 miles from a mobile site. In 30 counties with only mobile sites, 90% of the 10,439 beneficiaries residing in the counties had access to the sites fewer than 2 days per month. County-level mammography rates ranged from 37% to 72%. Mammography utilization was 57% in counties with permanent facilities only, 55% in counties with both permanent and mobile sites, 53% in counties with only mobile sites, and 53% in counties with neither (P=0.12). After adjusting for age, race, and county education level, the odds of receiving a mammogram was slightly lower for persons residing longer distances from a permanent facility (odds ratio=0.97 for each 5-mile increase in distance, 95% confidence interval=0.95-0.99). CONCLUSION: The majority of Kansans live near a mammography facility. Although there is a large variation in county-level mammography rates across Kansas, this disparity is not well explained by proximity to mammography facilities.