Lengthy Delays Research Articles

Current cancer therapies and their influence on glucose control.

This review focuses on the development of hyperglycemia arising from widely used cancer therapies spanning four drug classes. These groups of medications were selected due to their significant association with new onset hyperglycemia, or of potentially severe clinical consequences when present. These classes include glucocorticoids that are frequently used in addition to chemotherapy treatments, and the antimetabolite class of 5-fluorouracil-related drugs. Both of these classes have been in use in cancer therapy since the 1950s. Also considered are the phosphatidyl inositol-3-kinase (PI3K)/AKT/mammalian target of rapamycin (mTOR)-inhibitors that provide cancer response advantages by disrupting cell growth, proliferation and survival signaling pathways, and have been in clinical use as early as 2007. The final class to be reviewed are the monoclonal antibodies selected to function as immune checkpoint inhibitors (ICIs). These were first used in 2011 for advanced melanoma and are rapidly becoming widely utilized in many solid tumors. For each drug class, the literature has been reviewed to answer relevant questions about these medications related specifically to the characteristics of the hyperglycemia that develops with use. The incidence of new glucose elevations in euglycemic individuals, as well as glycemic changes in those with established diabetes has been considered, as has the expected onset of hyperglycemia from their first use. This comparison emphasizes that some classes exhibit very immediate impacts on glucose levels, whereas other classes can have lengthy delays of up to 1 year. A comparison of the spectrum of severity of hyperglycemic consequences stresses that the appearance of diabetic ketoacidosis is rare for all classes except for the ICIs. There are distinct differences in the reversibility of glucose elevations after treatment is stopped, as the mTOR inhibitors and ICI classes have persistent hyperglycemia long term. These four highlighted drug categories differ in their underlying mechanisms driving hyperglycemia, with clinical presentations ranging from potent yet transient insulin resistant states [type 2 diabetes mellitus (T2DM) -like] to rare permanent insulin-deficient causes of hyperglycemia. Knowledge of the relative incidence of new onset hyperglycemia and the underlying causes are critical to appreciate how and when to best screen and treat patients taking any of these cancer drug therapies.

Advocacy and the Innocent Client

Much of our knowledge about wrongful convictions is derived from known exonerations, which typically involve serious violent offences and lengthy sentences. These represent only a small proportion of offences prosecuted in Canada each year, and little is known about how often innocent defendants may be wrongfully convicted of less serious offences. Recent discussions have begun to focus on the problem of false guilty pleas, in which defendants choose to plead guilty to a lesser offence to avoid the time and cost required to defend their innocence. The majority of our knowledge of the factors contributing to wrongful convictions is based on American scholarship, with less empirical research exploring wrongful convictions within the Canadian context. The present research surveyed Canadian criminal defence lawyers about their experiences representing innocent clients, including their perspective on the underlying causes of wrongful convictions in Canada and their recommendations for reform to the criminal justice system. Nearly two-thirds of defence counsel in this study reported that they had represented at least one client who was convicted despite credible claims of innocence. Many reported that they regularly see innocent clients choose to enter a strategic false guilty plea, perceiving no meaningful or realistic alternative. Counsel described a system designed to elicit a guilty plea, with lengthy pre-trial delays, routine denial of bail, inadequate funding of Legal Aid, costly defence options, padded charges, and false evidence ploys. This research expands our knowledge of wrongful convictions in Canada, their hidden prevalence, and systemic problems that increase the likelihood of their occurrence.

Primary care physician perspectives on screening for axial spondyloarthritis: A qualitative study.

Many patients with axial spondylarthritis (axSpA) experience lengthy diagnostic delays upwards of 14 years. (5-14 years). Screening tools for axSpA have been proposed for use in primary care settings, but whether this approach could be implemented into busy primary care settings remains unknown. To solicit feedback from primary care physicians regarding questions from the Inflammatory Back Pain Assessment: the Assessment of Spondyloarthritis International Society (ASAS) Expert Criteria and gain insight about barriers and facilitators for implementing axSpA screening in primary care. Guided by Consolidated Criteria for reporting Qualitative Research (COREQ-criteria), we recorded, transcribed, and analyzed in-depth interviews with eight family medicine physicians and ten internists (purposeful sampling) using immersion/crystallization techniques. Few physicians reported awareness of existing classification criteria for axSpA, and many reported a lack of confidence in their ability to distinguish between inflammatory and mechanical back pain. From three domains, 10 subthemes emerged: 1) typical work-up of axSpA patients in primary care, with subthemes including the clues involved in work-up and role of clinical examinations for axSpA; 2) feedback on questions from the Inflammatory Back Pain Assessment: ASAS Expert Criteria, with subthemes to evaluate contents/questions of a potential screening tool for axSpA; and 3) implementation of the screening tool in primary care settings, with subthemes of perceived barriers including awareness, time, other conditions to screen, rare disease, and lack of structured questionnaire for back pain and perceived facilitators including workflow issues and awareness. Primary care physicians believed that an improved screening instrument and a strong evidence-base to support the need for screening for axSpA are required. The implementation of axSpA screening into a busy primary care practice requires integration into the practice workflow, with use of technology suggested as a possible way to improve efficiency.

Expanded access and early access provision: Awareness, educational needs and opportunities to improve access to care.

e18507 Background: An unmet medical need exists for many oncology patients who cannot be treated satisfactorily by available therapeutics. Despite notable efforts made by FDA and EMA to expedite development, review and approval of Innovative Medicinal Products (InMPs), there may still be a lengthy delay before oncology patients can gain access to new therapies. Expanded access (EA) in the USA and compassionate use (CU) in the European Union are pathways endorsed to improve patient access to InMPs. Recently reported data from CDER and CBER revealed that applications for EA pathways dealing with patient cohorts remain low, despite high approval rates. The challenges that practicing oncologists may face when dealing with EA or other early access provision (EAP), together with limited education, may influence the access of oncology patients to care. Methods: An on-line, fully anonymous survey reaching out to more than 3,258 practicing physicians was initiated between November 2020- January 2021. Participants were asked questions about their knowledge and understanding of EA/EAP, level of experience, decision process, interest for further educational activities and opportunities to improve process, both in general and specifically during COVID 19 pandemic. Attributes were rated on a 5-point scale. Results: Analysis of first respondents showed that 70% of practicing physicians rated their own understanding and knowledge about EA/EAP as above average (good or very good). However, only 60% of responders answered specific knowledge-based question correctly. At the same time, only 44% of practicing oncologists reported notable experience with EA/EAP in daily practice. The majority of respondents (90%) felt that availability of clinical efficacy data from comparative phase III RCTs would be considered of high importance; other evidence and study types (e.g. clinical safety, PK/PD, preclinical data) were rated substantially lower. The need for further education around better understanding of the processes and regulatory requirements, roles and responsibilities, and data collection was emphasized by 61%, 36% and 30% of respondents, respectively. During current COVID 19 pandemic, majority of respondents highlighted the need to improve and substantially adapt EA with regard to application process and documentation, InMP supply and logistics, and safety reporting process. Conclusions: Results from this survey suggest that challenges posed by the EA process, together with a lack of education, might contribute to the under-utilization of EA/EAP for oncology patients. Continuous educational efforts are required to better inform and support practicing oncologists during the EA application process and regulatory framework. Competent authorities should consider optimization and implementation of digital tools to facilitate EA applications and follow up during the COVID 19 pandemic.

Time intervals between U.S. Food and Drug Administration (FDA) and European Medicines Agency (EMA) new cancer therapy approvals.

1575 Background: Novel therapies are transforming cancer care. Regulatory review and approval are essential to deliver safe and efficacious innovations to patients. Studies prior to 2010 describe quicker approval decisions for new oncology drug registrations with the FDA compared to the EMA (median delay 238 days). Both regulatory agencies have subsequently improved procedures to expedite approval times. We compared regulatory market authorisation dates at the FDA and EMA for new oncology therapies from 2010-2020. Methods: New oncology therapeutic approvals between 2010-2020 were identified from the FDA and EMA regulatory databases. We analysed only initial approvals (not supplementary licenses) for active anti-cancer therapies (excluding biosimilars and supportive drugs). The delay in regulatory approval between the FDA and EMA was calculated in calendar days. We further analysed therapies by therapeutic class, evaluating for significant differences. Results: We identified 108 new therapy registrations during the study period. 104 (96.3%) therapies were approved by the FDA and 90 (83.3%) had EMA market authorisation. 4 (3.7%) drugs were not FDA registered, including 3 unsuccessful applications and 1 which sought licensing in a different indication. 18 (16.5%) drugs were not EMA registered, including 9 (8.8%) which did not pursue EMA licensing, 3 (2.9%) withdrawn licensing applications, 3 (2.9%) sought licensing in different tumour group/indication, 1 (0.9%) rejected application and 2 (1.9%) with applications under review at submission date. Of the 86 drugs approved by both agencies, 80 were approved first by the FDA and 6 by the EMA. The median delay in approval between the FDA and EMA was 227 days (IQR:124-354 days). Table shows approvals by therapeutic class. The shortest median time difference for approval was for monoclonal antibodies (171 days) with the longest for kinase inhibitors (281 days). Conclusions: This study shows more new oncology therapies are approved by the FDA than the EMA. Patients in the US typically have access to approved therapies earlier than in Europe. From 2010 to 2020 the median delay between FDA and EMA approval was 227 days, falling by 11 days compared to 2003-10, [non-statistically significant]. Such lengthy delays could exceed the life expectancy of many patients with advanced cancer. Innovations for accelerated approval at both the FDA (e.g. Project Orbis) and EMA (e.g., PRIME) have potential to lead to faster approval.[Table: see text]

Editors' Note: Association of Initial Imaging Modality and Futile Recanalization After Thrombectomy

In “Association of Initial Imaging Modality and Futile Recanalization After Thrombectomy,” Meinel et al. reported that the rate of futile recanalization (defined as 90-day modified Rankin Scale (mRS) score 4–6 despite successful recanalization) among patients enrolled in the BEYOND-SWIFT multicenter, retrospective observational registry was significantly higher in patients selected for thrombectomy based on a CT scan as compared with patients selected for thrombectomy based on an MRI. Siegler and Thon cautioned that these findings should not dissuade against (1) use of a CT scan to determine eligibility for thrombectomy because this could lead to unnecessary delays in care or (2) performance of thrombectomy after CT scans because the imaging modality itself does not directly affect outcome and 40% of patients selected for thrombectomy based on a CT scan had a good 90-day mRS score (which represents a 22%–27% absolute increase compared with patients treated with medical management in the DAWN and DEFUSE-3 trials). Meinel et al agreed that it is imperative to avoid delays before thrombectomy and reinforced that their findings should not influence the selection of imaging modality for potential thrombectomy candidates. They also pointed out that implementation of high-speed MRI protocols should be considered to obtain more detailed information than a CT scan can provide while avoiding lengthy delays between imaging and groin puncture. In “Association of Initial Imaging Modality and Futile Recanalization After Thrombectomy,” Meinel et al. reported that the rate of futile recanalization (defined as 90-day modified Rankin Scale (mRS) score 4–6 despite successful recanalization) among patients enrolled in the BEYOND-SWIFT multicenter, retrospective observational registry was significantly higher in patients selected for thrombectomy based on a CT scan as compared with patients selected for thrombectomy based on an MRI. Siegler and Thon cautioned that these findings should not dissuade against (1) use of a CT scan to determine eligibility for thrombectomy because this could lead to unnecessary delays in care or (2) performance of thrombectomy after CT scans because the imaging modality itself does not directly affect outcome and 40% of patients selected for thrombectomy based on a CT scan had a good 90-day mRS score (which represents a 22%–27% absolute increase compared with patients treated with medical management in the DAWN and DEFUSE-3 trials). Meinel et al agreed that it is imperative to avoid delays before thrombectomy and reinforced that their findings should not influence the selection of imaging modality for potential thrombectomy candidates. They also pointed out that implementation of high-speed MRI protocols should be considered to obtain more detailed information than a CT scan can provide while avoiding lengthy delays between imaging and groin puncture.

Depressive-Symptom Trajectories From End-of-Life Caregiving Through the First 2 Bereavement Years for Family Caregivers of Advanced Cancer Patients

BackgroundFamily caregivers’ distinct depressive-symptom trajectories are understudied and have been examined independently during end-of-life (EOL) caregiving or bereavement, making it difficult to validate two competing hypotheses (wear-and-tear vs. relief) of caregiving effects on bereavement. Existing studies may also miss short-term heterogeneity in depressive symptoms during the immediate postloss period due to lengthy delays in the first postloss assessment. PurposeThis secondary-analysis study examined distinct depressive-symptom trajectories for caregivers of advanced cancer patients from EOL caregiving through the first 2 bereavement years with closely spaced assessments. MethodsDepressive symptoms were measured monthly during EOL caregiving and 1, 3, 6, 13, 18, and 24 months postloss among 661 caregivers using the Center for Epidemiologic Studies-Depression scale. Depressive-symptom trajectories were identified using latent-class growth analysis while controlling for gender and age. ResultsWe identified seven distinct depressive-symptom trajectories (prevalence) characterized by the timing, intensity, and duration of depressive symptoms: minimal-impact resilience (20.4%), recovery (34.0%), preloss-grief only (21.6%), delayed symptomatic (9.1%), relief (5.9%), prolonged symptomatic (6.5%), and chronically persistent distressed (2.5%). ConclusionCaregivers of advanced cancer patients responded heterogeneously to the stresses of EOL caregiving and bereavement. The majority of caregivers was resilient while providing caregiving and quickly rebounded to healthy levels of psychological functioning during bereavement, whereas a minority experienced delayed-symptomatic, prolonged-symptomatic, or chronically-persistent-distressing depressive-symptom trajectories. Linking caregivers’ psychological experiences from caregiving through bereavement by closely spaced assessments can more comprehensively illustrate their depressive-symptom trajectories, which confirm both the wear-and-tear and relief hypotheses, and help in targeting interventions for distinct depressive-symptom trajectories.

Idempotence-Based Preemptive GPU Kernel Scheduling for Embedded Systems

Mission-critical embedded systems simultaneously run multiple graphics-processing-unit (GPU) computing tasks with different criticality and timeliness requirements. Considerable research effort has been dedicated to supporting the preemptive priority scheduling of GPU kernels. However, hardware-supported preemption leads to lengthy scheduling delays and complicated designs, and most software approaches depend on the voluntary yielding of GPU resources from restructured kernels. We propose a preemptive GPU kernel scheduling scheme that harnesses the idempotence property of kernels. The proposed scheme distinguishes idempotent kernels through static source code analysis. If a kernel is not idempotent, then GPU kernels are transactionized at the operating system (OS) level. Both idempotent and transactionized kernels can be aborted at any point during their execution and rolled back to their initial state for reexecution. Therefore, low-priority kernel instances can be preempted for high-priority kernel instances and reexecuted after the GPU becomes available again. Our evaluation using the Rodinia benchmark suite showed that the proposed approach limits the preemption delay to 18 ms in the 99.9th percentile, with an average delay in execution time of less than 10 percent for high-priority tasks under a heavy load in most cases.

A national audit of the management pathways for new HIV diagnoses.

The British HIV Association recommends that new diagnoses be reviewed by an HIV specialist within two weeks. NHS England outcome measures include the proportion of new diagnoses commencing antiretroviral therapy (ART) within 91 days. We aimed to review the extent to which these recommendations were followed, to explore the topics discussed with new diagnoses, and to identify reasons behind delayed ART initiation. UK specialist HIV services were invited to retrospectively review the notes of their last 40 new diagnoses over a 15-month period. One-hundred and thirty-two services provided data for 2281 eligible individuals. Most new diagnoses were reviewed by a specialist within two weeks (67.7%) and were commenced on ART within 91 days (83%), however, there were some concerning delays in those tested at home and in general practice. Partner notification and treatment benefits were discussed with most individuals, unlike the availability of community support and U = U ("undetectable equals untransmittable"). Lengthy delays in ART initiation were mostly due to individuals initially declining ART or missing appointments. Our findings suggest a need for more streamlined pathways into HIV care, review of new diagnoses who have not commenced ART within 8 weeks, and protocol development to ensure discussion of relevant topics.

The Efforts to Improve the Traffic Pattern Settings for the Zonation System at Teluk Bungus Ferries Port

Teluk Bungus Ferries Port, located in West Sumatra, does not have a history of optimal functionality. This is due to the lack of a proper the zoning system. Currently, people can enter and exit the dock area at will, and local residents’ likestock similarly violate established regulatroy standards. Moreover, a number of inefficiencies exist – for example foot passengers and vehicles purchase ferry tickets from the same place, requiring vehicle drivers to leave their vehicles to purchase tickets – resulting in lengthy delays. This study evaluates the port and considers methods by which it could better confirm to governmenrt regulations and create a transportation system that is safe, comfortable and orderly.
 Keywords: Efforts, Traffic Pattern, Zonation System

Management of Sub-ungual Glomus Tumor of the Finger Tips

Background: Glomus tumors present as painful lesions especially in colder weather, most commonly at finger tips. Glomus tumors are hamartomas that account for 1% to 5% of all soft tissue tumors of the hand. These tumors are usually benign. High-resolution magnetingresonence imaging (HR-MRI) is useful in the diagnosis of patients with subungualglomus tumor, excellent diagnostic informationin detecting the occult lesion. Objective: present study was aimed at delineatingcommon presentation and long term treatment outcome. Materials & methods: This prospective study was done from January 2004 to july 2019. We found 30patients diagnosed as having sub-ungualglomus tumorsin finger tips and thumbover 15 yearsperiod and which were operated in hand unit in the Department of orthopaedic surgery, Bangabandhu Sheikh Mujib Medical university (BSMMU) Dhaka, Bangladesh. The data were collected included demographics, presenting symptoms, duration, physical examination, treatment and recurrence. Results: The mean duration of symptoms before presentation was 3.2 years (range 6 months to 15 yrs) Mean age at presentation was 33.7 years (range 20 to 65 yrs.) andfemale to male ratio 20:10. Thirteen (13) patientshad left hand involvement among them ring finger were 06, index finger were 04, middle finger were 02, and thumb 1 and 17 patients had right hand involvement amongthem ring finger were 06, index finger were 05, middle finger were 03 and little finger were 03. Clinical and radiological assessment were made preoperatively. All the lesionsinvolvedthe sub- ungual region. The mean size of the lesion was 3.5 mm (range 2.5 to 10mm). All the patients confirmed by histopathological examination. No recurrence in this study and nail change were 03. Transungual approachto be simple procedure which can reduce the chances of recurrence by allowing examination of entiresub ungual region. Nail deformities are minimal if adequate care is taken during surgery. Conclusion: The diagnosis of glomus tumor is largely clinical butHR-MRI is also helpful in diagnosis of patient with sub- ungualglomus tumor. Complete surgical excision offers the only prospect of complete cure. Early diagnosis of glomus tumor is important to avoid lengthy treatment delays.

Negative factors in implementing public–private partnership in Indian road projects

For the Government projects, Public–Private Partnership (PPP) is an important parameter based on which the project is procured through a private-sector. The objective of this paper was to identify and evaluate the perception of respondents for negative factors affecting Indian road projects undertaken by PPP. Thirteen negative factors were identified through a literature survey and validated with experienced professionals from the public-sector, private-sector and researcher. A questionnaire survey was conducted among major PPP project participants and researchers of Indian PPP road projects to investigate the most important negative factors. Identified factors were grouped into four categories: lack of experience, high cost, project's effectiveness and high risk using factor analysis. The four most important negative factors of Indian PPP Road Projects were identified using the Importance Index Method, which is: excessive restriction on participation, lengthy delays in negotiation, confusion over government objectives and evolution criteria, and fewer employment opportunities. The perception was analyzed with various statistical tools. This paper gives recognition of very important negative factors in the PPP road sector in the Indian context which will help consider road projects under PPP during the development phase itself.

PRO5 Estimating the Health Benefits of Earlier Diagnosis and Treatment of Transthyretin Amyloid Cardiomyopathy

Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive, fatal disease with significant morbidity and mortality, where patients commonly experience delayed diagnosis and misdiagnosis. Adoption of non-invasive diagnostic techniques and the approval of disease-modifying therapies are expected to increase disease awareness and reduce diagnostic delay. This study estimated the expected health benefits of earlier ATTR-CM diagnosis and treatment with tafamidis. A discrete time, cohort-level Markov state-transition model was developed, with health states based on New York Heart Association (NYHA) classification. Clinical efficacy was informed by the Tafamidis Treatment for Patients with Transthyretin Amyloid Cardiomyopathy (ATTR-ACT) study. Exemplar wild-type (wtATTR-CM) and hereditary (hATTR-CM) patients were simulated for early (younger age and earlier NYHA classification) and delayed diagnosis/treatment scenarios; delay durations were informed by a literature review and treatment with tafamidis was assumed to commence at diagnosis. Health outcomes were evaluated over a lifetime horizon. Exemplar patients were male, baseline NYHA class II, with baseline ages of 70 and 60 years for wtATTR-CM and hATTR-CM, respectively. For the wtATTR-CM patient, relative to a 3.42 (range 0.75-3.83) year delay, early diagnosis and treatment was estimated to result in 4.42 (1.56-4.79) additional life years (LYs) and 3.70 (1.33-4.00) additional quality-adjusted life years (QALYs); for the hATTR-CM patient, relative to a 2.50 (range 2.08-3.67) year delay, 5.43 (4.77-7.25) additional LYs and 4.45 (3.92-5.89) additional QALYs were predicted. Estimated benefits were greater for younger patients and females and attenuated for later baseline NYHA class. Tafamidis, the first disease-modifying treatment, is predicted to significantly improve survival and quality of life outcomes for both wtATTR-CM and hATTR-CM patients. This study demonstrates that lengthy diagnostic delays represent a foregone opportunity to further extend and improve life for ATTR-CM patients using tafamidis treatment.

Factors that Influence Treatment Delay for Patients with Breast Cancer.

The diagnosis or treatment of breast cancer is sometimes delayed. A lengthy delay may have a negative psychological impact on patients. The aim of our study was to evaluate the sociodemographic, clinical and pathological factors associated with delay in the provision of surgical treatment for localised breast cancer, in a prospective cohort of patients. This observational, prospective, multicentre study was conducted in ten hospitals belonging to the Spanish national public health system, located in four Autonomous Communities (regions). The study included 1236 patients, diagnosed through a screening programme or found to be symptomatic, between April 2013 and May 2015. The study variables analysed included each patient's personal history, care situation, tumour history and data on the surgical intervention, pathological anatomy, hospital admission and follow-up. Treatment delay was defined as more than 30days elapsed between biopsy and surgery. Over half of the study population experienced surgical treatment delay. This delay was greater for patients with no formal education and among widows, persons not requiring assistance for usual activities, those experiencing anxiety or depression, those who had a high BMI or an above-average number of comorbidities, those who were symptomatic, who did not receive NMR spectroscopy, who presented a histology other than infiltrating ductal carcinoma or who had poorly differentiated carcinomas. Certain sociodemographic and clinical variables are associated with surgical treatment delay. This study identifies factors that influence surgical delays, highlighting the importance of preventing these factors and of raising awareness among the population at risk and among health personnel.

Differential effects of token production and exchange on responding of children with developmental disabilities

Token economies are commonly used in educational and clinical settings as tools for reinforcing appropriate behavior. However, little applied research has been conducted to investigate the behavioral mechanisms involved. What’s more, research with non-human animals suggests that tokens may serve discriminative functions which may actually suppress responding under high schedule requirements. This study explores the relationship between schedules of token production (i.e., dense, lean, and yoked reinforcement) and response patterns in three children with autism spectrum disorders (ASD). Relative to yoked reinforcement schedules, token production corresponded with higher response rates and shorter pre-ratio pauses (PRPs) under low schedule requirements. Under high schedule requirements, all three participants demonstrated higher response rates and shorter PRPs in the yoked reinforcement condition relative to either token production condition. These findings are consistent with research involving non-human animals suggesting that, under high schedule requirements, tokens may signal lengthy delays to reinforcement and potentially even suppress responding. Thus, we provide preliminary recommendations for using token reinforcement systems most effectively in applied contexts.

A network analysis approach to functioning problems in first psychotic episodes and their relationship with duration of untreated illness: Findings from the PAFIP cohort

BackgroundThe domains of functioning affected by first episode of psychosis (FEP) could be analysed as forming a network of interacting or even reinforcing elements. The reasons why longer duration of untreated psychosis (DUP) might be related to higher disability are not still clear. The aim of the present study is to evaluate how different areas of functioning are inter-related according to the length of DUP in patients with FEP, with a particular focus on studying the relative influence of each other according to lengthy delays in initial treatment. Method441 participants in an epidemiological and intervention program of first episode psychosis (PAFIP) were included in our study. Functioning problems at baseline were assessed with the WHO Disability Assessment Schedule (DAS). Three networks of functioning domains have been estimated according to the length of DUP. ResultsAll the DAS items took part in the different networks. We have not found differences across the edge weights in the short, medium and long DUP groups. The domains “social withdrawal”, “participation in the household activities”, “general interest and information”, and “low level of activity” seem to act as bridge items with other areas of functioning in people with longer DUP. ConclusionsOur results could have clinical implications for patients with longer DUP, in which case, social withdrawal, household activities, level of activity and general interest in the world around them, could be high-priority target areas of treatment, since they seem to be mediating the relation between others areas of functioning.

Can an advanced audiology-led service reduce waiting times for paediatric ear nose and throat outpatient services?

Children with middle ear disease often experience lengthy delays waiting for outpatient paediatric ear nose and throat (ENT) services. This study aimed to investigate whether an alternative service delivery model using audiologists working in an expanded scope of practice reduced waiting times for children to access such services. A total of 131 children consecutively referred to a large ENT outpatient service in Queensland, Australia, for middle ear and hearing concerns were prospectively allocated to either a standard ENT service or an advanced audiology (AA)-led service. Waiting times and attendance rates were collected and compared between the two patient groups. The median waiting time from referral to first offered appointment was 96 days for children in the AA-led service versus 417.5 days for children in the standard ENT service. Seventy-nine percent of children in the AA-led service attended their first offered appointment versus 61% in the standard ENT service. For children receiving grommets, the median waiting time from initial referral to grommet insertion was 226 days for children in the AA-led service versus 627 days for children in the standard ENT service. The AA-led service was an effective alternative pathway to reduce waiting times for children referred to ENT services with middle ear and hearing concerns.

Primary care physician perspectives on barriers to diagnosing axial Spondyloarthritis: a qualitative study

BackgroundThe average delay in diagnosis for patients with axial spondyloarthritis (axSpA) is 7 to 10 years. Factors that contribute to this delay are multifactorial and include the lack of diagnostic criteria (although classification criteria exist) for axSpA and the difficulty in distinguishing inflammatory back pain, a key symptom of axSpA, from other highly prevalent forms of low back pain. We sought to describe reasons for diagnostic delay for axSpA provided by primary care physicians.MethodsWe conducted a qualitative research study which included 18 US primary care physicians, balanced by gender. Physicians provided informed consent to participate in an in-depth interview (< 60 min), conducted in person (n = 3) or over the phone (n = 15), in 2019. The analysis focuses on thoughts about factors contributing to diagnostic delay in axSpA.ResultsPhysicians noted that the disease characteristics contributing to diagnostic delay include: back pain is common and axSpA is less prevalent, slow progression of axSpA, intermittent nature of axSpA pain, and in the absence of abnormal radiographs of the spine or sacroiliac joints, there is no definitive test for axSpA. Patient characteristics believed to contribute to diagnostic delay included having multiple conditions in need of attention, infrequent interactions with the health care system, and “doctor shopping.” Doctors noted that patients wait until the last moments of the clinical encounter to discuss back pain. Problematic physician characteristics included lack of rapport with patients, lack of setting appropriate expectations, and attribution of back pain to other factors. Structural/system issues included short appointments, lack of continuity of care, insufficient insurance coverage for tests, lack of back pain clinics, and a shortage of rheumatologists.ConclusionPrimary care physicians agreed that lengthy axSpA diagnosis delays are challenging to address owing to the multifactorial causes (e.g., disease characteristics, patient characteristics, lack of definitive tests, system factors).

Merchant transmission investment by generation companies

Budget constraints may cause delays in the development of transmission expansion projects. These delays increase the probability of congestion in power systems. The congestions preclude a non-discriminatory access of Generation Companies (GenCos) to transmission network, thus leading to financial losses to certain GenCos. On the other hand, a higher degree of risk is involved in transmission investment, and a long time period is required to return the capital cost. It would, therefore, be effective to offer structures to promote merchant investments in order to lighten the financial burden on the transmission service provider to avoid lengthy delays. This paper proposes a structure to involve the GenCos in merchant transmission investment. The rationale for engaging in such projects is that, as well as the profit from the merchant investment, the GenCos could make further profit from energy production by gaining improved access to load areas. The merchant investment cost of the transmission project is returned through long-term firm contracts together with revenues from financial transmission right. The most profitable plan of the GenCo is identified by conducting a cost-benefit analysis among expansion plans specified by the transmission system operator.

Current practices in the management of anterior glenohumeral instability in rugby union players

BackgroundRugby has the highest incidence of traumatic injuries of any sport, and glenohumeral injuries result in the lengthy delay in return to play. The purpose of this study is to survey surgeons from the American Shoulder and Elbow Surgeons (ASES), and the British Elbow and Shoulder Society (BESS) to evaluate the current state of management of anterior glenohumeral instability, and compare the differences in practices. MethodsA survey of surgeons from ASES and BESS was conducted. Treatment options were proposed in a variety of clinical scenarios of glenohumeral instability. The time of immobilization post-operatively, return to play, and attitudes on current contact regulations. Results were compared using the chi-square test or t-test. ResultsNinety-seven surgeons responded to the survey. There was a significant difference in treatment between ASES and BESS surgeons in the setting of primary dislocation (p < 0.05), but not recurrent dislocation (p > 0.05). The period of immobilization following injury and surgery was different between both treating groups. There was a significant difference in return to play between ASES and BESS surgeons with arthroscopic stabilization and open Bankart repair (p < 0.05), but not following conservative treatment or the Latarjet procedure (p > 0.05). ConclusionsThere remains wide variance on the management of glenohumeral instability in rugby union players among surgeons. While immobilization times post-operatively were similar, the BESS surgeons were more confident in allowing earlier return to play. There is also a significant concern that contact levels should be regulated to protect player safety. Level of evidenceLevel 4 (case series).