Diagnostic Delay In Patients Research Articles

Factors underlying diagnostic delay in tuberculosis patients in a rural area in Tanzania: a qualitative approach

BackgroundDiagnostic delay in patients with tuberculosis (TB) leads to ongoing TB transmission, higher mortality rates and increased patient and government health expenditure. Qualitative research focussed on patients’ self-perceptions of disease and their care-seeking behaviour helps to guide health education programmes by providing us with the understanding of the knowledge, attitudes and practices that underlie diagnostic delay.Patients and methodsSemi-structured interviews with 28 recently diagnosed TB patients and four traditional healers were conducted. The interviews were audio-recorded and content analysis was performed.ResultsThe median total delay was 188 days. The health provider delay (31 days) was longer than the patient delay (21 days) and the health system delay (26 days). The health system delay was longest in patients not being diagnosed at their first hospital visit and subsequently visiting other health care providers, mostly traditional healers.ConclusionsA poor knowledge of TB signs and symptoms and patients’ beliefs about curses as the origin of diseases lead to delayed care-seeking at the hospital level in an area of North-Western Tanzania. Failure to identify TB cases by formal and non-formal health providers indicates that the education of both communities as well as health workers is essential in order to reduce diagnostic delays.

Reducing the Hypomania Checklist (HCL-32) to a 16-item version

Background The under-recognition of hypomanic symptoms by both clinicians and patients is a major clinical problem which contributes to misdiagnosis and diagnostic delay in patients with bipolar disorder. The recent development of validated screening instruments for hypomania, such as the Hypomania Checklist (HCL-32), may help to improve the detection of bipolar disorder. In this study, we assess whether it is possible to reduce the number of items on the HCL-32 without any loss in the screening tool's ability to reliably differentiate between bipolar disorder (BD) and major depressive disorder (MDD). Methods Using our large samples of patients with DSM-IV defined bipolar I disorder (BD-I) ( n = 230) and recurrent MDD ( n = 322), we performed item correlations in order to identify potentially redundant items in the HCL-32. We then tested the performance of a shortened 16-item HCL questionnaire within a separate sample of patients with BD (including BD-I, BD-II and BD-NOS) ( n = 59) and MDD ( n = 76). Results The structure of the 16-item HCL demonstrated two main factors similar to those identified for the HCL-32 (an ‘active-elated’ factor and a ‘risk-taking/irritable’ factor). A score of 8 or more on a shortened 16-item version of the HCL had excellent ability to distinguish between BD and MDD. The sensitivity (83%) and specificity (71%) of the 16-item version were very similar to those for the full 32-item HCL. Limitations The HCL-16 was derived after subjects had completed the full HCL-32. It will be important to test the validity of a ‘stand-alone’ 16-item HCL questionnaire. Conclusions A shortened 16-item HCL (the HCL-16) is potentially a useful screening tool for hypomania within busy clinical settings.

Length of Diagnostic Delay in Patients with Non-small-cell Lung Cancer

Despite advances in diagnostic techniques and treatment, lung cancer is the leading cause of cancer death worldwide and in Cuba. Prompt initiation of cancer therapy depends on rapid diagnostic confirmation; however, most patients are diagnosed at an advanced stage. In the Cuban health system, primary, secondary and tertiary levels of care are interrelated; patients may seek care at any level or may be referred from one to another. Lung cancer diagnoses are confirmed at the tertiary level. Determine the length of diagnostic delay in patients diagnosed with non-small-cell lung cancer (NSCLC) at a tertiary care facility in Havana, Cuba, as well as mean diagnostic delay attributable to the patient and to the health system by level of care. A descriptive observational study of 96 patients with a cytologically and/or histologically confirmed diagnosis of non-small-cell lung cancer was conducted in 2005-2007. Patients initially sought care for disease symptoms at primary, secondary or tertiary levels in the Cuban public health system, but diagnosis of all patientas was confirmed at a specialized tertiary care facility. Total diagnostic delay was calculated as the time elapsed from onset of symptoms to confirmation of NSCLC diagnosis. Variables also included diagnostic delay attributable to the patient and diagnostic delay attributable to the health system by level of care. Data were arranged in tables and analyzed by absolute value, percentage, mean, and standard deviation. Of the 96 patients studied, 69% were male, and 54% were aged 50-69 years. Fifty-five percent of patients sought medical care within 15 days of onset of symptoms, 21% within 16-30 days, and 3% waited >90 days. Mean diagnostic delay attributable to the patient was 18.19 +/- 3.45 days while mean diagnostic delay attributable to the health system was 61.63 +/- 18.50 days, and overall diagnostic delay was 73.13 +/- 17.53 days. For the 71% of patients seen in primary care, mean diagnostic delay was 29.51 +/- 4.53 days; for the 45% seen exclusively or additionally at the secondary level, mean diagnostic delay was 24.45 +/- 7.31 days. Upon admission at the tertiary care level, mean diagnostic confirmation delay was 18.23 +/- 3.68 days. Diagnostic delay of lung cancer patients in this study was prolonged. Appropriate strategies are needed for reducing this delay.

S1033 Diagnostic Delay in Patients with Inflammatory Bowel Disease

S1033 Diagnostic Delay in Patients with Inflammatory Bowel Disease

Valor de la indicación de la colonoscopia como predictor de diagnóstico de cáncer colorrectal. ¿Se puede diseñar un circuito rápido de diagnóstico?

Diagnostic delay in patients with colorectal cancer (CRC) is a quality indicator and its reduction could improve prognosis of the disease.To analyze the diagnostic value of different colonoscopy indications in CRC and to select the signs or symptoms that, if prioritized in a rapid diagnostic circuit, would be most efficient.A retrospective analysis of 2219 outpatients who underwent colonoscopy from 2000 to 2007 was performed. For each indication we calculated the sensitivity (S), positive predictive value (PPV), positive likelihood ratio (LR+), and number of colonoscopies needed to diagnose a case of CRC (NND).A total of 179 patients were diagnosed with CRC. The indications with greatest PPV were liver metastases (35.3%), suspicious radiological image (20.8%), and non-distal rectal bleeding (22%). Iron deficiency anemia (11%), constitutional syndrome (10%), any rectal bleeding (9.4%) and rectal syndrome (9%) had intermediate PPV. Constipation (6.3%), alternating constipation-diarrhea (3.3%), changes in bowel habits (3%), distal rectal bleeding (2.1%), diarrhea (1.8%) and abdominal pain (1.1%) had low PPV. The NND was 4 in liver metastases, 7 in non-distal bleeding and 8 in suspicious radiological image. Distal bleeding (13), diarrhea (14), abdominal pain (14), changes in bowel habits (15) and alternating constipation-diarrhoea (21) had negative NND. The subgroup of patients aged >or= 50 years showed lower NND in non-distal rectal bleeding (5), suspicious radiological image (5) and any rectal bleeding (16).Patients with non-distal rectal bleeding should be prioritized over other indications in a strategy of rapid diagnosis of CRC. Age equal to or more than 50 years should also be considered because this factor seems to reduce NND. Distal bleeding, abdominal pain and changes in bowel habits had low PPV and were associated with other diagnoses than CRC. Consequently, prioritization of these factors would be inefficient.

Presenting phenotype and clinical evaluation in a cohort of 22 Williams–Beuren syndrome patients

Williams–Beuren syndrome (WS) is a rare multi-system genomic disorder, caused by 7q11.23 microdeletion with a prevalence of 1/7500–1/20,000 live births. Clinical phenotype includes typical facial dysmorphism (elfin face), mental retardation associated with a peculiar neuropsychological profile and congenital heart defects. We investigated 22 WS patients (mean age of 9.7 years, range 1 day to 39 years) with a multi-specialist follow-up protocol comprehensive of neuropsychological, cardiologic, nephrologic, ophthalmologic, endocrinologic, gastroenterologic, odontostomatologic and orthopaedic evaluations. The mean age at diagnosis was 5.38 years, being 1.02 years when genetic evaluation was requested for congenital heart defects (CHD) and 10.68 years in case of mental retardation and/or abnormal neuropsychological profile without an evident CHD. All patients showed facial dysmorphisms, with supravalvular aortic stenosis (SVAS) as the most common cardiovascular anomaly (12/22), followed by peripheral pulmonary stenosis (9/22); interestingly, in one patient we detected a total anomalous pulmonary venous return (TAPVR), confirming the possible association of this rare CHD with WS. Hypertension was detected by 24-h ambulatory blood pressure monitoring in 7/22 cases. A cognitive assessment was performed in 13 patients older than 6 years, showing various degrees of mental retardation in 12 and a normal intelligence quotient (IQ) in a single patient; evaluation of developmental milestones revealed various grades of developmental delay in all the patients younger than 6 years. Chiari malformation type 1 was found in 3 patients. Our study underlines a remarkable diagnostic delay in patients who present to genetic evaluation because of mental retardation and/or peculiar neuropsychological profile lacking an evident cardiopathy and confirms the multi-systemic nature of WS leading to a high clinical presentation's variability and complex follow-up strategies.

Nonconvulsive Status Epilepticus in the Emergency Room

The study reviewed emergent cases of nonconvulsive status epilepticus (NCSE) to evaluate causes of diagnostic and management delay and examined frequent diagnostic features suggestive of NCSE. In a retrospective study, we assessed the clinical presentation of 23 patients with one or more NCSE episodes, their medical history, EEG, and antiepileptic drug (AED) treatment. We also evaluated causes of diagnostic delay in patients referred to the emergency room (ER) in confusional states. There was considerable overlap in clinical features of patients with complex partial SE (CPSE) and generalized nonconvulsive SE (GNSE). Delays in seeking medical attention were common. Diagnosis was significantly delayed in 10 patients. Three cases illustrate the possible markedly different presentations of NCSE. NCSE often goes unrecognized or is mistaken for behavioral or psychiatric disturbance. The pleomorphic clinical presentation of NCSE indicates that EEG and a therapeutic trial of AEDs afford the best diagnostic measures in acute waxing and waning confusional states associated with agitation, bizarre behavior, staring, increased tone, mutism, or subtle myoclonus.

Diagnostic Delay in Duchenne's Muscular Dystrophy and Cystic Fibrosis

<h3>To the Editor.—</h3> In an analysis of diagnostic delays in patients with Duchenne's muscular dystrophy (DMD), Crisp et al (1982;247:478) found that the average elapsed time between initial parental concern and final diagnosis was 3.0 years. These delays occurred even though massive elevation of serum creatine kinase levels is a reliable biochemical marker for the early detection of DMD. It is of interest to note the similarities between DMD, which is transmitted as an X-linked recessive, and cystic fibrosis (CF), which is transmitted as an autosomal recessive. In the case of both diseases, the basic defect is unknown, there is no specific therapy, a reliable test is available for early diagnosis (sweat test for CF), the course is marked by recurrent pulmonary infections and eventual respiratory failure, and average survival is 20 years. There is also a similarity in diagnostic delays. We have reviewed the records of 194 patients with