Surgical Outpatient Department Research Articles

Primary neuroendocrine carcinoma of the breast

Background: Neuroendocrine carcinoma of the breast is a rare entity. Most patients are in the sixth to seventh decade of life. The criteria for diagnosis were established by the WHO in 2003, and modified in 2013. Based on the limited number of studies done; this entity is thought to have a worse prognosis compared to the usual type of intraductal carcinoma. Case Report: A 45 year old woman presented in the surgical outpatient department with complaint of lump breast. Fine needle aspiration was performed and the case was reported as suspicious of malignancy. Biopsy was advised for further evaluation. Histopathology showed a cellular tumor exhibiting a sheeting pattern with interspersed rosettes. The individual cells were relatively monomorphic, with a salt and pepper chromatin. Intraductal component was also identified. Based on the characteristic morphology and presence of chromogranin positivity in more than 50% of the tumor cells, the lump was diagnosed as primary neuroendocrine carcinoma, well differentiated. Conclusion: This case has been written up because of the rarity of this entity, its characteristic histopathological features, and the importance of differentiating it from intraductal carcinoma, due to a more aggressive course than invasive ductal carcinoma, with a higher propensity for local and distant recurrence and poorer overall survival attributed to this entity by some researchers. Keywords: Breast, Chromogranin, Neuroendocrine carcinoma, Primary, Prognosis

Retrospective analysis of breast lumps in a given population: an institutional study

Background:A lump in the breast is a common complaint presenting in the surgical outpatient department of all major hospitals, with anxiety regarding a possible malignancy being extremely common. Early presentation and prompt diagnosis is essential to relieve anxiety of non-neoplastic conditions, and in case of carcinoma, it can save the patient from metastases. This retrospective study aims to audit the clinic pathologic features of patients with breast lump at teaching hospital in northern India.Methods: A total of 138 patients were included for the present study. The data on all patients who presented with history of breast lump to the surgical outpatient department at a teaching hospital, Maharaja Agrasen Medical College, Agroha from 1st January 2013 to 31st December 2015 were retrospectively analyzed. Information on age at presentation, parity, duration of symptom before presentation, previous breast disease, side and quadrant of breast affected, maximum diameter of breast lump, clinical diagnosis made by the senior registrar or unit consultant, type of biopsy done and histology diagnosis for patients who returned with histology report were extracted from the case files. All the results were analyzed by Statistical Package for Social Sciences (SPSS) software. Chi-square test was used to measure the level of significance.Results:in our present study, out of all the patients, 7 were males and rests were females. Out of 131 females, 3 (2.1%) were premenstrual and 35 (25.4%) were postmenopausal. 39 (28.3%) female patients were nulliparous. Lump was painless in 75 (54.3%) patients. Duration from discovery of lump to presentation was < 1 months in 24 (17.4%), 1-3 months 10 (7.2%), 3-6 months 18 (13.0%), 6-12 months 20 (14.5%), > 12 months in 56 (40.6%) and ranges from 2 days to 19 years. The duration was not documented in 10 (7.2%) patients. Left breast was more affected i.e. 65 (47.1%) cases than right sided. Bilateral involvement in around 12 cases (8.7%). Breast lump was presenting complaint in 138 patients in 3 years. The mean age of patients presenting with breast lump was 36.8 years (Range 15-70 years).Conclusions:Breast lump was the most common presenting complaint with most patients not presenting within one month.

Acute Physiology and Chronic Health Evaluation II score as a tool to guide management strategies in ileal perforation

Background: Perforation peritonitis is the common surgical emergency. Despite advances in surgical techniques, antimicrobial therapy, and intensive care support, management of peritonitis continues to be highly demanding due to associated morbidity and mortality. Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system is the best available method for risk stratification in critically ill patients. Materials and Methods : This study was conducted in the 60 patients, who were admitted from causality and surgical outpatient department with a proven diagnosis of ileal perforation peritonitis. The patients were scored using by APACHE II into either of the two groups, Group A: <10 score. Group B: ≥10 score. Patients were operated for primary closure or ileostomy formation and were divided into two groups of 30 each depending on the surgical management. Group I (n = 30): These patients were managed by primary repair of the perforation with or without resection-anastomosis. Group II (n = 30): These patients were managed by ileostomy formation with closure/resection of the perforation. The outcome was assessed by postoperative complications and duration of hospital stay as related to APACHE II score. Results : Typhoid accounted for 38.3% of ileal perforations, Tuberculosis 15%, trauma 5% and nonspecific 41.6%. The majority of the perforations were single (90%), of size <1 cm (81.66%), and located within 60 cm of terminal ileum (95%). Simple closure of perforation with or without resection anastomosis was statistically significantly (P < 0.005) more done in patients with APACHE II score <10 whereas frequency of ileostomy was statistically significantly (P < 0.005) more done in patients with APACHE II score ≥10. As the APACHE II score increases the percentage of complication rate and hence hospital stay also increases, 12.97 ± 3.50 days in patients with APACHE II <10 score and 20.96 ± 5.09 days in patients with APACHE II ≥10 score (P < 0.001). Conclusion: Enteric fever is the most common cause of perforation peritonitis. Higher APACHE II scores in secondary peritonitis correlated significantly with the higher mortality and morbidity of the patients.

A RARE CASE OF INVASIVE PAPILLARY CARCINOMA OF BREAST

Papillary carcinoma of the breast is extremely rare variety of carcinoma breast with a mere incidence of only 0.5% of all recently diagnosed cases of breast cancer. We present a case of 63 years old postmenopausal female who came to surgical outpatient department with complaints of a slowly increasing mass in the left breast of 1 month duration which was painless. A Left-sided modified radical mastectomy was performed with an absolutely normal post operative period. The final histopathology report was suggestive of invasive papillary carcinoma. We report this case as it is rarely diagnosed. KEYWORDS: Invasive papillary carcinoma; Modified radical mastectomy; Carcinoma breast.

Penile Soft Tissue Swelling.

A two-year-old male presented to the surgical outpatient department of the Armed Forces Hospital, Muscat, with penile shaft swelling, which had been present for 10 months. He had no history of trauma, but had undergone circumcision one year prior and the swelling had developed after the procedure. He was referred to a urologist for further management. Clinical examination showed a soft swelling arising from the left lateral aspect of the penile shaft. Based on a presumptive diagnosis of soft tissue mass (fibroma), the swelling was excised and sent for histopathological assessment [Figure 1]. The specimen was a soft cystic nodule measuring 1cm. Figure 1 Hematoxylin and eosin staining showed cyst wall lined by histiocytes, cholesterol clefts, and giant cells with luminal keratin. Magnification=10×.

PP06.2 – 2223: The health status of children with severe cerebral palsy attending a tertiary referral centre in a resource limited setting

Objective The aim of the study was to document the health status of children with severe cerebral palsy attending a tertiary referral centre in a resource limited setting using the Child Health Questionnaire (CHQ). Methods Children with severe CP (GMFCS IV and V) between the ages of 5 and 18 years were recruited from the specialist cerebral palsy clinic. Healthy controls were recruited from medical and surgical outpatient departments at the same institution. The CHQ PF 28 caregiver questionnaire was completed by parents or caregivers and used to measure the parent's perception of their child's physical (PHY) and psychosocial (PSY) health. Ethics approval was obtained from the health sciences research ethics committee. Results The physical summary scores for children with severe cerebral palsy (median = 12.3, IQR = 5.57–31.03) were lower compared to the physical summary scores of the control group (median= 43.10, IQR=39.31–53.33). The psychosocial summary scores for children with cerebral palsy (median = 40.15, IQR = 32.52–47.59) were also lower when compared to the summary scores for control group (47.8, IQR = 37.77–54.69) The summary scores of children with cerebral palsy were lower when compared to reference samples as well as published international reports of children with cerebral palsy. No correlation was found between sex, socioeconomic background, presence of epilepsy, hearing or visual impairment, feeding difficulties or nutritional status and summary scores. Conclusion The health status of children with severe CP attending a tertiary referral centre in a resource limited setting as reported by the CHQ PF 28 is lower when compared to controls from the same setting. It is also lower compared to international reports of children with cerebral palsy. Further exploration of the factors which affect quality of life of children with cerebral palsy in resource limited settings is indicated.

Incidence of abdominal pain due to the anterior cutaneous nerve entrapment syndrome in an emergency department.

BackgroundPatients with chronic abdominal pain occasionally suffer from the anterior cutaneous nerve entrapment syndrome (ACNES). A substantial number of patients report previous visits to an emergency department (ED) with acute pain. Aim of this study was to obtain the incidence of ACNES in patients presenting with abdominal pain in the ED of a Dutch teaching hospital.MethodsIn this observational study, data sets of all patients visiting Máxima Medical Center’s (MMC) ED in 2011–2012 were searched for key terms ‘ACNES’, ‘intercostal neuralgia’ or ‘abdominal wall pain’. Files of potential patients living within hospital’s adherence area were checked using accepted criteria indicating the presence of ACNES. Disease incidence was calculated as a ratio to the hospital’s adherence data. The ACNES MMC 2013’s incidence in patients evaluated in the surgical outpatient department was also calculated.ResultsDuring the study period, 473 ED patient files met inclusion criteria. A total of 88 patients belonging to MMC’s adherence area were diagnosed with ACNES leading to a mean 22/100.000 ACNES yearly incidence rate. About one of 50 patients with abdominal pain visiting the ED suffered from ACNES. A 35/100.000 outpatient department ACNES incidence rate was calculated in the year of 2013. Combining these two ratios, a 1:1800 ACNES incidence in the general population was obtained.ConclusionsIn an ED setting of a Dutch teaching hospital, approximately 2% of patients presenting with acute abdominal pain suffered from ACNES. ED physicians should consider ACNES in abdominal pain patients with normal laboratory or imaging tests.

The use of nontreated mosquito-net mesh cloth for a tension free inguinal hernia repair: our experience.

Introduction:The prohibitive costs and scarcity of the imported prosthetic mesh for hernioplasty, has prevented its widespread use in most developing countries. We then set out to ascertain the outcome, complications (undue pain, wound infection, recurrence, and mesh extrusion) and cost implications in the use of a nontreated mosquito-net for inguinal hernioplasty.Materials and Methods:A prospective study of all consecutive adult patients with uncomplicated inguinal hernia who were admitted for open herniorrhaphy between January 2012 and December, 2013 at the Federal Medical Centre, Ido – Ekiti, South West, Nigeria. A sheet of the nontreated mosquito-net mesh 10 cm Χ 8 cm, autoclaved, a day prior to surgery was used for each patient's hernia repair. The operation sites were exposed and examined 3rd and 6th postoperative days. Findings were documented for analysis.Result:A total of 130 adult patients were recruited for this study of which 115 of the patients were males and 15 were females. Forty-four (41.53%) had inguinal hernia and 76 (58.46%) of them had inguinoscrotal hernia. They all had successful repair and were followed-up for complications for a period of 6 weeks to 6 months at the surgical out-patient department.Conclusion:Locally-sourced and autoclaved mosquito-net mesh is an effective alternative for hernioplasty especially in situations where commercial mesh is not readily available or affordable.

Impact of Physician-Pharmacist Collaborative Anticoagulation Clinic on Warfarin Therapy Management

Background: Approximately 40-45% interpatient variability in response to warfarin is still conspicuous. These uncertainties contribute to warfarin’s underuse in patients who could benefit from anticoagulation. Anticoagulation clinics provide systematic method for anticoagulation management, warfarin dosage adjustment and patient education. Methods: Prospective case-control study was conducted from May to September 2012 at surgical outpatient department at Shahid Gangalal National Heart Center, Nepal to compare physician-pharmacist collaborative anticoagulation clinic (PPAC) approach on warfarin therapy management (case) to usual anticoagulation therapy (UAT) provided by physicians (control). Control (n=75) and case group (n=75) were selected by systematic random sampling in such a way that ratio of control to case is 1:1. Participants who required warfarin for their mechanical heart valve replacement for at least three months via UAT approach were included. They were counseled on dosage regimen, diet, signs and symptoms of hemorrhagic or thromboembolic events. Patient anticoagulation therapy leaflet was provided to case group. Data related to warfarin were analyzed using repeated measure ANOVA. A p<0.05 was considered statistically significant. Results: Baseline international normalized ratio (INR) value in UAT approach (4.45 ± 2.00) was changed to 4.21 ± 1.75, 4.45 ± 2.00 and 4.21 ± 1.75 with p 0.807, 0.000 and 0.807 during first, second and third follow ups. In PPAC, baseline INR value (0.99 ± 0.81) was constantly maintained to 2.21 ± 0.77 with p 0.000 throughout all follow ups. In PPAC, baseline monthly cost minimizations were statistically significant, with p 0.000 on each. Conclusion: INR value of patient in PPAC approach was statistically within recommended range (p 0.000 on each condition). The study showed that INR value of the patients can be kept within the recommended range when physicians and pharmacist collaboratively manage patients’ warfarin therapy.

Clinical and Therapeutic Features of Neurofibromatosis in Ghana

Introduction. Neurofibromatosis (NF) is a generalized form of benign tumors of the peripheral nerves involving the skin, subcutaneous tissue, and bone. It comprises neurofibromatosis type 1 (NF-1), neurofibromatosis type 2 (NF-2), and schwannomatosis. Objective. To document the clinical and epidemiological features of patients with NF presenting at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, from January 2009 to December 2013, and the outcome of management. Patients and methods. This is a retrospective study. Data on all patients managed within the study period were retrieved from the records of the surgical outpatient department (SOPD) of KATH and theater records and analyzed. Results. Fifteen patients underwent surgery for function impairing and disfiguring lesions, comprising five males and 10 females. Their ages ranged from three years to 55 years, with a mean age of 27.3 years. Seventeen lesions were found on the 15 patients that required surgery: 10 on the head and neck, three on the trunk, two on the upper limbs, and two on the lower limbs. Three of the lesions were neurofibromas; 14 were plexiform lesions. Fourteen patients had NF-1; only one patient had NF-2; there were no cases of schwannomatosis. Debulking was done for 12 patients; this was combined with suspension in two cases and enucleation in one case. Excision was done for five patients. Eight of the lesions recurred and the patients underwent a second debulking procedure. Conclusion. NF causes disfigurement and functional deficits in affected patients. Surgery can achieve symptomatic relief. Early presentation is recommended for optimal results.

Pattern of drug utilization in surgical outpatient department of a teaching hospital located in western India

Pattern of drug utilization in surgical outpatient department of a teaching hospital located in western India

An unusual case of disseminated neuroendocrine tumor presenting with generalized lymphadenopathy

A 64-year-old male presented to the surgical out-patient department with multiple enlarged lymph nodes in the neck and axillae. As a routine practice in India, this patient was worked up on the lines of generalized lymphadenopathy with a provisional diagnosis of tuberculosis and lymphoma. The report of fine-needle aspiration cytology (FNAC) came as a surprise and on further work-up it turned out to be that the patient had disseminated neuroendocrine tumor from an unknown primary.

Crossed testicular ectopia, a rare congenital anomaly of the male genitalia, a case report

Crossed testicular ectopia (CTE) is a rare congenital anomaly of testicular descent in which migration of one testis towards the opposite inguinal canal. The ordinary presentation is that of ipsilateral inguinal hernia and contralateral cryptorchidism. Here, a 2-year-old boy presented in surgical outpatient department with right inguinal hernia and impalpable testis in left scrotum and inguinal canal. Right herniotomy was performed. Left testis was brought to the left scrotum through transceptal window.

Clinical, histopathological, radiological diagnosis of retro rectal developmental cysts, its review and differential diagnosis - A rare case report

Abstract: A 61 years female multiparous Indian woman presented in our surgical outpatient Department at Sri R.L.Jallappa Hospital Kolar, with chronic lower abdominal pelvic pain and swelling since 2 months, a retro rectal cyst was diagnosed keeping in mind Benign Cystic lesions like overian, recto rectal ,hydatid and other degenerative cystic lesions. Retro rectal cysts have been classified into traumatic, infective, degenerative, neoplastic, and developmental, according to their origin. This paper focuses on the developmental variety of retroperitoneal pelvic cysts, particularly those of mesothelium, mesonephric, or paramesonephric origin. Their clinical presentations depend on their location; they may be mesenteric, paraovorian, or vaginal. The pathogenesis and embryologic, diagnostic, and therapeutic aspects are reviewed and a case report is presented. Key words :- Recto- peritoneal pelvic cyst, degenerative cysts, Surgical excision, C.T, MRI,Histopathology

Comparative study of aspiration and non-aspiration cytology of palpable breast lumps and correlation with histopathology

Background: Breast lump is one of the most common presentations in surgical outpatient departments with anxiety regarding a possible malignancy. Hence a quick diagnosis of a lump in the breast is essential. Fine needle aspiration cytology is an ideal initial diagnostic modality in breast lumps. There is an alternative method of performing needle aspiration, known as fine needle capillary cytology where the specimen is obtained using just a needle without aspiration.Materials and Methods: This hospital-based cross sectional analytical study was carried out in Department of Pathology in National Academy of Medical Sciences, Bir Hospital for one year. The objective of this study was to compare aspiration and non-aspiration cytology of palpable breast lumps and correlation with histopathology.Results: The five criteria scored for each technique were background blood, amount of cellular material, cellular degeneration, cellular trauma and architectural preservation. Compared to fine needle aspiration cytology, fine needle capillary cytology yields less bloody smears with minimal degenerative changes and offers more diagnostically superior specimens. Fine needle aspiration cytology, on the other hand, gives a good yield of diagnostic material.Conclusion: Fine needle aspiration cytology and fine needle capillary cytology are quick, easy, safe and cost-effective techniques. . A high sensitivity and specificity of cytological diagnosis in this study proves that it is comparable to final histology report in its diagnostic efficiency. Thus, fine needle aspiration cytology is a very important preliminary diagnostic test in palpable breast lumps and the results show a high degree of correlation with the final histopathology report.DOI: http://dx.doi.org/10.3126/jpn.v4i8.11501 Journal of Pathology of Nepal; Vol.4,No. 8 (2014) 639-643

Giant unilocular hydatid cyst of spleen

Background: Hydatid cyst of spleen is a very rare condition. It is usually secondary to spread of cysts from other regions. Primary hydatid cyst of spleen without involvement of any other organ is even rarer. Here, we report a case of a giant unilocular hydatid cyst of spleen without involvement of any other organ. The patient underwent laparotomy and splenectomy was done. This case report aims at reporting a rare case of a primary giant unilocular hydatid cyst of spleen and describes its management. Case Presentation: A 45 year old female presented to the surgical outpatient department with complaint of fever, dull dragging ache and lump in the left upper abdomen. On examination there was a slightly tender lump in the left hypochondrium suggestive of splenomegaly. Ultrasonography and computed tomography of abdomen were suggestive of a giant unilocular splenic hydatid cyst. The patient was operated and splenectomy was performed. The patient was discharged on albendazole therapy and the follow-up was uneventful. Histopathological examination of the specimen confirmed the presence of hydatid cyst. Conclusion: Primary hydatid cyst of spleen is a very rare condition. Surgery remains the mainstay of treatment. The evolving concept is towards splenic preservation surgery with cyst enucleation to prevent overwhelming post-splenectomy infections.

Pattern of mammographic findings in Sokoto, Nigeria

Background: Radiological examination of the breast is established as an essential part of the modern multidisplinary approach to effective investigation and management of breast diseases. The standard techniques used for breast imaging are screen film X-ray mammography and real time ultrasound. The aim of this study is to document mammographic findings in females seeking medical attention at the Usmanu Danfodiyo University Teaching Hospital Sokoto, Nigeria. Methods: The study was a descriptive retrospective analysis of the mammographic breast examinations (both screening and diagnostic) seen over a period of one year (February 2012 - January 2013). A total 125 patients were recruited in this study. Relevant parameters extracted from the records included patients age, presenting complain, referring clinic/unit, indications and the reporting radiologist findings (diagnosis). All the data collected were analyzed using a Statistical Package for Social Sciences (SPSS) version 17.0 windows. Results: The age range of the study participants was 18 to 71 years with a mean and standard deviation value of 41.87±10.15. Majority of our patients (44%) were referred from GOPD (General Out Patient Department); followed by SOPD (Surgical Out Patient Department) with 41 patients (32.8%). Other referring clinics included Accident and Emergency (A and E) (3.2%), Staff Clinic (1.6%), Medical outpatient Department (MOPD) 4.0%, Clinic 1 less than 1%. Gynea Clinic (3.2%) and Radiotherapy Unit (1.6%). The commonest indications for these examinations in our patients include Breast Pain (unilateral or bilateral); Breast Lump (unilateral or bilateral), bloody nipple discharge, ?Breast Cancer (left or right), Fibrocystic dysplasia, mastitis among others. The predominant diagnosis observed in our results was BIRADS 1 (normal examination) which constituted 73 (58.4) patients. Conclusion: Most of our patients for diagnostic mammography were found to have Benign breast diseases than breast cancers; suggesting that there is a high diagnostic yield of mammography in the evaluation and management of breast diseases in this environment. DOI: http://dx.doi.org/10.3126/ajms.v5i4.9864 Asian Journal of Medical Sciences 2014 Vol.5(4); 79-83

Diarrhea Associated with Retroperitoneal Tumor

A 48-year-old male presented to the surgical outpatient department with complaints of copious, odorless, watery diarrhea for one year associated with abdominal pain, anorexia, and weight loss for 3 months. On examination, the patient was dehydrated; his pulse was 94 per minute and blood pressure was 100/64 mmHg. He was not icteric clinically. There was no palpable abdominal lump or any other significant findings. His laboratory investigations revealed hemoglobin of 9 gm/dL, fasting blood sugar of 5.1 mmol/L and post prandial 5.9 mmol/L, urea 6.4 mmol/L, serum Na 142 mmol/L, potassium 2.8 mmol/L, bilirubin 7 µmol/L with normal liver enzymes. Abdominal sonography showed a solid pancreatic mass arising from body and tail. Contrast-enhanced CT depicted a large pancreatic solid tumor 8 × 6 cm in size arising from body and tail of the pancreas (Fig. 1), with no dilatation of intra or extrahepatic biliary tree.

Duct Ectasia and Periductal Mastitis in Indian Women.

There is very little awareness of the general physicians and surgeons about the benign breast conditions such as duct ectasia (DE) and periductal mastitis (PDM) causing nipple discharge. Not only that these benign breast diseases ring a false alarm of cancer, they are also the second most common cause of benign breast diseases. The objective was to study the clinical and microbiological profiles of duct ectasia and periductal mastitis in Indian women for better understanding of the disease process, in order to be able to treat them well. Forty-one consecutive patients presenting to the Surgical Out-Patient Department with non-bloody nipple discharge with clinical and radiological features suggestive of DE or PDM were included. Microbial culture and cytopathological study of the nipple discharge were done. Histopathological studies and culture of the ductal tissue taken intraoperatively were carried out. There is no significant difference in the age distribution among women with DE and PDM. Smoking is not associated with DE and PDM of Indian patients in contrast to the Western literature evidence. Infective etiology was present in nearly 46% of the patients in the study population more so in the periductal mastitis cases. The most common isolated pathogens were Staphylococcus aureus and Staphylococcus epidermidis, unlike in Western population where nearly 50% were anaerobes. Since the isolated organisms were resistant to the routinely used antibiotics in high proportion of cases, culture and sensitivity should be done in all possible cases for appropriately treating the subareolar sepsis before proceeding with the definitive treatment in the form of duct excision.

Limited Potential for Prevention of Emergency Surgery for Femoral Hernia

Femoral hernias are frequently operated on as an emergency. Emergency procedures for femoral hernia are associated with an almost tenfold increase in postoperative mortality, while no increase is seen for elective procedures, compared with a background population. The aim of this study was to compare whether symptoms from femoral hernias and healthcare contacts prior to surgery differ between patients who have elective and patients who have emergency surgery. A total of 1,967 individuals operated on for a femoral hernia over 1997-2006 were sent a questionnaire on symptoms experienced and contact with the healthcare system prior to surgery for their hernia. Answers were matched with data from the Swedish Hernia Register. A total of 1,441 (73.3%) patients responded. Awareness of their hernia prior to surgery was denied by 53.3% (231/433) of those who underwent an emergency procedure. Of the emergency operated patients, 31.3% (135/432) negated symptoms in the affected groin prior to surgery and 22.2% (96/432) had neither groin nor other symptoms. Elective patients had a considerably higher contact frequency with their general practitioner, as well as the surgical outpatient department, prior to surgery compared with patients undergoing emergency surgery (p < 0.001). Patients who have elective and patients who have emergency femoral hernia surgery differ in previous symptoms and healthcare contacts. Patients who need emergency surgery are often unaware of their hernia and frequently completely asymptomatic prior to incarceration. Early diagnosis and expedient surgery is warranted, but the lack of symptoms hinders earlier detection and intervention in most cases.