Delay in diagnosis of rheumatoid arthritis: reasons and trends over a decade

INTRODUCTION

Delay in diagnosis and treatment initiation often lead to poorer outcomes in rheumatoid arthritis (RA). Most of the data on delay in diagnosis and management are from western population with no data from India. Additionally, with improved health care services, whether the delay has changed over years is not known. In this longitudinal observational study, we investigated delay to diagnosis and disease-modifying antirheumatic drugs (DMARDs) initiation over past 9 years.

METHODS

Patients aged ≥ 18 years having RA fulfilling 2010 ACR/EULAR criteria were enrolled from January to June in years 2012, 2017 and 2021. Diagnoses received before presenting to clinic, socioeconomic status, educational level and other demographic variables were recorded.

RESULTS

Each year, 323 patients (mean age 49.5-52.01 years) were enrolled. There was a significant reduction in delay in diagnosis from a median (IQR) of 36 (12-84, range 1-288) months in 2012 to 12 (4-36, range 1-180) months in 2017 and 10 (5-24, range 1-120) months) in 2021 (p < 0.0001). A significant improvement in time to initiating DMARDs from 2012 [48 (24-96) months] to 2017 [12 (6-36) months] (p < 0.0001) and from 2017 to 2021 [12 (5-24) months] (p = 0.03) was seen. Higher education, more patients opting for treatment from rheumatologists, and urbanisation contributed significantly to improvement in delay. There was no impact of age or gender on delay.

CONCLUSION

Delay in diagnosis has improved significantly between 2012 and 2021. However, delay still remains long as most patients miss the 3-month therapeutic window. Future work focussing on reasons for delays in the patient pathway could help improve consultation pathways in India.

Analysis of Factors Influencing Delayed Presentation in Japanese Patients with Subarachnoid Hemorrhage

OBJECTIVE

Some aneurysmal subarachnoid hemorrhage (SAH) patients are delayed in their presentation. This can cause a washout of the subarachnoid hematoma and a potential misdiagnosis. As a result, they may suffer rerupture of the aneurysm and preventable deterioration. We investigated the factors that influence delayed SAH presentation.

METHODS

Aneurysmal SAH patients treated at 9 stroke centers from 2002 to 2020 were included. Age, gender, pre-SAH modified Rankin scale, World Federation of Neurological Surgeons grade, Fisher group, day of presentation, aneurysm treatment method, past history of cerebral stroke, comorbidity of hypertension and/or diabetes mellitus, and modified Rankin scaleat discharge were assessed retrospectively. We formed 2 groups based on the day of presentation after the onset of SAH: day 0-3 (early) and other (delayed). Logistic regression analyses detected the factors that influenced the day of presentation and outcome for SAH. A P- value <0.05 was considered significant.

RESULTS

Delayed presentation comprised 282 cases (6.3%) of 4507 included cases. Logistic regression analyses showed that patients in an urban area, of male gender, low WFNS grade and low Fisher group correlated significantly with a delayed presentation. But delayed presentation did not influence outcome at discharge.

CONCLUSIONS

Area of residency and gender correlated with delayed presentation after SAH in Japan. Urbanization, male gender, and mild SAH lead patients to delay presentation. The factors underlying these tendencies will be analyzed in a future prospective study.

[Result of the update of the clinical pathway for hip fracture in the elderly at a university hospital in Madrid]

BACKGROUND AND OBJECTIVES

Orthogeriatric management with clinical pathways (CP) in hip fracture (HF) has been shown to be superior to other models. We studied whether updating the CP, through prioritization of admission and surgery, improvement in the prevention and treatment of delirium, management of anticoagulants and antiplatelet agents and the use of perioperative peripheral nerve block, modifies surgical delay, stay, readmissions, mortality, suffering delirium and functional status at discharge.

MATERIAL AND METHOD

A retrospective observational study of unicenter cohorts of 468 patients with HF, 220 from 2016 (old VC) and 248 from 2019 (new VC). The variables are: intervention in the first 48hours, surgical delay (hours), stay (days), stay less than 15 days, delirium, functional loss at discharge (Barthel prefracture scale less Barthel scale at discharge), readmission at one month, and mortality at admission, month and year.

RESULTS

Median age: 87.0 [interquartile range 8.0], mostly women (76.7%). Significantly, with the new VC, there was a greater number of patients operated on in the first 48hours (27,7% vs 36,8% p=0.036), less surgical delay (72.5 [47,5-110,5] vs 64.0 [42,0-88,0] p<0.001), shorter stay (10,0 [7,0-13,0] vs 8,0 [6,0-11,0] p<0.001), greater number of discharges in 15 days (78,2% vs 91,5% p<0.001), lower delirium (54,1% vs 43,5% p=0.023). No significant changes in readmissions, functional loss at discharge, mortality at admission, 3 months or year.

CONCLUSIONS

Updating the VC brings benefits to the patient (less surgical delay, equal functional status at discharge with fewer days of admission) and benefits in management (lower admission) without modifying mortality.

Impact of COVID-19 pandemic on treatment of colorectal cancer patients

BACKGROUND

Modifications to practice during COVID pandemic impacted health maintenance and treatment of cancer patients.

METHODS

We conducted a retrospective cohort study of all consecutive patients presenting to our institution with a new diagnosis of colorectal cancer pre-COVID (January 2017 to December 2019) and post-COVID (January to December 2020).

RESULTS

The total number of patients with a new diagnosis of CRC was 2196. The pre-COVID period had 1891 patients whereas post-COVID period had 305. The median number of patients diagnosed with CRC per month was 50 and 35.5 pre and post-COVID, respectively. Time to treatment initiation was similar with no difference in stage at presentation for the pre and post-COVID periods.

CONCLUSION

There was a significant decrease in colorectal cancer diagnosis number and rate (p < 0.01) during the COVID era with no difference in staging at diagnosis or time to treatment initiation.

A fuzzy delay-bandwidth guaranteed routing algorithm for video conferencing services over SDN networks

Video conferencing is one of the advanced technologies for users that allows online communication despite long distances. High quality communication and ongoing support for the principles of video conferencing service that can be achieved through Software-Defined Networking (SDN). SDN is a new architecture for computer networks that separates the control plane from the data plane to improve network resources and reduce operating costs. All routing decisions and control mechanisms are made by a device called a controller. Traffic engineering can be well implemented in SDN because the entire network topology is known to the controller. Considering SDN features, user requests can be dynamically routed according to current network status and Quality of Service (QoS) requirements. In general, the purpose of SDN routing algorithms is to maximize the acceptance rate of user requests by considering QoS requirements. In this literature, most routing studies to provide satisfactory video conferencing services have focused solely on bandwidth. Nevertheless, some studies have considered both delay and bandwidth constraints. In this paper, a Fuzzy Delay-Bandwidth Guaranteed Routing (FDBGR) algorithm is proposed that considers both delay and bandwidth constraints in routing. The proposed fuzzy system is based on rules that can postpone requests with high resource demands. Also, the purpose of the FDBGR is to distribute the network workload evenly for all requests, where this is done by maintaining the capacity to accept future requests. The combination of conventional routing algorithms and SDN provides remarkable improvements in mobility, scalability and the overall performance of the networks. Simulations are performed on different scenarios to evaluate the performance of the FDBGR compared to state-of-the-art methods. Besides, FDBGR has been compared with a number of most related previous works such as H-MCOP, MH-MCOP, QoMRA, QROUTE and REDO based on criteria such as number of accepted requests, average path length, energy consumption, load balancing, and average delay. The simulation results clearly prove the superiority of the proposed algorithm with an average delay of 48 ms in different topologies for video conferencing applications.

Trends in vaccination schedules and up-to-date status of children 19-35 months, United States, 2015-2020

OBJECTIVES

To estimate trends in, and factors associated with, vaccination patterns and up-to-date immunization status of U.S. children by 19 to 35 months of age.

METHODS

Data from the 2015 to 2020 National Immunization Surveys were used to assess trends in vaccination patterns, up-to-date status, and zero vaccination status of U.S. children by 19-35 months. Vaccination patterns were categorized as: 1) recommended, 2) alternate, or 3) unknown or unclassifiable. Multivariable analyses were conducted to examine factors associated with each vaccination pattern and up-to-date status for all recommended vaccines.

RESULTS

From 2015 to 2020, the proportion of U.S. children completing the recommended schedule increased from 62.5% to 69.4%, alternative schedule decreased from 21.6% to 16.2%, and unknown or unclassifiable schedules decreased from 15.9% to 14.3%. In addition, being not up-to-date decreased from 39.7% to 35.6%. There was no change in the percentage of children receiving zero vaccinations from 2015 to 2020 (0.9% to 0.9%). Respondents with lower household income or who were uninsured were more likely to follow an alternate or unknown/unclassifiable schedule, or not be up-to-date with vaccines.

CONCLUSION

Following any schedule other than the recommended schedule was associated with not being up-to-date on immunizations. Increased efforts to catch up on recommended vaccines is important for protecting children's health. Further efforts should be made to improve timely adherence to recommended vaccination schedules, particularly among populations with the largest disparities in coverage through a tailored approach to increase confidence in and access to vaccines.

Optimal control strategy analysis for an human-animal brucellosis infection model with multiple delays

Firstly, we consider an animal-human infection model of brucellosis with three distributed delays, representing the latent period of brucellosis in infected animal and human population and the survival time of brucella in the environment, respectively. The equilibrium points and basic reproduction number R 0 are calculated. By building appropriate Lyapunov functionals and applying LaSalle's invariance principle, the sufficient conditions for global asymptotic stability of two equilibria are given. Secondly, by introducing four control variables, we set the corresponding optimal control model and drive the first order necessary conditions for the existence of optimal control solution. Finally, we perform several numerical simulations to validate our theoretical results and show effects of different control strategies.

[Lawsuits related to delays in the investigation and treatment of coronary artery diseases]

Coronary disease results from the slow formation of atherosclerotic plaque, accelerated by plaque ruptures that make it serious. Cardiologists have many explorations, but with a lead time that can take several weeks. The organization of a revascularization can sometimes also be long. The medico-legal analysis reports frequent cases of acceleration of the disease in this interval, which can lead to death. It is then necessary to stratify the individual risk of each patient, if this delay is accepted. However, it is imperative to give instructions in case of the development of symptoms, remembering that at any time, it is sometimes necessary to call the emergency services (911 or others). Care teams must ensure that a process for receiving calls is organized during this period. It is sometimes preferable for the cardiologist to make the appointment personally or for him to opt directly for a coronary angiogram from the outset, if his clinical conviction is strong. It is with a complete strategy that we can reduce the risk of a medical accident and therefore of a complaint.

Reasons for delay in accessing free treatment of obstetric fistula in South-East Nigeria - A qualitative study

Obstetric fistula continues to be a menace in Nigeria and other low- and middle-income countries. The national policy for its elimination makes surgical repair free in dedicated national centres. However, the majority of the clients present late for repair. The aim of the study was to explore the reasons for this delay in seeking treatment. It was a qualitative (exploratory) study carried out at the National Obstetric Fistula Centre (NOFIC), Abakaliki, Nigeria among obstetric fistula patients who presented for treatment with a duration of leakage of over six months. A consecutive sampling technique was used for patient recruitment. Data was collected from twenty patients using in-depth interviews. Thematic analysis of the responses and recurring patterns was done, with themes illustrated using the word cloud. The mean age of the participants was 37.1 years (range = 21-75 years) while the mean duration of leakage was 64.3 months (range = 8-564 months). Reasons for delay in accessing treatment of obstetric fistula were lack of awareness of the availability of free treatment in a specialized centre, delay in referral from index health care facilities, wrong information from health care workers, failed repairs at other health facilities, secondary delay due to transportation challenges, cultural beliefs and other issues peculiar to the patients. The commonest reason for the delay in accessing treatment for obstetric fistula is a lack of awareness on the part of patients, the public, and health workers. We recommend improved campaigns, advocacy, and community mobilization.

Bifurcation analysis for a single population model with advection

In this paper, the dynamics of a single population model with a general growth function is investigated in an advective environment. We show the existence of a nonconstant positive steady state, and give sufficient conditions for the occurrence of a Hopf bifurcation at the positive steady state. Moreover, the theoretical results are applied to the diffusive Nicholson's blowflies and Mackey-Glass's models with advection and delay, respectively. We numerically show that the population density decreases as the increase of advection rate or death rate, and a delay-induced Hopf bifurcation is more likely to occur with small advection or low mortality rate.

Dynamics of a delayed rumor spreading model with discontinuous threshold control

In this paper, we studied a delayed rumor spreading model with discontinuous threshold control. First, we studied the existence of equilibria of the subsystem. Regarding the delay as bifurcating parameter, the local asymptotic stability and Hopf bifurcation of the positive equilibrium are discussed by analyzing the corresponding characteristic equations of linearized systems. Then, we studied the existence of the sliding mode and analyzed the existence of the tangent equilibria, boundary equilibria, regular equilibria, and the stability of the pseudo-equilibrium. Finally, we provide some numerical simulations to verify the theoretical results.

Pattern mechanism in stochastic SIR networks with ER connectivity

The diffusion of the susceptible and infected is a vital factor in spreading infectious diseases. However, the previous SIR networks cannot explain the dynamical mechanism of periodic behavior and endemic diseases. Here, we incorporate the diffusion and network effect into the SIR model and describes the mechanism of periodic behavior and endemic diseases through wavenumber and saddle-node bifurcation. We also introduce the standard network structured entropy (NSE) and demonstrate diffusion effect could induce the saddle-node bifurcation and Turing instability. Then we reveal the mechanism of the periodic outbreak and endemic diseases by the mean-field method. We provide the Turing instability condition through wavenumber in this network-organized SIR model. In the end, the data from COVID-19 authenticated the theoretical results.

A temporal analysis on patient and health service delays in pulmonary tuberculosis in Portugal: inter and intra‑regional differences and in(equalities) between gender and age

BACKGROUND

Tuberculosis (TB) diagnosis and treatment delays increase the period of infectiousness, making TB control difficult and increasing the fatality rates. This study aimed to determine the evolution of health care service delay (time between the patient's first contact with the health service and the diagnosis/start of treatment) and patient delay (time between onset symptoms date and the date of first contact with health services) for Pulmonary Tuberculosis (PTB) in Portugal between 2008 and 2017 across different regions, age groups and gender.

METHODS

An exploratory analysis was performed, trends of both delays were studied, and 36 months forecasts were generated. We used the permutation test to test differences between groups and the Seasonal and Trend decomposition using Loess (STL) method and Autoregressive Integrated Moving Average (ARIMA) models for forecasting for both Health and Patient delays. We used data from notified PTB cases in mainland Portugal between 2008 and 2017, provided by the national surveillance system.

RESULTS

Health delays remained relatively constant while patient delays increased. Females had significantly higher health delays in some regions. Individuals older than 64 had higher health delays than younger individuals, while patient delay for working-age individuals between 15 and 64 years old, presents higher patient delay.

CONCLUSIONS

Forecasts presage that the upward trend of the delays is unlikely to fall in the coming years. It is important to understand the evolution of the delays and predict how these will evolve. Our understanding of the delays behaviours will contribute to better health policies and resources allocation.

Drugs Used in Circadian Sleep-Wake Rhythm Disturbances

This article focuses on melatonin and other melatonin receptor agonists and summarizes their circadian phase shifting and sleep-enhancing properties, along with their associated possible safety concerns. The circadian system and circadian rhythm sleep-wake disorders are described, along with the latest American Academy of Sleep Medicine recommendations for the use of exogenous melatonin in treating them. In addition, the practical aspects of using exogenous melatonin obtainable over the counter in the United States, consideration of the effects of concomitant light exposure, and assessing treatment response are discussed.

Microsurgical treatment of ruptured aneurysms beyond 72 hours after rupture: implications for advanced management

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) patients admitted to primary stroke centers are often transferred to neurosurgical and endovascular services at tertiary centers. The effect on microsurgical outcomes of the resultant delay in treatment is unknown. We evaluated microsurgical aSAH treatment > 72 h after the ictus.

METHODS

All aSAH patients treated at a single tertiary center between August 1, 2007, and July 31, 2019, were retrospectively reviewed. The additional inclusion criterion was the availability of treatment data relative to time of bleed. Patients were grouped based on bleed-to-treatment time as having acute treatment (on or before postbleed day [PBD] 3) or delayed treatment (on or after PBD 4). Propensity adjustments were used to correct for statistically significant confounding covariables.

RESULTS

Among 956 aSAH patients, 92 (10%) received delayed surgical treatment (delayed group), and 864 (90%) received acute endovascular or surgical treatment (acute group). Reruptures occurred in 3% (26/864) of the acute group and 1% (1/92) of the delayed group (p = 0.51). After propensity adjustments, the odds of residual aneurysm (OR = 0.09; 95% CI = 0.04-0.17; p < 0.001) or retreatment (OR = 0.14; 95% CI = 0.06-0.29; p < 0.001) was significantly lower among the delayed group. The OR was 0.50 for rerupture, after propensity adjustments, in the delayed setting (p = 0.03). Mean Glasgow Coma Scale scores at admission in the acute and delayed groups were 11.5 and 13.2, respectively (p < 0.001).

CONCLUSIONS

Delayed microsurgical management of aSAH, if required for definitive treatment, appeared to be noninferior with respect to retreatment, residual, and rerupture events in our cohort after adjusting for initial disease severity and significant confounding variables.

The effect of the number of biopsies on the delay in the time from the delivery of mammography results to breast cancer histopathological diagnosis

PURPOSE

The delay in the time (in calendar days) from the delivery of mammography results to histopathological breast cancer (BC) diagnosis could be associated with more advanced clinical stages, a worse prognosis and higher mortality. Therefore, we assessed the association between the number of biopsies and the delay in the time (in calendar days) from the delivery of mammography results to histopathological BC.

METHODS

A survey was performed on 563 women aged between 35 and 69 years with histopathologically confirmed BC who attended 11 Mexican hospitals.

RESULTS

After adjusting for potential confounders, the odds of having a delay in the time (in calendar days) from the delivery of mammography results to histopathological BC diagnosis (≥ 60 days) among women with ≥ 3 biopsies were 2.99 times the odds of those who had only one biopsy (95% CI 1.35, 6.63).

CONCLUSION

The number of biopsies should be considered as a predictor of the time delay between the delivery of the mammography result and the diagnostic result.

Predictors and outcome of time to presentation among critically ill paediatric patients at Emergency Department of Muhimbili National Hospital, Dar es Salaam, Tanzania

Background

Mortality among under-five children in Tanzania remains high. While early presentation for treatment increases likelihood of survival, delays to care are common and factors causing delay to presentation among critically ill children are unknown. In this study delay was defined as presentation to the emergency department of tertially hospital i.e. Muhimbili National Hospital, more than 48 h from the onset of the index illness.

Methodology

This was a prospective cohort study of critically ill children aged 28 days to 14 years attending emergency department at Muhimbili National Hospital in Tanzania from September 2019 to January 2020. We documented demographics, time to ED presentation, ED interventions and 30-day outcome. The primary outcome was the association of delay with mortality and secondary outcomes were predictors of delay among critically ill paediatric patients.

Logistic regression and relative risk were calculated to measure the strength of the predictor and the relationship between delay and mortality respectively.

Results

We enrolled 440 (59.1%) critically ill children, their median age was 12 [IQR = 9–60] months and 63.9% were males. The median time to Emergency Department arrival was 3 days [IQR = 1–5] and more than half (56.6%) of critically ill children presented to Emergency Department in > 48 h whereby being an infant, self-referral and belonging to poor family were independent predictors of delay. Infants and those referred from other facilities had 2.4(95% CI 1.4–4.0) and 1.8(95% CI 1.1–2.8) times increased odds of presenting late to the Emergency Department respectively. The overall 30-day in-hospital mortality was 26.5% in which those who presented late were 1.3 more likely to die than those who presented early (RR = 1.3, CI: 0.9–1.9). Majority died > 24 h of Emergency Department arrival (P-value = 0.021).

Conclusion

The risk of in-hospital mortality among children who presented to the ED later than 48 h after onset of illness was 1.3 times higher than for children who presented earlier than 48 h. It could be anywhere from 10% lower to 90% higher than the point estimate. However, the effect size was statistically not significant since the confidence interval included the null value Qualitative and time-motion studies are needed to evaluate the care pathway of critically ill pediatric patients to identify preventable delays in care.

Irregular delay of adjuvant chemotherapy correlated with poor outcome in stage II-III colorectal cancer

AIMS

Adjuvant chemotherapy (ACT) plays an important role in improving the survival of stage II-III colorectal cancer (CRC) patients after curative surgery. However, the prognostic role of irregular delay of ACT (IDacT) for these patients has been less studied.

MATERIALS AND METHODS

A total of 117 stage II-III CRC patients who underwent radical resection and received at least 3 months ACT were enrolled retrospectively. The significance of IDacT, including total delay (TD) and delay per cycle (DpC), in predicting disease-free survival (DFS) was determined using receiver operating characteristic curve (ROC) analysis. The survival differences between the TD, DpC-short and DpC-long subgroups were tested using Kaplan-Meier analysis, and risk factors for prognosis were determined using a Cox proportional hazards model.

RESULTS

Using 35.50 and 3.27 days as the optimal cut-off points for TD and DpC, respectively, ROC analysis revealed that TD and DpC had sensitivities of 43.60% and 59.00% and specificities of 83.30% and 62.80%, respectively, in predicting DFS (both P < 0.05). No differences in the clinicopathological parameters were found between the TD, DpC-short or -long subgroups except histological differentiation in different TD subgroups and combined T stages in different DpC subgroups (both P = 0.04). Patients in the TD or DpC-long group exhibited significantly worse survival than in the -short group (TD: Log rank = 9.11, P < 0.01; DpC: Log rank = 6.09, P = 0.01). DpC was an independent risk factor for prognosis (HR = 2.54, 95% CI: 1.32-4.88, P = 0.01).

CONCLUSIONS

IDacT had a profound effect on the outcome for stage II-III CRC. Although TD and DpC were significant for the prognosis, DpC was more robust, and patients who presented DpC for a long time had a significantly worse DFS.

Understanding the journeys of patients with an asthma exacerbation requiring urgent therapy at a primary care clinic

BACKGROUND

Asthma is a significant health issue in primary care. We examined the journeys of patients with asthma exacerbations requiring urgent therapy at a primary care clinic in Singapore.

METHODS

Face-to-face semi-structured interviews were conducted with patients who received urgent therapy for asthma exacerbation at a primary care clinic. Data collected was used to construct themes.

RESULTS

Fifteen multi-ethnic adult patients were recruited. Participants cited treatment cost, underuse of preventer medication, difficulties attending routine asthma care due to work, and stigma as barriers to asthma control. Reasons for delay in seeking urgent care for asthma were: inability to access medical care out of hours, competing priorities, perception that an exacerbation was 'not serious enough', difficulty recognizing symptoms of asthma exacerbation, and being tired or despondent. Participants were triggered to seek care due to failure of reliever inhalers, duration of symptoms, sleep disturbance, inability to work, or advice from others. During an exacerbation, participants often initiated other self-management measures besides using reliever medication. This included over-the-counter medications and non-pharmacological interventions (e.g. drinking water). Of the 15 patients interviewed, only one stepped up preventer inhaler adequately, according to their Asthma Action Plan (AAP).

CONCLUSIONS

In caring for patients with asthma, primary care providers should address patients' asthma self-management skills, such as recognizing symptoms of asthma exacerbations and regular preventer use, and provide clear instructions on how to respond to asthma symptoms (AAP). Minimizing direct (medication and consultation fees) and indirect costs (loss of earnings and adverse impact on employment prospects) are also important considerations.

Choices favoring cognitive effort in a foraging environment decrease when multiple forms of effort and delay are interleaved

Cognitive and physical effort are typically regarded as costly, but demands for effort also seemingly boost the appeal of prospects under certain conditions. One contextual factor that might influence choices for or against effort is the mix of different types of demand a decision maker encounters in a given environment. In two foraging experiments, participants encountered prospective rewards that required equally long intervals of cognitive effort, physical effort, or unfilled delay. Monetary offers varied per trial, and the two experiments differed in whether the type of effort or delay cost was the same on every trial, or varied across trials. When each participant faced only one type of cost, cognitive effort persistently produced the highest acceptance rate compared to trials with an equivalent period of either physical effort or unfilled delay. We theorized that if cognitive effort were intrinsically rewarding, we would observe the same pattern of preferences when participants foraged for varying cost types in addition to rewards. Contrary to this prediction, in the second experiment, an initially higher acceptance rate for cognitive effort trials disappeared over time amid an overall decline in acceptance rates as participants gained experience with all three conditions. Our results indicate that cognitive demands may reduce the discounting effect of delays, but not because decision makers assign intrinsic value to cognitive effort. Rather, the results suggest that a cognitive effort requirement might influence contextual factors such as subjective delay duration estimates, which can be recalibrated if multiple forms of demand are interleaved.

Numerical simulations of one- and two-dimensional stochastic neural field equations with delay

Neural Field Equations (NFE) are intended to model the synaptic interactions between neurons in a continuous neural network, called a neural field. This kind of integro-differential equations proved to be a useful tool to describe the spatiotemporal neuronal activity from a macroscopic point of view, allowing the study of a wide variety of neurobiological phenomena, such as the sensory stimuli processing. The present article aims to study the effects of additive noise in one- and two-dimensional neural fields, while taking into account finite axonal velocity and an external stimulus. A Galerkin-type method is presented, which applies Fast Fourier Transforms to optimise the computational effort required to solve these equations. The explicit Euler-Maruyama scheme is implemented to obtain the stochastic numerical solution. An open-source numerical solver written in Julia was developed to simulate the neural fields in study.

"I was Confused … and Still am" Barriers Impacting the Help-Seeking Pathway for an Autism Diagnosis in Urban North India: A Mixed Methods Study

Timely recognition of autism in children is integral to improve developmental outcomes. This study used mixed-methods (84 case-registers and 20 in-depth interviews with caregivers of children with a diagnosis of autism) to explore the extent to which the nature of parental concerns and prior knowledge of developmental disorders impact the time between symptom recognition and autism diagnosis, and the contextual family, societal and health-system related factors that impede the autism help-seeking pathway. Lack of awareness of age-appropriate child developmental milestones, apparent amongst the community and health professionals, contributed to a 1.5-year delay between parental concerns and autism diagnosis. Recommendations to shorten this help-seeking pathway include harnessing the potential of non-specialist workers to increase awareness and enable developmental monitoring of young children through scalable tools.

Management of etonogestrel implant migration into the pulmonary artery

OBJECTIVES

To evaluate the relationship between time since contraceptive implant placement and retrieval outcomes in patients with implant migration into the pulmonary artery.

STUDY DESIGN

We reviewed all cases of pulmonary artery implant migration referred to the Marie Lannelongue hospital from 2015 through 2020. Using our hospital database, we collected patients' clinical data and removal information to assess the success of therapeutic management according to the delay between implant insertion and removal.

RESULTS

We identified eight cases. Physicians located two in the upper and six in the lower lobe. Five patients had associated pulmonary symptoms, most commonly, chest pain and dyspnea. Physicians attempted an endovascular procedure in all cases with successful removal in three patients. In the five failures, angiography displayed arterial thrombosis distal to the implant. These patients had successful removal with an open mini-thoracotomy (<5 cm). None of the eight patients had serious post-operative complications.  For the three patients with successful endovascular retrieval, two had early diagnosis (≤ 3 months).

CONCLUSION

Endovascular approach with angiography should be performed as a first line treatment modality. Endothelialization and fibrosis within the vessel represent the principal limitations of endovascular strategy, but a retrieval could be attempted anyway with caution. In case of failure, an open approach is required.

IMPLICATIONS STATEMENT

When a migration into the pulmonary artery is diagnosed, health care professionals should refer patients as soon as possible to a tertiary center with a vascular surgery/interventional radiology and thoracic surgery departments.

Study of outcomes of delay in referral of patients with acute myocardial infarction

BACKGROUND

Delay in seeking medical help in patients with acute myocardial infarction (AMI) challenges the patients in terms of diagnosis and treatment. This study aimed to evaluate the outcomes of delay referral (≥12 h) in patients with AMI.

MATERIALS AND METHODS

In this retrospective cohort study, the medical records of 252 patients with AMI (2017-2019) admitted to Shahid Beheshti Hospital, Qom, Iran, was reviewed. Data collection tool was a researcher-made data sheet that included demographic characteristics, times, hospitalization costs, risk factors, history of heart disease, results of paraclinical tests, clinical information at the time of admission, and outcomes of delayed referral. Data were analyzed using t-test, Chi-square, Kaplan-Meier estimator, log-rank test, Cox regression by STATA, and SPSS (version 25).

RESULTS

The levels of troponin, creatine phosphokinase, lactate dehydrogenase were significantly higher in the delayed referral group (P < 0.05). After treatment, the cardiac ejection fraction was significantly different in the nondelayed referral (41.56 ± 9.16) and the delayed referral group (38.39 ± 11.01) (P < 0.001). There was no significant difference in the percentage of hospital deaths in the groups (P = 0.078).

CONCLUSION

Delayed referral of patients with AMI is associated with decreased physiological cardiac function, which complicates recovery for these patients.

Delay in making decision to seek care on institutional delivery and associated factors among postpartum mothers in South Gondar zone hospitals, 2020: A cross-sectional study

Background

Delay in seeking emergency obstetric care contributes to high maternal mortality and morbidity in developing countries. One of the major factors contributing to maternal death in developing countries is a delay in seeking emergency obstetric care. This study aimed to assess the proportion and associated factors of delay in deciding to seek emergency obstetric care on institutional delivery among postpartum mothers in the South Gondar zone hospitals, Ethiopia, 2020.

Methods

An institution-based cross-sectional study design was conducted from September to October 2020. A total of 650 postpartum mothers were recruited using a systematic random sampling technique. We collected the data through personal interviews with pretested semi-structured questionnaires. We used a logistic regression model to identify statistically significant independent variables, and entered the independent variables into multivariable logistic regression. The Adjusted Odds Ratio was used to identify associated variables with delay in deciding to seek emergency obstetric care, with a 95% confidence interval at P-value < 0.05.

Results

The proportion of delay in deciding to seek emergency obstetric care on institutional delivery was 36.3% (95% CI: 32.6–40.1). The mean age of the respondents was 27.23, with a standard deviation of 5.67. Mothers who reside in rural areas (AOR = 3.14,95%, CI:2.40–4.01), uneducated mothers (AOR = 3.62, 95%, CI:2.45–5.52), unplanned pregnancy (AOR: 2.01, 95% CI: 1.84–7.96), and no health facilities in Kebele (AOR: 1.62, 95% CI: 1.43–6.32) were significantly associated with delay in a decision to seek emergency obstetric care.

Conclusion

The proportion of delay in deciding to seek emergency obstetric care was 36.3% among postpartum mothers in the South Gondar zone hospitals. One of the factors contributing to maternal death is a delay in seeking emergency obstetric care in South Gondar zone. Pregnant mothers living in the rural area, unplanned pregnancy, uneducated mothers, no health facilities in Kebele were associated factors in the study area. Therefore, stakeholders must address them to reduce the proportion of delay in deciding to receive on-time obstetric care as per the standards.