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Klebsiella invasive syndrome is a rare condition that typically presents as a liver abscess with metastatic infection, with mortality rates as high as 14% potentially due to diagnostic delay by clinicians. Here, we present a case of a woman in her 60s, who presented with symptoms and signs consistent with meningitis, imaging findings suggestive of possible leptomeningeal carcinomatosis a long with areas of lung consolidation and abdominal nodules and lymphadenopathy, presumably metastatic malignancy. We diagnosed Klebsiella invasive syndrome and treated it conservatively with medical management, including a long course of intravenous antibiotic therapy and supportive care. This is an infrequently encountered clinical entity with potentially fatal consequences, and we hope to add to the existing literature on the subject and drive home the point that it should be considered in the differential diagnoses in the appropriate clinical scenario.

Interstitial pregnancies present a diagnostic and management challenge and are associated with significant bleeding risk. We present a case of an interstitial ectopic pregnancy where there was a diagnostic delay due to the presence of uterine fibroids and where a laparoscopic myomectomy was required in order to perform laparoscopic resection of the ruptured interstitial pregnancy.This case demonstrates the possibilities at laparoscopy for ectopic pregnancy, highlights the benefit of a structured ‘buddy’ system between gynaecology surgeons and brings attention to the paucity of literature on the unique management challenges of ectopic pregnancy in the presence of leiomyoma.

A woman in her late 40s who works as a veterinary technician represented to the emergency department with increasing headache, confusion, neck stiffness, subjective fevers and distorted hearing 2 days after diagnosis of viral infection at an outside emergency department.Diagnosis of

Embolic events causing stroke and intracranial haemorrhage are among the most catastrophic complications of infective endocarditis (IE).A female patient presented with acute unilateral weakness following a 3-month history of fever, for which she had multiple remote consultations with her general practitioner. A brain MRI confirmed a left sided infarct with haemorrhagic transformation. Blood cultures grew Streptococcus mitis and her cardiac imaging showed an aortic valve vegetation with severe aortic regurgitation. Following 2 weeks of antibiotics she developed a new cerebral haemorrhage associated with a mycotic aneurysm which was treated with two coils. After discussions within the multidisciplinary meeting, she underwent aortic valve replacement 3 weeks later. She made a remarkable recovery and was discharged.Our case highlights the importance of face-to-face clinical review in the post-COVID era. It stresses that the management of patients with infective endocarditis and neurological complications is challenging and requires a multidisciplinary approach.

Introduction and Objectives Obstructive sleep apnea (OSA) is a prevalent sleep condition which is very heterogeneous although not formally characterized as such, resulting in missed or delayed diagnosis. Cluster analysis has been used in different clinical domains, particularly within sleep disorders. We aim to understand OSA heterogeneity and provide a variety of cluster visualizations to communicate the information clearly and efficiently. Materials and Methods We applied an extension of k-means to be used in categorical variables: k-modes, to identify OSA patients’ groups, based on demographic, physical examination, clinical history, and comorbidities characterization variables (n = 40) obtained from a derivation and validation cohorts (211 and 53, respectively) from the northern region of Portugal. Missing values were imputed with k-nearest neighbours (k-NN) and a chi-square test was held for feature selection. Results Thirteen variables were inserted in phenotypes, resulting in the following three clusters: Cluster 1, middle-aged males reporting witnessed apneas and high alcohol consumption before sleep; Cluster 2, middle-aged women with increased neck circumference (NC), non-repairing sleep and morning headaches; and Cluster 3, obese elderly males with increased NC, witnessed apneas and alcohol consumption. Patients from the validation cohort assigned to different clusters showed similar proportions when compared with the derivation cohort, for mild (C1: 56 vs 75%, P = 0.230; C2: 61 vs 75%, P = 0.128; C3: 45 vs 48%, P = 0.831), moderate (C1: 24 vs 25%; C2: 20 vs 25%; C3: 25 vs 19%) and severe (C1: 20 vs 0%; C2: 18 vs 0%; C3: 29 vs 33%) levels. Therefore, the allocation supported the validation of the obtained clusters. Conclusions Our findings suggest different OSA patients’ groups, creating the need to rethink these patients’ stereotypical baseline characteristics.

We report the case of a 10-year-old boy that presented with a palpable, painless, frontal lesion. Laboratory assessments were unremarkable and the patient was asymptomatic. Initial investigation, with a skull radiograph and unenhanced CT scan, showed a lytic midline frontal lesion involving the inner and outer tables of the skull and a large subgaleal hypodense component. MRI further depicted communication with the epidural space and contact with the superior sagittal sinus (SSS). Subsequent evaluation by Doppler ultrasound and MR angiography excluded a sinus pericranii and showed normal patency of the SSS. Surgical biopsy revealed chronic granulomatous inflammation; PCR was positive for Mycobacterium sp. One year after surgical resection and antitubercular therapy, there are no signs of recurrence. Primary calvarial involvement by tuberculosis is rare, even in developing countries. Familiarity with the expected clinical and imaging features is required to avoid diagnostic delay.

ImportanceHidradenitis suppurativa (HS) is associated with considerable diagnostic delay. Although most patients report adolescent onset, existing HS diagnostic criteria may not adequately capture disease in pediatric populations.ObjectivesTo determine the proportion of physician-diagnosed pediatric patients with HS who met diagnostic criteria, and describe demographics, disease characteristics, and diagnostic patterns among pediatric patients with HS.Design, Setting, and ParticipantsIn this retrospective, cross-sectional study, electronic medical records from 2 sites of a single academic tertiary care center were included. Eligible patients were those born after January 1, 1993, and assigned International Classification of Diseases, Ninth and Tenth Revisions (ICD-9/10) codes for HS (ICD-9 705.83/ICD-10 L73.2) between January 1, 2012, and July 1, 2021. Patients were excluded if they were older than 18 years at diagnosis, had inaccessible diagnostic visit notes, or were unintentionally assigned an HS ICD code.ExposuresPediatric patients with HS.Main Outcomes and MeasuresFulfillment of diagnostic criteria in pediatric patients with HS.ResultsA total of 297 adolescents with HS were included in the study; 123 patients were female (78.1%), 78 self-identified as Black (26.3%), and 116 self-identified as Hispanic (39.1%). The median (IQR) age at diagnosis was 14.0 (13.0-16.0) years. Documentation from the diagnostic visit demonstrated that 127 (42.8%) patients did not meet all 3 major HS diagnostic criteria. Of these patients, 122 (96.1%) did not meet the recurrence interval criterion (≥2 lesions within 6 months). Overall, 96 patients who did not meet the recurrence interval criterion had documentation from additional visits in the health system; 59 (61.5%) had documentation of 1 or more additional lesions consistent with HS. Review of these additional records demonstrated that 26 of these 59 (44.1%) patients met the recurrence interval criterion after diagnosis, and 44 (74.6%) had recurrent lesions within a 1-year interval (median, 6.5 months; interquartile range, 3.5-12.2 months). Medical chart review was conducted from November 22, 2021, to January 12, 2022. Analysis was conducted from January 12, 2022, to January 15, 2022.Conclusions and RelevanceOverall, 118 (40%) of 297 pediatric patients with HS in this retrospective cross-sectional study did not meet all major diagnostic criteria at the time of diagnosis, largely due to failure to fulfill the 6-month recurrence interval criterion. Future studies are needed to determine the appropriate recurrence interval to facilitate timely diagnosis and promote clinical trial eligibility for pediatric patients with HS.

Access to breast imaging was restricted during the first wave of the COVID-19 pandemic. We assessed the impact of healthcare restrictions on the Gattuso Rapid Diagnostic Centre (GRDC) at the Princess Margaret Cancer Centre.A retrospective review of patients seen at the GRDC between March 12 - August 31, 2020 and the corresponding period from 2019 was performed.There was an 18.6% decrease in patients seen at the GRDC (n = 429 in 2020 vs. 527 in 2019). Time from the first abnormal breast image to diagnosis was significantly shorter (17.4 days [IQR 13.0-21.8] in 2020 vs. 25.9 days [21.0-30.8] in 2019; p = 0.020) with no appreciable difference in time from diagnosis to consult or from consult to surgery.The GRDC enabled patients with concerning breast symptoms to access breast imaging, which helped to ensure timely treatment during the first wave of the pandemic.

Multiple myeloma is the second most common hematologic malignancy in the United States and the most common hematologic malignancy among Blacks/African Americans. Delay in diagnosis is common and has been associated with inferior disease-free survival and increased rates of myeloma-related complications. Despite a roughly 2-times higher risk of multiple myeloma, diagnostic delay appears more common, and improvements in 5-year survival rates have been slower among Blacks/African Americans than their White counterparts. When patient symptoms and basic laboratory findings are suggestive of multiple myeloma, the primary care provider should initiate extended laboratory work-up that includes serum protein electrophoresis, serum immunoglobulin free light chain assay, and serum immunofixation. Heightened awareness within high-risk populations such as Blacks/African Americans may help to eliminate racial disparities in the diagnosis and treatment of multiple myeloma.

The aim of this study was to compare outcomes between cases of Acanthamoeba keratitis (AK) diagnosed and treated with or without the use of in vivo confocal microscopy (IVCM).We performed a retrospective comparative case series of 26 eyes of 23 patients diagnosed with AK at the Massachusetts Eye and Ear Infirmary over a 5-year period. The characteristics of all identified cases were summarized. We compared the time from presentation to diagnosis of AK (primary outcome), visual acuity, and rates of therapeutic penetrating keratoplasty between eyes diagnosed by culture-only group (n = 8) and by IVCM to diagnose AK (n = 9) and later confirmed by culture (IVCM/C group).The diagnostic delay was significantly longer in the culture only group (25 ± 29 days) compared with the IVCM/C group (3 ± 3 days, P0.01). At 6 months, there was a significant difference in best-corrected visual acuity between the culture-only group (1.46 ± 1.07, n = 7) and the IVCM/C group (0.22 ± 0.22, n = 8), after adjusting for initial baseline visual acuity (P = 0.02). Therapeutic penetrating keratoplasty was performed in 50% of culture-only (n = 7) and 11% of IVCM/C group eyes (n = 9), but this was not statistically significant (P = 0.13).IVCM can expedite the diagnosis of AK, and its use as an adjunct tool in the diagnosis of AK may result in better patient outcomes compared with basing treatment decisions on corneal cultures alone.

Despite improvements in survival of people with HIV admitted to the intensive care unit (ICU), late diagnosis continues to contribute to in-ICU mortality. We quantify the population attributable fraction (PAF) of in-ICU mortality for recent late diagnosis among people with HIV admitted to a London ICU.Index ICU admissions among people with HIV were considered from 2000 to 2019. Recent late diagnosis was a CD4 T-cell count 350 cells/μL and/or AIDS-defining illness at/within 6 months prior to ICU admission. Univariate comparisons were conducted using Wilcoxon rank-sum/Cochran-Armitage/χIn all, 207 index admissions were included [median (interquartile range) age: 46 (38-53) years; 72% male]; 58 (28%) had a recent late diagnosis, all of whom had a CD4 count 350 cells/μL, and 95% had advanced HIV (CD4 count 200 cells/μL and/or AIDS at admission) as compared with 57% of those who did not have a recent late diagnosis (p 0.001). In-ICU mortality was 27% (55/207); 38% versus 22% in those who did and did not have a recent late diagnosis, respectively (p = 0.02). Recent late diagnosis was independently associated with increased in-ICU mortality risk (adjusted RR = 1.75) (95% confidence interval: 1.05-2.91), with 17.08% (16.04-18.12%) of deaths being attributable to this.There is a need for improved public health efforts focused on HIV testing and reporting of late diagnosis to better understand potentially missed opportunities for earlier HIV diagnosis in healthcare services.

The proportion of people who are diagnosed late is a key metric to measure the public health response to HIV. But this percentage remains stubbornly high in nearly every country. Delays in accessing antiretroviral therapy affects both (i) individual health, due to a higher risk of mortality, and (ii) population-based health, due to continued risk of transmission. Despite huge efforts to increase testing, late diagnosis continues to be an indication of a public health failure.This short review includes community perspectives on why late diagnosis continues and how it may be reduced. We discuss both structural barriers that prevent people from testing earlier and personal reasons why some people still refuse testing when offered. We note that late diagnosis is reported in all countries and in all demographic groups and that sex, gender, age, and sexuality all affect these rates. However, even in groups with high HIV awareness, such as in gay and bisexual men in the UK, more than one in three people with HIV continue to be diagnosed late. Fears and prejudice about HIV based on outdated information are still common among both health workers and people using health services. For example, testing is still not offered in primary or emergency care settings, and even free testing might not be accepted if someone fears the outcome might jeopardize their resident status, employment, relationship, or health.In addition to developing targeted projects to reach the highest-risk groups, a positive mainstream public campaign could make testing more acceptable at a broad population level across all demographics. This could challenge and repair the media campaigns from the 1980s that still contribute to the stigma that frightens people away from testing now. We hope that an effective approach in one country might also help others.

Lung cancer is the top reason for cancer-related deaths worldwide. The 5-year overall survival rate of lung cancer is approximately 20 % due to the delayed diagnosis and low response rate to regular treatments. Microbiota, both host-microbiota and alien pathogenic microbiota, have been investigated to be involved in a complicated and contradictory relationship with lung cancer initiation, treatments, and prognosis. Disorders of certain host-microbiota and pathogen infection are associated with the risk of lung cancers based on epidemiological evidence, and antibiotics (ATBs) could dramatically impair anti-cancer treatment efficacy, including chemotherapy and immunotherapy. Moreover, probiotics and microbe-mediated drugs are potential approaches to enhance regular anti-tumor treatments. Therefore, the knowledge of the complex dual effect of microbes on lung cancer is beneficial to take their essence and remove their dross. This review offers insight into the current trends and advancements in microbiota or microbial components related to lung cancer.

The ongoing COVID-19 pandemic has been impeding HIV diagnosis and treatment worldwide. Data on the impact of COVID-19 on late diagnosis (LD) in Germany are lacking. Here we present novel data of a single-centre German HIV cohort assessing LD during COVID-19.This is a non-interventional, single-centre retrospective cohort assessing the rate of LD comparing HIV diagnoses pre-COVID-19 with those during the COVID-19 pandemic. New diagnoses between 1 January 2019 and 1 February 2020 were classified as pre-COVID-19, and diagnoses between 1 February 2020 and 1 October 2021 were classified as during COVID-19.Between 1 January 2019 and 1 October 2021, 75 patients presented with newly diagnosed HIV infection, 34 pre-COVID-19 and 41 during COVID-19. LD increased to 83% (n = 34/41) during COVID-19 versus 59% (n = 20/34) pre-COVID-19, and CDC stage C3 rose to 44% (n = 18) versus 27%. Hospitalization rate increased to 49% (n = 20) during COVID-19 versus 29% pre-COVID-19, and 12% (n = 5) presented with HIV-associated neurological disease, whereas none were observed in the pre-COVID-19 group. The incidence of LD (p = 0.020), CD4 count 350 cells/μL (p = 0.037) and 200 cells/μL (p = 0.022) were statistically significantly associated with the ongoing COVID-pandemic. An association with HIV transmission risk was borderline significant (p = 0.055).Despite comparable annual rates of new HIV diagnoses, LD has been increasing during the COVID-19 pandemic, resulting in more opportunistic infections and higher hospitalization rates, possibly reflecting pandemic-related shortages in HIV testing and care facilities. Maintaining HIV testing opportunities and access to treatment during a pandemic is crucial so as not to impede WHO elimination goals and so as to prevent an increase in AIDS-related morbidity and mortality.

Caecal volvulus is a rare cause of intestinal obstruction, of which the caecal bascule is the most uncommonly encountered subtype. Definitive radiological diagnosis of a caecal bascule can be challenging. Lack of familiarity with this rare condition can contribute to delayed diagnosis and treatment, which may result in unnecessary morbidity. This article highlights the case of a patient who presented with a diagnostic challenge, and also discusses the pathogenesis and diagnostic features of caecal bascules. Various options in the surgical management of caecal bascules are reviewed, including the feasibility of laparoscopic-assisted approaches in the emergency setting.

SUMMARY OBJECTIVE: Malignant cutaneous melanoma is the most aggressive type of skin cancer, and its early detection and prompt initiation of treatment play an important role in reducing disease-associated morbidity and mortality. Many factors influence the diagnosis of melanoma, and its recognition is essential for the development of strategies for its early detection. This study was carried out to Identify the main variables related to the delay in diagnosis of Malignant Cutaneous Melanoma and correlate them with the time interval for making the definitive diagnosis. METHODS: Retrospective analysis of 103 patient records from January 2015 to December 2020 correlating social, economic, demographic, and cultural factors with the time elapsed between the onset of symptoms and the diagnosis of malignant cutaneous melanoma. RESULTS: The average time to seek medical services from the onset of symptoms was 29.54 months. The mean time for a referral from the primary to the referral service was 1.35 months, and the factors that contributed to a faster diagnosis were lesion Breslow (>1 mm), lesion growth, income range (≤1.5 minimum wages), lower phototypes (I and II), not having gone to the Basic Healthcare Units, profession (household), smoking, and type of housing. CONCLUSIONS: Our findings demonstrate that there is still a great delay in the recognition of signs and symptoms related to the diagnosis of malignant cutaneous melanoma in our country, influenced by several socioeconomic and demographic factors.

Clarification of propagation patterns in amyotrophic lateral sclerosis (ALS) is challenging, but understanding these has implications for individual prognostication and clinical trial design. However, systematic knowledge in this area is lacking. The aim of this study was to characterize the spatial and temporal features of propagation patterns in ALS, and to evaluate the association between propagation patterns and survival.A cohort of 833 patients with ALS, diagnosed between January 2018 and December 2019 and followed to August 2021, was analysed. Spatial and temporal features of propagation patterns were determined based on the involved functional regions (bulbar, cervical, thoracic/respiratory and lumbar) in time order. The final propagation pattern was identified in patients with at least three functional regions involved. Kaplan-Meier analysis and Cox regression analysis were performed.During a median follow-up of 21.2 months, 19 final propagation patterns were identified in 657 patients (78.9%). In survival analysis, we found that the earlier the respiratory functional region becomes involved, the higher the risk of death (time order: 1st: hazard ratio [HR], 3.35, 95% confidence interval [CI] 1.23-9.15; 2nd: HR 2.45, 95% CI 1.55-3.87; 3rd: HR 1.94, 95% CI 1.52-2.49), adjusting for age, sex, diagnostic delay, revised ALS Functional Rating Scale score, cognitive impairment and riluzole. Shorter interval time between involved regions was an independent adverse prognostic factor.The propagation patterns of ALS are varied. The order in which the respiratory region becomes involved and the interval time between involvement of functional regions are predictors for prognosis.

Objectives: Late HIV diagnosis (CD4

This study aims to examine the duration and rate of delayed diagnosis in Charcot foot. We systematically reviewed articles published in Medline, SCOPUS, and Cumulative Index of Nursing and Allied Health Literature to identify articles discussing delayed or misdiagnosis of Charcot foot. Random-effects models were generated to determine the average time from symptom onset to correct diagnosis (diagnostic delay duration) and proportion of patients misdiagnosed prior to being correctly diagnosed (delayed diagnosis rate). Our search identified 142 articles, 7 of which are included in this review. The review found that 53.2% of cases of Charcot osteoarthropathy experienced a delay in diagnosis (95% CI: 28.9%-77.4%). Overall, the duration of diagnostic delay was determined to be 86.9 days (95% CI: 10.5-162.1). We found that patients with Charcot foot experienced prolonged delays from symptom onset to correct diagnosis, and a majority of patients are misdiagnosed. These delays in diagnosis contribute to worse patient outcomes.

We cover intensive care unit-acquired neuromuscular disorders associated with coronavirus disease 2019. Outcomes may be worse than expected in these patients, and there is some evidence that coronavirus disease 2019 causes myopathy directly. Corticosteroid regimens in Duchenne muscular dystrophy are addressed including outcomes in pulmonary and cardiac function. A recent article notes a continued diagnostic delay in Duchenne muscular dystrophy. An interesting report of a Canary Islands cohort of patients with oculopharyngeal muscular dystrophy is discussed. Features and clinical pearls related to a series of patients with limb-girdle muscle dystrophy R12 (anoctaminopathy) and a misdiagnosis of idiopathic inflammatory myopathy are provided. The last section on autoimmune myopathy includes articles on clinical and pathologic features associated with myositis-specific antibodies and dermatomyositis, the epidemiology of immune-mediated necrotizing myopathies (IMNMs) in Olmsted County, Minnesota, and features of a German cohort of hydroxy-3-methylglutaryl coenzyme A reductase-associated IMNM. A recent article proposes the benefit of early intravenous immunoglobulin use for adults with IMNM. We also highlight a report of 2 unusual cases of antisignal recognition particle myopathy presenting with asymmetric distal weakness.

Delays in breast cancer care, one important attributable factor for breast cancer being diagnosed at advanced stages, are not systematically studied in many countries. This study assessed the magnitude and factors associated with delays in breast cancer care in Sri Lanka, from symptom detection to treatment initiation.We interviewed 800 consecutively sampled female breast cancer patients, diagnosed within the last 12 months, using context-specific questionnaires and medical records. We defined the cut-off times for delays using international guidelines and features of the national health system and care-seeking patterns in the country. Delays were estimated as proportions with 95% confidence intervals and presented for: (i) presentation delay; (ii) diagnosis delay and (iii) treatment delay. We looked at how sociodemographic and healthcare availability and accessibility at the individual level were associated with delays using multivariate logistic regression, with a P value of 0.05 to define statistical significance.Nearly two-thirds of patients reported a presentation delay (63.3%, 95% confidence interval 59.9-66.6%). A diagnosis delay (36.7%, 95% confidence interval 33.4-40.0%) was also seen among one-third, whereas treatment delays (13.2%, 95% confidence interval 10.8-15.5%) were less common. Low family monthly income (odds ratio 6.3; 95% confidence interval 4.2-9.3) and poor knowledge on breast cancer (odds ratio 2.7; 95% confidence interval 1.8-3.8) were associated with presentation delay. Poor health literacy (odds ratio 1.7; 95% confidence interval 1.1-2.7) and the need to make more than two visits to the first contact health provider prior to diagnosis (odds ratio 7.2; 95% confidence interval 4.6-11.1) were associated with diagnosis delays, whereas directly contacting an appropriate specialised health provider once the lump was detected reduced diagnosis delay (odds ratio 0.3; 95% confidence interval 0.2-0.4). Having undergone a core biopsy (odds ratio 0.5; 95% confidence interval 0.3-0.8) and having a mammogram (odds ratio 0.6; 95% confidence interval 4.7-32.7) reduced the likelihood of treatment delays.Our study findings show that delays in breast cancer care in Sri Lanka are much lower than those in other lower-middle income countries. However, there is significant room for improvement, especially in relation to the excellence in quality of care, such as improving access to mammography services. Periodical estimation of breast cancer delays enabling temporal comparisons will probably provide useful information to policy makers in improving care delivery for breast cancer patients and, hence, is recommended. Such future assessments designed for comparisons between different treatment modalities would provide more information to assist policy decisions in care improvement.

The evaluation of epilepsy features and factors with impact to diagnosis delay in children with CLN2.The study included children with CLN2 treated from 2000 to 2020. Diagnosis was confirmed by: TPP1 deficiency and/or TPP1 gene mutation or pathognomonic electron microscopy findings. The seizure features were evaluated: the age of onset, provocation, semiology and EEG. The disease severity was assessed by CLN2 Clinical Rating Scale (CLN2-CRS). Statistical analysis included T test, chi-square test, Wilcoxon-Mann-Whitney test, using SPSS statistics 25.The study included 22 children with CLN2. Seizures were experienced by all cases at the early stage of disease, preceded by language delay in 18, and behavior problems in 14 pts. The first seizure was provoked in 9 children at mean age of 33.8 ± 4.6 months, and unprovoked in 13 at mean age of 34.6 ± 2.7 months. In patients with provoked first seizure, the average period from the first seizure to diagnosis was longer (35.1 months), with lower CLN2-CRS, then in those with unprovoked (23.8 months) first seizures (p 0.008). Initial seizures were generalized tonic-clonic (Pampiglione and Harden, 1973 Feb) [8], atonic (Pampiglione and Harden, 1973 Feb) [8], and focal (Beltrán et al., 2018 Aug) [4], with recurrence within two months. With progression, the patients experienced multiple seizure types, and 1/3 suffered status epilepticus.Provoked seizures at the onset of CLN2 have impact to diagnosis delay. The red flags are: preceding language delay and behavior problems, later FS onset comparing to the typical age, atonic, focal and long-lasting seizure, and recurrence of seizures within two months.

A 69-year-old man with dementia presented to our hospital with fever and left back pain. He was diagnosed with acute pyelonephritis based on microscopy and CT findings indicating bacteriuria and elevated fat density around the right kidney, respectively. Three days post admission, the diagnosis of a urinary tract infection was queried and the patient was re-examined. Marked tenderness was observed in the left buttock; contrast CT scan was subsequently performed and a left piriformis abscess was diagnosed. This diagnostic delay occurred due to a communication error—the referral letter to the radiologist stated ‘fever and back pain’—and the physician’s hyposkillia; hence, differential diagnoses were not considered. Physicians can reduce the frequency of related errors by conducting proper physical examinations and not relying on imaging findings alone. Furthermore, to ensure accurate diagnoses, the comments to the radiologist should be clear and detailed when requesting diagnostic imaging.

We report a patient in China with fever of unknown origin who visited 3 hospitals in 3 weeks and was finally given a diagnosis of acute Q fever, determined by metagenomics next-generation sequencing. Our results indicate that physicians are unfamiliar with Q fever and the disease is neglected in China.

Newborn screening (NBS) for Pompe disease (PD) was added to the Recommended Uniform Screening Panel (RUSP) in the United States in 2015 because there was compelling evidence of health benefits for early diagnosis of Infantile-onset Pompe disease (IOPD). However, one limitation of NBS for PD is its inability to distinguish IOPD and late onset forms of Pompe disease (LOPD). Management of LOPD is challenging because of uncertainty around progression of LOPD and determining the appropriate time for treatment initiation. The aims of this study were to understand the impact of LOPD identified through NBS, by exploring the differences in attitudes, emotions and opinions among parents and identify their needs for follow-up care. Study participants were recruited from states that included PD on their NBS panel. Semi-structured interviews were conducted with parents of nine children who were diagnosed with LOPD after an abnormal NBS result. Predominantly, parents reported a lack of adequate information, guidance, and psychosocial support from the very beginning and through the course of their diagnosis. This caused uncertainty, anxiety, frustration, and fear of the unknown. Parents live in a 'worry or not to worry' phase, balancing between coping methods to avoid over medicalization of their child, but also preparing concrete follow-up plans to be on the lookout for any signs of PD-related symptoms. Understanding parents' experiences allows genetic counselors and NBS programs to proactively design care plan for parents during this difficult period.

Cardiac amyloidosis is an infiltrative disease characterized by extracellular deposition of insoluble amyloid fibrils in the heart leading to organ dysfunction. Despite recent diagnostic advances, the diagnosis of cardiac amyloidosis is often delayed or even missed. Furthermore, a long diagnostic delay is associated with adverse outcomes, with the early diagnosed patients showing the longest survival. In this narrative review we aimed to summarize the 'red flags' that may facilitate the correct diagnosis. The red flags may be classified as clinical, biohumoral, electrocardiographic, echocardiographic, and cardiac magnetic resonance features and should promptly raise the suspicion of cardiac amyloidosis in order to start a correct diagnostic pathway and targeted treatment strategies that may improve patients' outcomes.

Non-radiographic axial spondyloarthritis (nr-axSpA) data from South America are scarce, especially regarding image features. Objective To estimate the frequency of nr-axSpA and ankylosing spondylitis (AS) in a cohort of Argentinian patients with chronic low back pain (LBP) and to analyze the difference between both, with focus on magnetic resonance imaging (MRI) lesions, at diagnosis.Patients with LBP and a diagnosis of axSpA who participated in a reuma-check program were included. All patients with a suspicion of SpA were evaluated using blood analytics, HLA-B27, and images (MRI). Sociodemographic data, SpA features, diagnostic dela,y and clinimetrics were assessed by an operator who was blinded to the patient's test results. On MRI, the presence of SpA lesions was assessed and a concordance exercise was carried out between rheumatologists and radiologist.Of 198 LBP patients, 97 had axSpA, 54% of whom were nr-axSpA. A positive MRI was found in 50%. No difference in terms of disease activity, functional impact, laboratory or treatments between nr-axSpA and AS were found. Higher frequencies of male sex and chronic lesions on sacroiliac MRI were found in AS patients. In the logistic regression, an independent association with AS diagnosis was found: male (odds ratio [OR] 4.8), MRI fat replacement (OR 4.6), MRI sclerosis (OR 7.6), and diagnostic delay of more than 2 years (OR 10). The concordance between rheumatologists and radiologists was considered good to very good (κ 0.7-0.8).The frequency of nr-axSpA was 54%. We found a higher frequency of being male, more SpA features, and a longer diagnostic delay in patients with AS. Patients with AS had more structural lesions, with a good concordance between rheumatologist and radiologist.

Objectives. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been recognized as the first method of choice in the diagnosis of mediastinal and hilar lesions. Although the procedure is commonly used, there is no study assessing its contribution to the duration required for diagnosis and treatment. In this study, we aimed to determine the extent of diagnosis and treatment delays when using the EBUS-TBNA procedure and to address the possible factors contributing to these delays. Materials and Methods. The demographic data, pathological diagnosis, need for additional procedures, symptoms, presenting complaints, and the time until the beginning of treatment were recorded retrospectively in all patients who had undergone EBUS-TBNA. Results. A total of 134 patients (mean age 60.7 ± 12 years, M/F: 78/56) were included. Delay of the patients was found in 60.4% (n = 81), delayed referral in 35.8% (n = 48), diagnosis delays in 84.3% (n = 113), treatment delays in 38.8% (n = 52), and total delay in 73.1% (n = 98) of the patients. A statistically significant association was found between referral delay and total delay with age groups ( p = 0.006 ) and between patient delay and the presence of symptoms ( p = 0.027 ). EBUS-TBNA was found to have the lowest effect among all delay parameters (β: 0.104, p < 0.001 ) in the regression analysis. When diagnosis times’ subgroups were compared, EBUS-TBNA was found to have the least effect (correlation coefficient: 0.134, p = 0.004 ). Conclusion. We found that approximately ¾ of the patients had a delay and this is not acceptable in real terms. Considering that the patient burden is increasing day by day, it is necessary to make a radical change in health care or a change in strategy in order to prevent delays. EBUS-TBNA, which is in the diagnosis delay subgroup, is less invasive and accelerates the process.

Hypopituitarism is a state of complete or partial deficiency of pituitary hormones, including adrenal insufficiency, hypothyroidism, hypogonadism, growth hormone deficiency, and, rarely, diabetes insipidus.The article describes a clinical case of hypopituitarism due to a pituitary tumor in a postmenopausal woman. Difficulties in diagnosing hypopituitarism were due to a history of primary hypothyroidism. The first identified component of panhypopituitarism in the patient, (central hypothyroidism) had previously been seen as laboratory indications of medication-induced hyperthyroidism.The non-specific nature of the clinical symptoms, as well as a relatively rare combination of endocrine diseases, led to a long examination period and delayed diagnosis of the pituitary tumor.Whether the development of hypopituitarism in a patient with a nonfunctional pituitary tumor is an indication for transsphenoidal pituitary surgery remains a controversial issue. The decision for surgery is made taking into account the characteristics of the course of the disease in a particular patient. In this clinical case, a conservative tactic was chosen with hormone replacement therapy for glucocorticoid and thyroid deficiency.

To study changes in the subbasal nerve plexus by In vivo confocal microscopy (IVCM) in Sjögren's Syndrome (SS) with or without associated Small Fiber Neuropathy (SFN), in order to prevent diagnostic delay.Seventy-one patients with SS, including 19 with associated SFN, 20 healthy volunteers and 20 patients with Meibomian gland dysfunction (MGD) were included in this retrospective case-control study. IVCM was used to investigate subbasal nerve plexus density and morphology.Corneal sensitivity as evaluated with the Cochet-Bonnet aesthesiometer was significantly reduced in the SS group versus the control group (P = 0.026) and the MGD group (P = 0.037). The number of inflammatory cells was significantly increased in the SS group to 86.2 ± 82.1 cells/mmIVCM can be useful to detect corneal nerve changes in SS patients and may allow earlier diagnosis of the disease and to consider new therapeutic approaches.

The transradial access approach is a well-established route for coronary angiography and percutaneous intervention, given its lower complication rate over the transfemoral route. However, complications are still apparent, some of which can lead to serious injury. We report a case of delayed diagnosis of localized compartment syndrome , caused by haematoma and pseudoaneurysm formation following a radial procedure which resulted in long term disability. We emphasize the importance of early recognition and diagnosis of compartment syndrome to avoid long term sequalae.

Tumor-induced osteomalacia (TIO) is an acquired fibroblast growth factor 23 (FGF23)-related hypophosphatemic osteomalacia caused by phosphaturic mesenchymal tumors (PMTs) developed in the bone or soft tissue. Diagnostic delay should be addressed, and ideal techniques to localize PMTs and efficient treatment options should be explored to improve the outcomes of this rare disease. To clarify the detailed clinical course and outcomes of TIO patients, retrospective questionnaire surveys were conducted among physicians from the Japanese Society for Bone and Mineral Research (JSBMR) and the Japan Endocrine Society (JES). The primary survey collected the number of TIO patients between January 2007 and December 2018. The secondary survey aimed to obtain the detailed characteristics, laboratory data, and outcomes. Eighty-eight patients (52 males, mean: 52 years old) were included, and 24 patients were clinically diagnosed with TIO without localized PMTs. The median duration from the onset to detection of high FGF23 levels was 3.4 years, with 77 patients being initially misdiagnosed. Among the methods used to detect small, localized PMTs (≤10 mm), fluorine-18-fluorodeoxyglucose-positron emission tomography/computed tomography and somatostatin receptor scintigraphy were less sensitive than somatostatin receptor positron emission tomography/computed tomography (SRPET/CT). Systemic venous sampling (SVS) of FGF23 was performed in 53 patients; among them, SVS was considered useful for detecting localized PMTs in 45 patients with diverse tumor sizes. Finally, 45 patients achieved biochemical remission by surgery, 39 patients continued pharmaceutical treatment, including burosumab (11 patients), and four patients died. These results encouraged us to further increase the awareness of TIO and to improve the accessibility of SRPET/CT and SVS. Further evidence about the efficacy of new pharmaceutical treatments is awaited. © 2022 American Society for Bone and Mineral Research (ASBMR).

In India, around 70% of health care services are offered by the private sector. National strategic plan (NSP) has emphasized private sector engagement to TB program. Public private mix strategy along with web based mandatory notification of TB cases were established in 2002. However, feasibility of consulting an informal provider first was seen to be associated with significant increases in total delay (absolute increase 22.8 days, 95%CI 6.2–39.5) and in the risk of prolonged delay >90 days. Study design A mixed method literature review, descriptive information and evaluative outcomes data extracted and analysed. Objective This review aimed to systematically review public private mix strategy in TB control in Indian tuberculosis disease burden and efforts towards elimination. Methods Available published literatures were searched with key words, articles related with objectives were selected, analysed and systematically synthesized. Overall 30 studies were reviewed. Result Available literatures were selected based on study objective and analysed. The modes of PPM strategy its success and problems of implementation and shortcomings were synthesized. Discussion After implementing PPM from 2002, case detection is seen to have significantly increased for smear positive cases and high detection rate and better treatment outcomes achieved. However, implementation of PPM has been challenged to fully deliver the intended services. Interestingly, seeking initial care from PPs is significant risk factor for diagnostic delay. Conclusion PPM is a proven and tested strategy to achieve End TB goal globally and even in India. However, studies indicated there is the need to strengthen and motivate public sector to engage private practitioners in specific districts and sync their activities into the mainstream programme. Conflict of interest and mistrust between private practitioners and public sector has to be well addressed to build sustainable relationship among the sectors. Routine and institutionalized systematic monitoring and evaluation of the system is required to meet the End TB goal by 2025.

Disparities in health care for racial/ethnic minority children in the United States who are burdened by pediatric Crohn's disease (PCD) are not well understood.A retrospective review of the Texas Children's Hospital ImproveCareNow database from 2007 to 2015 was performed. CD patients with a minimum of 2-year follow-up were included if the onset of symptoms attributable to inflammatory bowel disease was clearly documented. We primarily aimed to identify race and ethnicity associations in diagnostic delay, presentation, treatment, and 2-year outcomes. We also examined early versus late diagnosis (ie, over 6 months from disease onset) associations with these variables unrelated to race/ethnicity.One hundred and sixty-six PCD patients [57.8% non-Hispanic White (NH-White), 18.1% African American (AA), and 15.7% Hispanic] met selection criteria. Time to diagnosis was shorter in Hispanic patients ( P0.01) and they were older at diagnosis than NH-White patients ( P = 0.0164). AA patients (33%, P0.01) and Hispanic patients (35%, P0.05) had lower rates of granuloma detection than NH-White patients (63%). AA patients had lower rates of steroid-free remission (SFR) at 2 years than NH-White patients ( P0.05). Higher ESR and lower hemoglobin levels were associated with early diagnosis ( P0.01). Early diagnosis was associated with higher rates of surgery within 2 years of diagnosis ( P0.05). Diagnostic fecal calprotectin levels inversely associated with SFR at 2 years ( P0.05). Early use of biologics positively, and early use of corticosteroids negatively correlated with 2-year SFR ( P0.05).Race and ethnicity may influence the diagnosis, treatment, and outcomes of PCD. This recognition presents a nidus toward establishing equity in PCD care.

Spinal cord compression etiology depends on geographic region. In sub-Saharan Africa, the etiologies are mostly infectious, and management is characterized by diagnostic delay and limited treatment modalities. In Togo, treatment was nonoperative until 2008. However, management has improved with the development of imaging and availability of specialists. We sought to report etiology and outcome of spinal cord compression since establishment of a neurosurgery unit in Togo.A retrospective descriptive study was performed of patients admitted for spinal cord compression in the neurosurgery unit of a referral hospital in Togo between 2008 and 2018. Follow-up was conducted at 3, 6, and 12 months after discharge.Spinal cord compression represented 4.2% of hospitalizations. Median patient age was 41 years; 5 patients were children. Men accounted for 64.6% of patients. Patients presented late to the hospital; 40.7% reported symptoms lasting1 year. Claudication was the presenting symptom in 75.2%. At presentation, 20.3% of patients had complete neurological lesions. The main etiology of compression was degenerative disease. Surgery was performed in 81.4% of patients; only 16.3% were operated on within 72 hours of admission. Chemotherapy was administered in 5 cases. At 1 year after surgery, 33.7% of patients had total neurological recovery, and 50% had partial recovery. Factors influencing neurological recovery were age, initial neurological status, and type of treatment.This study found increased degenerative causes of spinal cord compression in Africa. The pathology is characterized in our context by late consultation and operative delay affecting recovery, morbidity, and mortality.

Spondyloarthritis (SpA) is one of the most common extraintestinal manifestations of inflammatory bowel disease (IBD). Diagnostic delay must be avoided.We assessed the validity of SpA screening criteria (any of the following characteristics: chronic low back pain with onset before 45 years of age; inflammatory lower back pain or alternating buttock pain; arthritis; heel enthesitis; dacylitis; HLA-B27 positivity; sacroiliitis on imaging).This was a multicenter cross-sectional observational study in IBD patients aged ≥18 years. After evaluating the SpA screening criteria, the gastroenterologists referred the participants to the rheumatologists, who determined whether the patient fulfilled the screening criteria and carried out the necessary tests for SpA diagnosis.35 (11.7%) out of 300 patients were diagnosed with SpA. The combination with the best balance between sensitivity and specificity (91.4% and 72.1%, respectively, when applied by the rheumatologists; 80% and 78.9%, when applied by the gastroenterologists) for SpA screening, was fulfillment of any of the following: chronic low back pain with onset before age 45 years, inflammatory low back pain or alternating buttock pain, arthritis, or dactylitis.This is one of the first studies to validate SpA screening criteria in IBD patients in routine clinical practice.

Background: Celiac disease (CD) is still underestimated. To close this diagnostic gap, the Health Sicilian Authorities have constituted the "Sicilian Network for CD". Aims: A) To verify the quality of the current diagnostic approach using the data sheet of the Network. B) To evaluate the clinical, serologic and histologic data of new diagnoses in the context of the Network METHODS: We retrospectively evaluated the data collection forms of 369 patients with CD from three Centers within the Sicilian Network. All the Centers used a standard data collection form. Results: A non-classical CD presentation was more frequent than the classical one, anemia being the most frequent symptom (50%). An IBS-like presentation was found in one third of the cases. A diagnostic delay of about 9 years following the onset of symptoms was observed. Almost half of the patients had not undergone multiple duodenal biopsies; unrecommended CD serology assays were prescribed in 59.9% of the cases. Conclusions: The regional data sheets allowed an assessment of the diagnostic delay. We recorded a frequent use of unrecommended tests prescribed before referring patients to the regional Centers. Updating the education of physicians regarding CD is necessary to avoid unwarranted health expenditure.

PURPOSE: Time from diagnosis to treatment has been associated with worse survival outcomes in non–small-cell lung cancer (NSCLC). However, little is known about the impact of delay in time to diagnosis. We aimed to evaluate the impact of time from radiographic suspicion to histologic diagnosis on survival outcomes using the US SEER-Medicare population database. METHODS: We identified patients from the SEER-Medicare data set diagnosed with any stage NSCLC between January 1, 2011, and December 31, 2015, who received stage-appropriate treatment and had a computed tomography scan within 1 year of diagnosis. Time to confirmation was determined as the interval between most recent computed tomography imaging and date of histologic diagnosis. Our primary outcome was overall survival (OS). RESULTS: In total, 10,824 eligible patients were identified. The median time to confirmation was 20 (range 0-363) days. Using multivariate Cox regression models, longer time to confirmation was associated with improved OS in all comers driven by stage IV patients after adjustment for age, sex, diagnosis year, histology, and comorbidity index. In a separate landmark analysis excluding patients deceased within 6 months of diagnosis, the association between time to diagnosis and survival was no longer evident. CONCLUSION: Time to confirmation of NSCLC was inversely associated with OS in this US SEER population study. This association was lost when patients deceased within 6 months of diagnosis were excluded, suggesting that retrospective registry-claims databases may not be the optimal data source to study time to diagnosis as a quality metric because of the unaccounted confounding effects of tumor behavior. Prospective evaluations of clinically enriched data sources may better serve this purpose.

Worldwide, the coronavirus 19 disease pandemic caused a worse chance of a timely diagnosis for cancer patients. We conducted a retrospective analysis of new diagnoses registered in the national pediatric oncology database, comparing the first lockdown period (March-May 2020) with the same period of 2015-2019. The total number of cases (0-19 years) dropped by 20.8% (from 441 between 2015 and 2019 to 349 in 2020). A major reduction was observed for adolescents (15-19 years) (-32.9%) and for adolescents with solid tumors (-56.4%, p = 0.03). Our data suggest that the enforced lockdown reduced the possibility for these already vulnerable patients to access the referral centers.

Osteochondral defect or osteochondritis dissecans (OCD) of the knee usually affects young, active populations. It is a challenging diagnosis as patients typically present with poorly localised activity-related pain, which is non-specific and covers many differentials. We present an active 11-year-old girl with bilateral osteochondral defects of the patellae: a rare clinical disorder which was affecting her sporting activities. She had a 12-month history of bilateral anterior knee pain before the diagnosis was achieved with appropriate imaging. Her pain significantly improved with activity modification and physiotherapy. Follow-up will require outpatient clinic assessment and imaging to determine if non-operative management continues to be successful or surgery may be required. This case report emphasises the importance of appropriate high index of suspicion when managing patients with non-specific knee pain. It also demonstrates the importance of judicious use of imaging to avoid a missed or delayed diagnosis.

Paragonimiasis is a food-borne infection caused by several species of the Paragonimus fluke. Clinical manifestations can mimic tuberculosis and contribute to diagnostic delay. We report a cluster of paragonimiasis in a community in Ecuador, where active surveillance was set up after detection of the first 2 cases.

In Brazil, 75% of the population uses the Sistema Único de Saúde (SUS), public health system, where the general practitioner (GP) is responsible for melanoma diagnosis. Identify the factors related to the delay in diagnosing melanoma patients assisted by SUS. A prospective observational study based on a questionnaire and medical records review assessed the sociodemographic features, melanoma signs and symptoms, previous knowledge of the disease, and factors related to delays in seeking medical care. One hundred sixty-six patients were included. Healthcare professionals suspected a lesion in only 23.5% of cases. The average time between lesion suspicion by patient/relative and first medical appointment with GP was over 6 months (31%). The time between the first GP exam and biopsy conducted by a specialist ranged from less than 1 month (34.9%) to more than 1 year (18.7%). Half of the patients (49.4%) experienced delays in histopathological diagnosis due to SUS bureaucracy/slowness. Most (80%) patients did not know what melanoma was before diagnosis. Delay in melanoma diagnosis was related to a lack of knowledge about the disease's signs and symptoms for both the study population and the primary physicians, indicating that both players must receive proper education about melanoma. Also, the infrastructure and work processed at SUS impeded the patient flow, contributing to the diagnosis of the lesions at more advanced stages.

Coccidioidomycosis is caused by the dimorphic fungi Coccidioides species which is endemic in the Western hemisphere. Reports on the characteristics of travel-related disseminated coccidioidomycosis in immunocompetent patients are rare, especially in non-endemic regions. The multifaceted symptoms of this condition present a diagnostic challenge to clinicians. This study aimed to review immunocompetent patients diagnosed with disseminated coccidioidomycosis in a tertiary hospital in Eastern China and other non-endemic areas, and to emphasize the importance of combining travel history with clinical manifestations and proper diagnostic examinations. This study retrospectively reviewed a case series of disseminated coccidioidomycosis diagnosed in an academic hospital in Eastern China. We conducted a global literature review of disseminated coccidioidomycosis in immunocompetent patients with travel history. We identified six patients in our case series and reviewed 42 cases in the literature. Travel history included Mexico, Arizona, California, and regions of low endemicity. Extrapulmonary sites of infection, which presented with diverse signs and symptoms, involved the skin and soft tissue, musculoskeletal system, lymph nodes, and central nervous system. Misdiagnoses and diagnostic delays were common. Next-generation sequencing substantially promoted precise diagnosis in our series. The overall prognosis for immunocompetent individuals was positive, mainly benefited from long-term azole therapies. The patients that succumbed had either central nervous system involvement or multiorgan dissemination. Progressive pneumonia with varied symptoms and travel history should alert healthcare professionals in non-endemic areas to consider the possibility of Coccidioides species infection. We recommend detailed history-taking and hypothesis-free detection of pathogens for cases with diagnostic delay.

Congenital myopathies (CM) were traditionally classified according to the muscle histopathological features, but in recent years, molecular diagnosis has become increasingly important. CM may present a wide phenotype variability, and while adult-onset CM have been increasingly recognized, substantial diagnostic delays are still reported.To describe a cohort of adult CM patients, including clinical, genetic, and histopathological features, and further characterize the subgroup of adult-diagnosed patients.We performed a retrospective observational cohort study to characterize the CM patients evaluated in our adult Neuromuscular outpatient clinic, including the subgroup of adult-diagnosed patients.We identified 19 CM patients with compatible molecular and/or histological diagnoses, of which 14 were diagnosed in adulthood. Eleven adult-diagnosed patients had symptoms since childhood and 9 had a family history of myopathy. The median age of symptoms' onset was 4 years old and the median age at diagnosis was 37 years old. The most common causative gene was RYR1, followed by TTN and MYH7. Three patients had non-specific features on muscle biopsy, all diagnosed during adulthood.In our cohort, the majority of CM were diagnosed in adulthood, despite most having pediatric-onset symptoms and positive family history. The diagnostic delay may be associated with mild presentation, slow course, atypical muscle histology, and lack of awareness of adult-onset CM. Studies with larger populations are needed.

Blood cell properties effectively reflect immune status. Basophil and CD8Two-sample Mendelian randomization (MR) analyses were performed on 35 published blood cell properties, using genome-wide association study (GWAS) datasets and one published GWAS dataset of narcolepsy, to explore causality between blood cell count and narcolepsy risk. Inverse variance weighted, MR-Egger, and weighted median approaches were employed for the MR analysis, odds ratio (OR) calculations, and heterogeneity tests of single nucleotide polymorphisms were conducted with the TwoSampleMR package in R. Multivariable Mendelian randomization (MVMR) was used to adjust the analysis further and eliminate the mediation effect between exposures.Basophil counts, total basophil neutrophil counts, total neutrophil eosinophil counts, granulocyte counts, and myeloid white cell counts showed inverse associations with narcolepsy risk based on the two-sample MR analysis. MVMR confirmed that only basophil counts were significantly associated with narcolepsy risk for the blood cell properties tested (OR = 0.23, 95% confidence interval 0.08-0.62; p = 0.004, power = 99.99%). Each standard deviation increase in basophil count (0.03 per nL), compared to the median level (0.04 per nL), decreased narcolepsy risk by 77%.Higher white blood cell counts, especially basophil counts, are protective factors for narcolepsy. Basophil counts has great potential to be used as a new biomarker to shorten diagnostic delay and to monitor the therapeutic effects of treatments for narcolepsy.

The purpose of this study was to clarify the clinical characteristics of spondyloarthritis (SpA) patients with inflammatory bowel disease (IBD) compared to those without IBD. Furthermore, among patients with SpA and IBD, we aimed to clarify what clinical characteristics lead rheumatologists to diagnose "IBD-related arthritis." Utilizing SpA and psoriatic arthritis (PsA) patients' data from an international, cross-sectional, observational study, we analyzed information on demographics and disease characteristics, dichotomizing patients by IBD status. The presence or absence of IBD was determined based on data collection of treating rheumatologists. Patients with SpA (including PsA) and IBD were also categorized based on treating rheumatologists' definitive diagnosis in regard to SpA type, and compared by whether the patients had IBD-related arthritis or not. Among 4465 SpA patients, 287 (6.4%, 95%CI 5.7-7.2%) were identified with IBD. Compared to SpA patients without IBD, patients with SpA and IBD had a longer diagnostic delay (5.1 vs. 2.9 years, p 0.001). In patients with SpA and IBD, 111 (38.7%, 95%CI 33.0-44.6%) were diagnosed with IBD-related arthritis. Multivariable analyses showed that HLA-B27 positivity [OR = 0.35, (95%CI 0.15-0.80)], psoriasis [OR = 0.14, (95%CI 0.04-0.50)], IBD as first symptom of SpA [OR = 3.32, (95%CI 1.84-6.01)], and need for IBD-specific treatment [OR = 5.41, (95%CI 2.02-14.50)] were independently associated with the definitive diagnosis of IBD-related arthritis. Collaboration with gastroenterologists is needed to shorten the diagnostic delay in patients with SpA and IBD. The recognition of the factors for the diagnosis of "IBD-related arthritis" may lead to the elucidation of the pathogenesis.

Acute type A aortic dissection requires timely diagnosis and intervention. Previous studies have examined risk factors associated with delayed diagnosis; however, the effect of socioeconomic status (SES) has not been previously studied. Our study examined the impact of various SES measures on time to diagnosis. We examined time to diagnosis in consecutive cases of acute type A aortic dissection at a single institution. SES variables included race/ethnicity, Medicaid eligibility, and residence in a zip code with an increased Distressed Communities Index-an aggregate measure of community SES. Delayed diagnosis was defined as time to diagnosis in the upper quartile of the study population (6.6 hours). A model predicting risk factors for delayed diagnosis was created using multivariable logistic regression. Our study included 124 patients with a median time to diagnosis of 3.36 hours (interquartile range [IQR] 1.83 to 6.63). A total of 92 patients were in the nondelayed cohort (median diagnosis time of 2.59 hours, IQR 1.49 to 4.18) and 32 patients were in the delayed cohort (median diagnosis time of 15.57 hours, IQR 9.34 to 28.75). In multivariable logistic regression, residence in a high-Distressed Communities Index zip code was associated with diagnostic delay (adjusted odds ratio [aOR] 5.108, p = 0.008). Patient age (aOR 0.944, p = 0.011), chest pain at presentation (aOR 0.099, p = 0.004), back pain at presentation (aOR 0.247, p = 0.012), evidence of malperfusion syndrome (aOR 0.040, p0.001), history of hyperlipidemia (aOR 3.507, p = 0.026), and history of congestive heart failure (aOR 0.061, p = 0.036) were also significantly associated. In conclusion, our findings suggest community-level SES affects time to diagnosis in acute type A aortic dissection.