Delay In Presentation Of Patients Research Articles

Treatment seeking experiences of ACS patients in Yogyakarta, Indonesia during COVID-19 pandemic: A qualitative study.

Delay in treatment seeking is recognized as a major contributor for Acute Coronary Syndrome (ACS) mortality in Indonesia. Despite the significance of timely treatment, decline in admission and delay in presentation of patients with ACS were consistently reported during the COVID-19 pandemic. These suggested that treatment seeking performance of patients during the pandemic might be different from the previous period. This qualitative study aimed to explore treatment seeking behaviour, barriers in seeking medical treatment, and experiences of patients with ACS in Yogyakarta, Indonesia during COVID-19 pandemic. In depth-interviews were carried out with 30 patients, who were hospitalized with ACS at one of the three selected hospitals in Yogyakarta during the pandemic period. Thematic analysis was performed to create vital explanations for treatment seeking practices of patients with ACS during pandemic. Three significant themes were identified: treatment seeking decisions, barriers in seeking medical treatment during COVID-19, and experiencing both good and bad impression from entering and staying in the hospital. The intensity of ACS symptoms and fear of COVID-19 infection dominated the delay in seeking medical treatment. Strict safety measures, religious belief, and fear of ACS helped patients overcome barriers and seek medical treatment during pandemic. ACS patients also had convenient medical care during the pandemic and believed medical staff would provide excellent care to them. However, visit restriction policy could cause psychological discomfort. Increase awareness of ACS symptoms and the risk of delays ACS treatment are essential to support patients' decisions to seek medical helps in a timely manner at any situations including pandemic. Interventions aim at alleviating psychological distress should also be designed and implemented to improve treatment experiences of ACS patients, who sought medical treatment during the pandemic crisis.

Analysis of Presentation Delay in Patients with Advanced Breast Cancer Visiting Dharmais National Cancer Hospital

Background: Breast cancer is still one of the significant causes of the increasing mortality rate due to cancer. Treatment of breast cancer patients was delayed by 66.34%. The majority of patients arrive at stages IIIB and IV and are therefore treated at an advanced stage. This study aimed to analyze the factors causing the arrival delay of breast cancer patients to Dharmais Cancer Hospital with advanced stages. Methods: A descriptive study with a qualitative approach was used as the research design. Indepth interviews and document reviews were used to collect data. In-depth interviews were conducted with 12 advanced-stage breast cancer patients. Thematic data analysis was performed by tracing and identifying the main topics of the entire interview process. The triangulation method was used to validate the data by conducting interviews with 4 patient families and 2 oncology surgeons, as well as document review. Results: The presentation delay of advanced breast cancer patients was analyzed based on the interpretation and recognition of symptoms. There was an attitude of ignoring when there were symptoms and not seeking treatment. On psychological factors, there was a feeling of fear after being diagnosed and a sense of worry in the treatment process. On socioeconomic factors, there was no early detection, lack of information on early detection, waiting time constraints, and the selection of alternative treatments. Conclusions: Late-stage breast cancer patients were drawn to Dharmais Cancer Hospital due to issues with the interpretation and experience of symptoms, psychological issues patients reported, and socioeconomic difficulties during treatment. As a result, patients must be given additional care to deal with late arrivals, especially in cases of advanced breast cancer.

Optometric Practice Patterns for Acute Central and Branch Retinal Artery Occlusion.

Optometrists are often the first providers to evaluate patients with acute vision loss and are often the first to diagnose a central retinal artery occlusion (CRAO). How quickly these patients present to the optometrist, are diagnosed, and referred for evaluation are major factors influencing the possibility of acute therapeutic intervention. Our aim was to survey the U.S. optometric community to determine current optometric practice patterns for management of CRAO. An anonymous seven-question survey was emailed in 2020 to the 5,101 members of the American Academy of Optometry and the 26,502 members of the American Optometric Association. Of 31,603 optometrists who were sent the survey, 1,926 responded (6.1%). Most respondents (1,392/1,919, 72.5%) worked in an optometry-predominant outpatient clinic and were less than 30 minutes from a certified stroke center (1,481/1,923, 77.0%). Ninety-eight percent (1,884/1,922) of respondents had diagnosed less than 5 CRAOs in the previous year, and 1,000/1,922 (52.0%) had not diagnosed a CRAO in the prior year. Of the optometrists who diagnosed at least one CRAO in the previous year, 661/922 (71.7%) evaluated these patients more than 4 hours after the onset of vision loss. Optometrists who diagnosed a CRAO or branch retinal artery occlusion referred patients to an emergency department (ED) affiliated with a certified stroke center (844/1,917, 44.0%), an outpatient ophthalmology clinic (764/1,917, 39.9%), an ED without a stroke center (250/1,917, 13.0%), an outpatient neurology clinic (20/1,917, 1.0%), or other (39/1,917, 2.0%); most (22/39, 56.4%) who responded "other" would refer to a primary care physician. Optometrists are likely the first providers to evaluate patients with acute vision loss, including from a retinal artery occlusion. However, only 6.1% of optometrists responded to our survey despite 2 reminder emails, likely reflecting the lack of exposure to acute retinal artery occlusions, and a potential lack of interest of optometrists in participating in research. Of the optometrists who reported evaluating a CRAO in the previous year, less than 29% saw the patient within 4 hours of vision loss. In addition, a large portion of optometrists are referring acute CRAO patients to outpatient ophthalmology clinics, delaying appropriate acute management. Therefore, it is imperative that optometrists and ophthalmologists are educated to view acute retinal arterial ischemia as an acute stroke and urgently refer these patients to an ED affiliated with a stroke center. The delay in patient presentation and these referral patterns make future clinical trials for acute CRAO challenging.

Abstract Number ‐ 31: No Mercy on Stroke Campaign: The Use of Pop Culture Icons to Raise Stroke Awareness

Introduction About 24–46% of acute ischemic strokes are due to large vessel occlusions1, however only a small fraction2,3 of thrombectomy eligible patients undergo emergent clot retrieval. Despite advances in thrombolytics and endovascular interventions, many patients are not candidates for emergent therapies due to delay in patient presentation, prehospital delay, triage delay and limited access to care. No Mercy on Stroke (NMOS) campaign aims to raise public stroke awareness by increasing social media footprint. Thereby enabling the general population with tools for earlier symptom detection, seeking rapid medical attention and fighting for legislature to improve prehospital networks. Methods Society of Vascular and Interventional Neurology (SVIN) launched NMOS campaign just prior to World Stroke Day (WSD) on October 25th, 2021 via Twitter. Pop culture icon and martialist Martin Kove launched the campaign as Sensei Kreese from the movie Cobra Kai in a video encouraging viewers to “strike fast and strike hard” when treating stroke. SVIN and Kove urged followers to spread the fight against stroke by sharing karate poses with hashtag #NoMercyOnStroke. Metrics such as social media reach, impact, location and others were extracted via Tweepsmap and Tweetbinder from October 25th, 2021 to August 20th, 2022. Results #NoMercyOnStroke was tweeted 716 times by 211 contributors4 across 19 countries and 77 cities5 for a potential reach of 374,200 people and potential impact of 2,051,908 people4. Tweet breakdown consisted of 126 original tweets and 590 retweets4. Engagements were primarily likes recorded at 2437, and followed by 97 replies and 55 quotes. Activity timeline was highest during week of WSD and accounted for majority exposure, however, there was another small peak in activity one month later. Top 3 countries involved were USA, Canada and India although USA accounted for 90.4% of all activity. Other countries include Mexico, Colombia, Spain, Egypt, Croatia, UK, Saudi Arabia, Kenya, Libya, Vietnam, Italy, Cuba, France, Peru, Chile and Venezuela5. Top associated hash tags were #worldstrokeday, #WSD and #alz0212465. Conclusions Use of pop culture icon as an advocate for stroke awareness greatly increased reach and impression of the NMOS campaign by touching nearly two million followers. Compared to raw data across three social media platforms for a similar campaign by Mission Thrombectomy called #BEFASTChallenge, #NoMercyOnStroke had exponentially more engagement with almost double the original posts and triple the retweets. Still, activity was concentrated around initial launch with minimal tail in the activity timeline. The overall impact of such campaigns on the end‐goal of decreasing the ratio of eligible thrombectomies to number of thrombectomies performed is yet to be uncovered. However, it is clear that larger campaigns involving celebrity influencers and community outreach are imperative to keeping the momentum of raising stroke awareness.

Impact of demographic factors on delayed presentation of oral cancers

Background: Oral cancer is a major health issue in India. The majority of patients with oral cancer present at an advanced stage. Objectives: We aimed to understand the factors responsible for delay in presentation of patients with oral cancer in rural areas. Materials and Methods: This questionnaire-based, cross-sectional study on patients with oral cancer was conducted in the head and neck surgical outpatient department of our tertiary care center at Homi Bhabha Cancer Hospital, Sangrur, between June and September 2021. A questionnaire consisting of 31 multiple choice questions was administered to consenting patients. The demographic and socio-economic profile of the patients, their knowledge of risk factors, and their symptomatology, attitude towards cancer management, access to cancer care, and knowledge about cancer treatment and its outcomes were assessed. Results: A total of 200 patients were included; 70% were men. About 60% of the participants had to travel more than 100 km to reach our center. About 50% of the patients were addicted to tobacco in some form. Only 30% of the participants were aware of the risk factors for oral cancer. The median time between symptom onset and seeking any medical consultation was 120 days, whereas the median time between symptom onset and cancer diagnosis was 165 days. About 75% of patients initially consulted an alternative medicine practitioner, and 90% took some form of alternative treatment before consulting a cancer specialist. Around 80% considered alternative medicines to be an effective form of cancer treatment. Conclusion: Our study shows a gross lack of awareness and multiple misconceptions that prevail in the rural population. Increasing public awareness, training primary healthcare workers to pick up on early signs of oral cancer, promoting tobacco cessation activities, and teaching oral self-examination and its importance to people can help tackle the problem of delayed presentation of oral cancers.

Delay in presentation of patients with rheumatoid arthritis for specialty care

The Journal of the Ceylon College of Physicians (JCCP) is a peer-reviewed, open access journal published bi-annually by the Ceylon College of Physicians (CCP) in the last week of June and December.The objective of the Journal is to promote good clinical practice and influence policy making across the medical world through publication of original research and peer reviewed articles on current issues and to foster responsible and balanced debate on issues that affect medicine and health care in Sri Lanka. Contributions to the JCCP reflect its national and multidisciplinary readership and include current thinking across a range of medical specialties.

Outcomes of patients with ST-segment myocardial infarction admitted during the COVID-19 pandemic : Aprospective, observational study from atertiary care center in Germany.

BackgroundSince the beginning of the SARS-CoV‑2 outbreak, healthcare professionals reported that patients admitted with ST-segment myocardial infarction (STEMI) were in worse condition compared to STEMI patients admitted before the outbreak. However, data on their outcomes are sparse.MethodsWe conducted a prospective, observational, cohort study of STEMI patients admitted during the COVID-19 pandemic from March 21, 2020 to July 31, 2020 (COVID-19 group). Clinical outcomes, 30-day mortality, and reasons potentially related to a delay in patient presentation were assessed and compared with STEMI patients admitted between November 1, 2019 and March 20, 2020 (pre-COVID-19 group).ResultsA total of 124 patients were enrolled, comprising 57 patients in the pre-COVID-19 group and 67 patients in the COVID-19 group. Significantly more patients in the COVID-19 group had a time to first medical contact of greater than 24 h. Additionally, those admitted during the pandemic had a significantly lower left ventricular ejection fraction (LVEF), worse thrombolysis in myocardial infarction (TIMI) flow, received circulatory support significantly more often, and had a significantly higher 30-day mortality. Furthermore, significantly more patients stated that “information by the media” made them hesitate to contact the emergency medical services as soon as possible.ConclusionHere, we show that STEMI patients admitted during the COVID-19 pandemic had significantly prolonged times to first medical contact, were in worse condition at admission, and had an increased 30-day mortality. Additionally, we found that “information by the media” made patients during COVID-19 hesitate to contact the emergency medical services. Consequently, public health strategies have to be developed to avoid potential excess mortality of STEMI patients during the pandemic.Supplementary InformationThe online version of this article (10.1007/s00059-021-05058-7) contains supplementary material, which is available to authorized users.

Waiting Times for Prostate Cancer Diagnosis in a Nigerian Population.

Background Prostate biopsy remains an important surgical procedure in the diagnostic pathway for prostate cancer, but access to prostate biopsy service is poorly studied in the Nigerian population. While there has been a well-documented delay in patient presentation with prostate cancer in Nigeria, little is however known about how long patients wait to have a histological diagnosis of prostate cancer and start treatment after presenting at Nigerian hospitals. Method This was a descriptive retrospective study to document the specific duration of the various timelines in getting a diagnosis of prostate cancer at the Lagos State University Teaching Hospital, Ikeja, Nigeria. Results There were 270 patients. The mean age was 69.50 ± 8.03 years (range 45-90). The mean PSA at presentation was 563.2 ± 1879.2 ng/ml (range 2.05-15400), and the median PSA was 49.3 ng/ml. The median waiting times were (i) 10 days from referral to presentation; (ii) 30 days from presentation to biopsy; (iii) 24 days from biopsy to review of histology; (iv) 1 day from histology review to discussion/planning of treatment. The median overall waiting time from referral to treatment was 103 days. The mean time from presentation to biopsy was significantly shorter for patients with PSA of ≥50 ng/ml compared to those with PSA < 50 ng/ml. p = 0.048. Overall, the median time from biopsy to histology was significantly shorter for patients whose specimens were processed in private laboratories (17 days) compared to those whose specimens were processed at the teaching hospital laboratory (30 days), p ≤ 0.001. Conclusion There is a significant delay within the health care system in getting a prostate cancer diagnosis in the Nigerian population studied. The major points of the identified delay were the waiting time from patient presentation to having a biopsy done and the histology report waiting time.

Left ventricular free wall rupture as a result of delayed presentation of an inferior ST-elevation myocardial infarction due to fear of COVID-19: case report

BackgroundLeft ventricular free wall rupture (LVFWR) is a rare complication after myocardial infarction and usually occurs 1 to 4 days after the infarct. Over the past decade, the overall incidence of LVFWR has decreased given the advancements in reperfusion therapies. However, during the COVID-19 pandemic, there has been a significant delay in hospital presentation of patients suffering myocardial infarctions, leading to a higher incidence of mechanical complications from myocardial infarctions such as LVFWR.Case presentationWe present a case in which a patient suffered a LVFWR as a mechanical complication from myocardial infarction due to delay in seeking care over fear of contracting COVID-19 from the medical setting. The patient had been having chest pain for a few days but refused to seek medical care due to fear of contracting COVID-19 from within the medical setting. He eventually suffered a cardiac arrest at home from a massive inferior myocardial infarction and found to be in cardiac tamponade from a left ventricular perforation. He was emergently taken to the operating room to attempt to repair the rupture but he ultimately expired on the operating table.ConclusionsThe occurrence of LVFWR has been on a more significant rise over the course of the COVID-19 pandemic as patients delay seeking care over fear of contracting COVID-19 from within the medical setting. Clinicians should consider mechanical complications of MI when patients present as an out-of-hospital cardiac arrest, particularly during the COVID-19 pandemic, as delay in seeking care is often the exacerbating factor.

Profile of patients receiving intravitreal anti-vascular endothelial growth factor injections during COVID-19-related lockdown.

Purpose:The aim of this study was to analyze the impact on vision due to delay in presentation of patients requiring intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections, consequent to COVID-19-related travel restrictions.Methods:Data were collected retrospectively of patients who received anti-VEGF injections during four months of the COVID-19 pandemic. Visual acuities, indication for treatment were noted along with basic demographic characteristics.Results:Data were analyzed for 303 eyes of 263 patients. The indication for treatment was age-related macular degeneration (AMD) in 60 eyes (19.8%), while 162 eyes (53.5%) had Diabetic Macular Edema, 71 eyes (23.4%) had Retinal Vein Occlusion and 10 eyes (3.3%) had other diagnosis. The visual acuity in the treatment naïve eyes (Group A, n = 168) was significantly worse (P < 0.001) than those who presented for retreatment (Group B, n = 135). In Group B, there was a significant decline in vision for the entire cohort (P = 0.009) and those with AMD (P = 0.036). Those in Group B presented at a mean interval of 19.1 ± 10.6 (range, 4–64) weeks for retreatment.Conclusion:The COVID-19 pandemic has led to a delay in patients receiving anti-VEGF injections. The visual acuity is worse in both treatment naïve as well as those requiring retreatment. This could have long-term impact on vision of patients requiring this vision preserving treatment.

Letter: May Cooler Heads Prevail During a Pandemic: Stroke in COVID-19 Patients or COVID-19 in Stroke Patients?

To the Editor: Along with the novel coronavirus (COVID-19) pandemic comes a growing public fear of its severe complications and possible central nervous system involvement.1 Neurointerventionalists in COVID-19 prevalent regions raised an alarm toward an increased risk of acute large-vessel-occlusion stroke in COVID-19 patients. It has been proposed that large-vessel stroke could be the presenting symptom of COVID-19 in younger patients.2 This has brought upon heightened fear and anxiety among younger adults. Yet, the scientific literature lacks evidence supporting a higher risk of stroke with COVID-19 in mildly symptomatic patients, or providing a causal link between COVID-19 and large-vessel stroke in younger adults. Systemic inflammation that may occur after severe COVID-19 infection promotes a prothrombotic state that may predispose to thrombotic events, including stroke. However, stroke as the presenting complaint of COVID-19 patients with otherwise mild or no systemic disease raises concerns over COVID-19 being a bystander given its high prevalence in reporting regions.2 In a report of 5 patients younger than 50 yr, 2 of whom were underscored for having no stroke comorbidities, stroke was described as a presenting symptom of young COVID-19 patients.2 This led to a robust news coverage to alarm young healthy adults of stroke secondary to COVID-19. We find this alarm unfounded. Stroke is less common, but not rare, in young adults. The findings presented remain anecdotal and lack the methodological and statistical rigor to claim that COVID-19 infection increases stroke risk in the youth or that stroke could be the presenting symptom of COVID-19. In fact, our Stroke Thrombectomy and Aneurysm Registry reports that 12% of 5000 patients undergoing thrombectomy are younger than 50 yr.3,4 Of young adults, 47% had no stroke comorbidity. Similarly, 8% of patients from the stroke thrombectomy trials were under 50 yr.5 Therefore, anecdotal reports of small case series of stroke in younger adults with COVID-19 do not reach the threshold, to date, to raise public fear among young adults. Although sounding early alarms during outbreaks may prevent delayed responses to novel threats, sufficient evidence is required to limit unnecessary burdens of the alarm itself on the healthcare system and public. Efforts to increase stroke awareness are always commended to avoid delay in patient presentation; however, in times of uncertainty and anxiety, it is critical to minimize misinformation that can have profound ramifications, even if it were well intended. Physicians are encouraged to seek sound medical evidence during care for patients and news appearances. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

Locally advanced breast cancer: an observational study for the delay in presentation of patients

Background: Breast cancer is the most common cause of cancer in women and cancer related mortality all over the world. There is strong evidence that delayed diagnosis of breast cancer is associated with poor survival. At our center most of the patients with breast cancer presented as locally advanced breast cancer (LABC) which drew our attention to find out the reasons of delay and its association with different socio-demographic variables.Methods: We enrolled 50 histologically proven cases of LABC in this study. With help of semi structured interview, questions were asked from each patient which could reflect their understanding about the disease to find likely reasons for their delayed presentation, including socioeconomic status.Results: In present study most of our patients were more than 45 years, married. 88% presented late due to unawareness and ignorance about nature and severity of breast cancer disease, 86% had financial issues, 64% had shyness as reason, 20% wasted time by taking alternative treatment, 52% presented late due to painless lump; 30% had fear of losing breast, 18% didn’t get support from family, 4% presented late due to other reasons.Conclusions: Awareness and knowledge of breast cancer was found to be poor amongst sufferers prior to their diagnosis, making it important reason for delayed presentation. Other significant factors being socioeconomic status and education. The need for increased awareness and use of screening practices was identified to be essential for early diagnosis of the disease and for improved outcomes.

1568 Don't Skip the Retroflexion: A Case of Disseminated Anorectal Mucosal Melanoma

INTRODUCTION: Less than 4% of melanomas are of mucosal origin with primary anorectal mucosal melanomas comprising a small subset. Mucosal melanomas are often diagnosed late due to delay in patient presentation and obscured tumor origins noting a more aggressive behavior and less favorable prognosis when compared to cutaneous melanomas. We present a case of metastatic anorectal mucosal melanoma with a negative colonoscopy 1-year prior. CASE DESCRIPTION/METHODS: A 68 year-old female presented to the hospital with a history of several months of intermittent fecal impaction complicated by sporadic outlet type rectal bleeding and a negative colonoscopy 1-year prior. She endorsed progressive anorexia and a 20 lb. weight loss over the last few months. She was hemodynamically stable with normal hemoglobin level. CT imaging depicted multiple lesions in the liver and lungs concerning for metastatic disease. A colonoscopy was repeated and revealed a rigid mass on rectal exam and granular nodularity with ulceration in the rectum at the dentate line on retroflexion (Figure 1). Excisional biopsy confirmed mucosal melanoma. Same session endoscopic ultrasound showed several lesions in the left lobe of the liver with FNA demonstrating malignant melanoma (Figures 2 and 3). MRI revealed primary tumor involvement of the anal canal and rectum in addition to metastases to the liver, lungs, and lymph nodes. The patient was diagnosed with T4N1M1, stage IV anorectal mucosal melanoma (BRAF/C-KIT negative) and was recommended to undergo ipilimumab and nivolumab (I3/N1) immunotherapy with palliative radiation. DISCUSSION: Anorectal mucosal melanomas occur infrequently, but at the time of diagnosis, are more likely to be metastatic with poor prognoses. Rectal bleeding is the most common symptom, and diagnosis is often seen in fifth to seventh decade of life. This case is a prime example of not only the aggressive nature of anorectal mucosal melanoma presenting with disseminated disease despite normal colonoscopy 1-year prior but also of the significance of the rectal exam and retroflexion maneuver during colonoscopy.

Presumed tuberculous uveitis in a university-based tertiary referral center in Saudi Arabia.

To describe clinical characteristics and outcomes of treatment in patients with presumed tuberculous uveitis (PTU). All patients diagnosed with PTU between January 1996 and March 2013 were reviewed. The diagnosis was made when clinical findings were consistent with possible intraocular tuberculosis, strongly positive purified protein derivative (PPD) skin test result, and response to anti-tuberculous therapy with no other cause of uveitis as suggested by history, symptoms, or ancillary testing. Ninety patients (141 eyes) were identified. There were 43 males (47.3%) and 47 females (52.7%). Mean age was 48.2±14.4years. Mean duration of symptoms prior to presentation was 6.7±8.3months. Ten eyes (7.1%) had anterior uveitis, 18 eyes (12.8%) had intermediate uveitis, 34 eyes (24.1%) had posterior uveitis, and 79 eyes (56%) had panuveitis. Macular edema was present in 33.3% of the eyes at presentation. All patients received anti-tuberculous therapy and systemic corticosteroids. Mean follow-up after completion of therapy was 36±2.5months. Only 2 eyes developed recurrent inflammation after treatment completion. At last follow-up, all eyes showed resolution of inflammation, associated with significant improvement in visual acuity. There was a significant positive correlation between initial and final VA. Eyes that had macular edema at presentation showed a significant reduction in central macular thickness at final follow-up. There is delay in presentation of patients with PTU. The most common anatomic diagnosis was panuveitis. Treatment with anti-tuberculous therapy combined with systemic corticosteroids resulted in resolution of inflammation and macular edema with significant improvement in visual acuity.

Time to Presentation Is Associated with Clinical Outcome in Hemispheric Stroke Patients Deemed Ineligible for Recanalization Therapy

Delayed thrombolysis adversely impacts functional outcome after stroke. Therefore, great efforts are undertaken to reduce delay in patient presentation and initiate treatment as quickly as possible. However, little is known regarding the impact of time to presentation (TTP) on outcome in patients who are ineligible for acute stroke therapy. Thus, we sought to determine whether the TTP is associated with the 90-day outcome irrespective of eligibility for acute recanalization therapy. We retrospectively analyzed 258 consecutive acute ischemic stroke patients evaluated between January 2013 and February 2014. Multivariable logistic regression was used to determine whether a greater TTP is independently associated with a poor 90-day outcome defined as a modified Rankin scale (mRS) score of 3-6. In the unadjusted analyses, the TTP was inversely correlated with transfer from an acute facility (r = -.126, P = .043), cardioembolic stroke etiology (r = -.146, P = .019), and acute recanalization therapy (r = .-412, P < .001). Conversely, a longer TTP was correlated with a worse 90-day mRS score (r = .127, P = .045). After adjustment, the TTP (P = .019), age (P < .001), female sex (P = .001), National Institutes of Health Stroke Scale score (P < .001), preadmission mRS score (P = .001), atrial fibrillation (P < .001), and infarct volume (P < .001) were independently associated with a poor 90-day outcome. Importantly, a longer TTP (odds ratio 1.016, 95% confidence interval 1.001-1.032, P = .036) remained independently associated with the 90-day outcome when we restricted the analyses to patients ineligible for acute intravenous and endovascular recanalization therapies. Each hour delay in the TTP decreased chances for good outcome by approximately 2% independent of patient eligibility for acute recanalization therapies.

LO026: Outcomes of a provincial cardiac reperfusion strategy: a population-based, retrospective cohort study

Introduction: Nova Scotia has a province wide reperfusion strategy for the treatment of patients presenting with acute ST-Elevation Myocardial Infarction (STEMI). Patients are referred for primary percutaneous coronary intervention (PPCI) if a first medical contact to device time can be achieved within 90 to 120 minutes; otherwise, fibrinolytic therapy is administered, as per guideline recommendations. Since 2011, Nova Scotian paramedics have been providing prehospital fibrinolysis (PHF) and prehospital catheterization (cath) lab activation for STEMI patients outside and within the PPCI catchment area, respectively. Patients who received fibrinolysis are transferred to a PCI facility if rescue PCI is required or if there are other indications for urgent intervention. This province wide approach is unique and the objective of this retrospective cohort study is to compare the impact of this approach on the primary outcome of 30-day mortality. Methods: For the study period, July 2011 to July 2013, STEMI patients who were diagnosed prehospital or in the ED who subsequently underwent reperfusion therapy were identified in the Emergency Health Services (EHS), Cardiovascular Information Systems (CVIS) and Cardiovascular Health Nova Scotia (CVHNS) databases. Baseline demographics and outcomes were then compared according to the treatment received: 1) PHF; 2) ED Fibrinolysis (EDF); 3) prehospital activated PPCI (EHS PPCI); and 4) ED activated PPCI (ED PPCI). Results: There were a total of 1107 STEMI patients identified during the study period, of whom 742 received lytic therapy (146 PHF; 596 EDF) and 332 underwent PPCI (202 EHS PPCI; 130 ED PPCI). Demographic variables were similar across the groups. The primary outcome of 30-day mortality was not significantly different across groups: 5 (3%) in PHF, 26 (4%) in EDF, 8 (4%) in EHS to PPCI and 2 (2%) in ED to PPCI. The number of rescue PCIs was 28 (19%) in PHF and 102 (17%) in EDF. Other outcomes (key timestamps) are pending. Conclusion: Our results show that the 30-day mortality was lowest for patients undergoing PPCI and slightly less for patients receiving pre-hospital fibrinolytic compared to those receiving ED fibrinolytic with no difference in the proportion requiring subsequent rescue PCI. The majority of patients in rural areas received EDF as opposed to PHF; pending results will show if this represents a delay in patient presentation after symptom onset.

A Pilot Study on Factors Associated with Presentation Delay in Patients Affected with Head and Neck Cancers.

Patient delay can contribute to a poor outcome in the management of head and neck cancers (HNC). The main objective of the present study was to investigate the factors associated with patient delay in our population. Patients with cancers of the head and neck attending a regional cancer center of North East India were consecutively interviewed during the period from June 2014 to November 2014. The participation of patients was voluntary. The questionnaire included information on age, gender, residential status, educational qualification, monthly family income, any family history of cancer, and history of prior awareness on cancer from television (TV) program and awareness program. Of 311 (n) patients, with an age range of 14-88 years (mean 55.4 years), 81.7% were males and 18.3% females (M:F=4.4). The overall median delay was 90 days (range=7 days-365 days), in illiterate patients the median delay was 90 days and 60 days in literate patients (P=0.002), the median delay in patients who had watched cancer awareness program on TV was 60 days and in patients who were unaware about cancer information from TV program had a median delay of 90 days (p=0.00021) and delay of <10 weeks was seen in 139 (44.6%) patients, a delay of 10-20 weeks in 98 (31.5%) patients, and a delay of 20-30 weeks in 63 (20.2%) patients. Education and awareness had a significant impact in reduction of median patient delay in our HNC cases.

Diabetic foot disease in Ethiopian patients: A hospital based study

Background: Ulcers of the foot are one of the most feared and common complications of diabetes. It is a major cause of disability, morbidity and mortality among diabetic patients and about 15% develop foot ulcers in their lifetime. So far, there are few published data in relation to the high-risk diabetic foot in Ethiopian subjects. Methods: A retrospective study was done to determine the various risks as well as antecedent factors, other long term complications, treatment profile and subsequent follow up of 196 patients with diabetic foot disease admitted to the Tikur Anbessa Specialized Referral Hospital from Jan 1999 to Dec 2003. Patients’ medical records were reviewed using pre-prepared formats and relevant data were abstracted. The data were analyzed using Epi info version 3.4.3 statistical soft ware. Results: A total of 196 patients were included in this study. The male to female ratio was 3 to 1. The median age was 60 years (IQR, 47-65). Median duration of symptoms before presentation was 21 days (IQR, 14-30) and the median duration of diabetes mellitus was144 months (IQR, 60-216). More than two thirds had type 2 diabetes mellitus. Among 109 patients with identified antecedent risk factors for their foot problem, ill fitting or new shoes attributed in 48(44%). Neuro-ischaemic ulcers were seen in 113 (58%) of the cases and neuropathic ulcer in 63 (32%). Ulcer with cellulitis or gangrene was the most common mode of presentation seen in 92 (47%) of the patients. Ninety two (47%) patients had amputations. Re-amputation was necessary in 24 (26%) of these cases. Less than 40% of the total cases had a regular follow up either at a clinic or hospital. Diabetes was diagnosed for the first time in 7 cases (4%) on presentation with foot ulcer. The mean glycemic level was poorly controlled in over 80% of the cases. The overall mortality rate was 21% and sepsis was the most identified cause. Conclusion: Lack of regular patient follow up and diabetes education on foot care, poor glycemic control, delay in patient presentation and surgical intervention as well as patients’ refusal to undergo surgical interventions were the reported contributing factors for the observed high mortality. Recommendation: Diabetic education on foot care, emphasis on metabolic control of diabetes, early presentation and surgical intervention when appropriate has to be highlighted in the management of diabetic patients. More studies have to be done in relation to the high-risk diabetic foot particularly in the Ethiopian setting emphasizing on preventive aspects.

Lunate Fracture in an Amateur Soccer Player

The patient was a 19-year-old male soccer player who sustained a right wrist injury after running into a soccer goal post with a clenched fist. The patient eventually sought medical care 9 weeks after the initial injury. Based upon the physical examination findings—including swelling, palpatory tenderness, and decreased range of motion due to pain—and general lack of improvement following the injury, radiographs of the right wrist were ordered. The radiographs were of concern due to an apparent fracture of the lunate. To evaluate the extent of the fracture, a computed tomography scan was completed. It revealed a central transverse fracture of the lunate with a depressed fragment seen centrally, with some comminution. Additionally, the anterior and posterior fragments of the lunate were minimally displaced with impaction of the capitate. Because of the significant delay in patient presentation in this case, a nonoperative treatment strategy was utilized, which involved casting, followed by treatment provided by a physical therapist. J Orthop Sports Phys Ther 2009;39(12):884. doi:10.2519/jospt.2009.0415

A systematic review of delays in seeking medical attention after transient ischaemic attack

Background:Prompt assessment and investigation of transient ischaemic attack (TIA) followed by early initiation of secondary prevention is effective in reducing recurrent stroke. Nevertheless, many patients are slow to seek medical...