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Breast cancer is the first cancer in women in terms of incidence and mortality. In Morocco, it is a public health problem. Its prognosis is strongly linked to the stage at which it is diagnosed. It is a pathology for which diagnosis means are highly developed today, ranging from early detection to the demonstration of infra-clinical lesions, which has markedly improved the prognosis in developed countries. This work aims to identify the factors that lead patients to consult at an advanced stage in our daily practice. It is a retrospective study carried out from January 2018 to December 2018 including 525 patients with breast cancer followed in the medical oncology department of the Mohammed VI University Hospital in Marrakech. The average age was 54. The average time for consultation was 10.3 months. 63% of patients were from rural areas. Delayed diagnosis affected women above 35 years of age (80%). The most common method of detection was self-examination in 74% of cases. Inflammation (2.66%), ulceration (1.14%), signs of metastases (17.14%), and isolated breast nodes (79.4%) were other reasons for consultation. 82.2% of patients were locally advanced at the time of diagnosis. The time for treatment in our study was 3.7 weeks. In our practice, it is the conjunction of ignorance, poverty, socio-cultural habits, and difficult geographical access that are the essential factors in the late diagnosis of breast cancer.

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OBJECTIVE: Ulcerative colitis and Crohn's disease are chronic inflammatory diseases and represent the two most important types of inflammatory bowel diseases (IBD), while spondyloarthritis (SpA) comprises a heterogeneous group of systemic inflammatory chronic rheumatic diseases, including peripheral SpA and axial SpA. Joint manifestations are the most commonly observed extraintestinal manifestations, and they can precede or not the diagnosis of IBD. Notably, in women, misdiagnoses of IBD as irritable bowel syndrome and SpA as fibromyalgia are common, leading to delayed diagnoses, increased disease burden, and poorer prognoses. This narrative review emphasizes the critical role of diagnostic tools in facilitating early referrals of IBD patients with suspected SpA and vice versa to rheumatologists and gastroenterologists, respectively. Special attention is given to the multidisciplinary approach for more effective management of these conditions, particularly in female patients. METHODS: In this narrative review, we critically evaluated the literature on this topic, focusing on papers written in English that address female issues in IBD and SpA. RESULTS: IBD and SpA are chronic inflammatory disorders often occurring in the same patients. Female patients are often misdiagnosed, and this delay in diagnosis is associated with a higher disease burden and a poorer prognosis. CONCLUSIONS: A multidisciplinary approach is needed to enable early referral between gastroenterologists and rheumatologists, as this means a better prognosis for patients with a reduction in the economic and social burden associated with IBD and SpA.

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OBJECTIVE: The aim of the present review was to highlight gender and sex differences in spondyloarthritis (SpA) to achieve a better awareness of the unmet needs of women with SpA. METHODS: A literature search of PubMed was performed, including manuscripts in English published in the last twenty years, to select and analyze articles related to SpA and sex and gender differences in epidemiology, genetics, immunology, clinical features, and response to treatment. RESULTS: Women and men with SpA have different disease phenotypes, and this heterogeneity mirrors anatomical, physiological, and hormonal differences, as well as peculiar variability in response to treatment. These underestimated differences, which include several biological factors and intertwined social factors, contribute to diagnostic delay and increased disease burden in women with SpA. CONCLUSIONS: This review elucidates gender differences in SpA and raises awareness about the need for gender-related stratification of SpA patients with the concomitant implementation of SpA gender differences in future research and upcoming clinical trials. A deeper knowledge of SpA in women is indispensable to pave the way for real personalized medicine for SpA patients to reduce misdiagnosis and delay in intercepting the disease.

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Chronic kidney disease (CKD) presents a significant global health challenge, often progressing to end-stage renal disease (ESRD) necessitating renal replacement therapy (RRT). Late referral (LR) to nephrologists before RRT initiation is linked with adverse outcomes. However, data on CKD diagnosis and survival post-RRT initiation in Kazakhstan remain limited. This study aims to investigate the impact of late CKD diagnosis on survival prognosis after RRT initiation. Data were acquired from the Unified National Electronic Health System (UNEHS) for CKD patients initiating RRT between 2014 and 2019. Survival post-RRT initiation was assessed using the Cox Proportional Hazards Model. Totally, 211,655 CKD patients were registered in the UNEHS databases and 9,097 (4.3%) needed RRT. The most prevalent age group among RRT patients is 45-64 years, with a higher proportion of males (56%) and Kazakh ethnicity (64%). Seventy-four percent of patients were diagnosed late. The median follow-up time was 537 (IQR: 166-1101) days. Late diagnosis correlated with worse survival (HR = 1.18, p < 0.001). Common comorbidities among RRT patients include hypertension (47%), diabetes (21%), and cardiovascular diseases (26%). The history of transplantation significantly influenced survival. Regional disparities in survival probabilities were observed, highlighting the need for collaborative efforts in healthcare delivery. This study underscores the substantial burden of CKD in Kazakhstan, with a majority of patients diagnosed late. Early detection strategies and timely kidney transplantation emerge as crucial interventions to enhance survival outcomes.

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Depersonalization/derealization disorder (DPD) is a prevalent yet inadequately understood clinical condition characterized by a recurrent or persistent sense of unreality. This study aims to provide insight into DPD through descriptive and comparative analyses involving a large group of Chinese participants. The socio-demographic details (age, gender proportion, education, occupational status, marital status), depersonalized and dissociative symptom characteristics (symptomatic factors or subscales of the Cambridge Depersonalization Scale and the Dissociative Experiences Scale), development trajectory (age of onset, potential precipitating factors, course characteristics), treatment history (duration of delayed healthcare attendance, duration of delayed diagnosis, previous diagnoses), and adverse childhood experiences of the DPD patients are presented. Comparisons of anxiety and depressive symptoms, alongside psychosocial functioning, between DPD participants and those diagnosed with generalized anxiety disorder, bipolar disorders, and major depressive disorder were conducted. The analysis highlights a higher male preponderance and early onset of DPD, symptomatology marked by derealization, notable impairment in psychosocial functioning, and prolonged periods of delayed healthcare attendance and diagnosis associated with symptom severity. Furthermore, noteworthy relationships between adverse childhood experiences and symptom levels were identified. The findings substantiate the view that DPD is a serious but neglected mental disorder, urging initiatives to improve the current condition of DPD patients.

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BACKGROUND: Hair thread tourniquet syndrome occurs when tissue is strangulated by a hair thread. It occurs most commonly in the digits of infants and young children, but can also occur in the genitalia. CASE REPORT: A 13-year-old postmenarchal girl with several days of severe vulvar pain and swelling presented to the emergency department. Diagnosis was unclear and she was referred to pediatric and adolescent gynecology. Pelvic examination under anesthesia revealed a hair thread tourniquet involving the bilateral labia minora. The hair tourniquet and portions of bilateral labia minora were excised. Why Should an Emergency Physician Be Aware of This? Genital hair thread tourniquet syndrome is uncommon but must be considered in patients with severe genital pain and swelling. Prompt diagnosis and treatment are important to prevent tissue necrosis and may be facilitated by means of a pelvic examination with sedation.

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RATIONALE: Gaucher disease (GD) is a rare hereditary lysosomal storage disorder disease progression and inappropriate treatment. However, not all patients with GD receive timely diagnosis and treatment. PATIENT CONCERNS: Early diagnosis is important for initiating proper treatment and preventing complications. DIAGNOSES: Two patients were diagnosed as GD in this study. INTERVENTIONS AND OUTCOMES: These 2 patients received the imiglucerase enzyme replacement and symptoms significantly improved by the follow-up. LESSONS: Herein, we report 2 patients with a delayed diagnosis of GD to increase awareness and improve education regarding rare diseases. However, noninvasive ß-glucocerebrosidase activity or GBA gene testing had not been done before bone marrow aspiration, which are the noninvasive and reliable tests that indicate the diagnosis of GD.

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Introduction: The lungs are most commonly involved in tuberculosis, but infection can also involve other organs through lymphohematogenous dissemination. The clinical presentation of disseminated tuberculosis is variable. Diagnosis is difficult, because clinical manifestations are diverse, more than 50% of patients present late, because microbiological testing relies on invasive procedures for mycobacterial culture and supportive histopathology. Case report: A 30-year-old male patient, deprived of his liberty, with no co-morbidities, was admitted to the hospital for severe pain in the left wrist, with a previous history of having received systemic glucocorticoids for 7 months. He developed clinical symptoms of pulmonary tuberculosis, in the pleura, in the joint of the left wrist and in the left testicle, and tests confirmed the presence of M. tuberculosis. He underwent surgery on the wrist and testicle and was also treated for susceptible tuberculosis. Concomitant sequelae of iatrogenic Cushing's disease, chronic anemia and chronic inactive proctitis were diagnosed. Conclusions: Diagnosis of disseminated tuberculosis was difficult due to the non-specific clinical picture, limitations of confirmatory diagnostic tools and timely specialized evaluations. Prolonged use of systemic corticosteroids may have played a role in the dissemination of tuberculosis.

Introducción: Los pulmones son más afectados en la tuberculosis. La infección también puede comprometer a otros órganos a través de la diseminación linfohematógena. La presentación del cuadro clínico de la tuberculosis diseminada es variable. El diagnóstico es difícil, porque las manifestaciones clínicas son diversas. Más del 50% de los pacientes acuden tardíamente, porque las pruebas microbiológicas dependen de procedimientos invasivos para el cultivo de micobacterias y la histopatología de apoyo. Caso clínico: Paciente varón de 30 años, persona privada de su libertad, sin comorbilidades, ingresó al hospital por dolor intenso en muñeca izquierda, con historia previa de haber recibido glucocorticoides sistémicos durante siete meses. Desarrolló cuadro clínico de tuberculosis pulmonar en pleura, en articulación de la muñeca izquierda y en testículo izquierdo. En los análisis se confirmó presencia de . Fue intervenido quirúrgicamente en muñeca y en el testículo. Además, recibió tratamiento para tuberculosis sensible. Concomitantemente se diagnosticó secuelas de Cushing iatrogénico, anemia crónica y proctitis crónica inactiva. Conclusiones: El diagnóstico de tuberculosis diseminada fue difícil debido al cuadro clínico inespecífico, a las limitaciones de herramientas de diagnóstico confirmatorio y a las evaluaciones especializadas en forma oportuna. El uso prolongado de corticoides sistémicos habría influido en la diseminación de la tuberculosis.

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Delays in both the presentation and referral of soft tissue lesions have been extensively recorded in the existing literature. Such delays may result in lesions invading into surrounding tissues including neurovascular structures, increasing the risk of surgical complications and adverse consequences for patients. Delays in initiation of treatment of soft tissue sarcomas have further been associated with increased rates of metastasis. As such, patients' recovery may be limited due to late presentations, and residual morbidity may be more pronounced. This case report presents the predicament of a fungating mass in a female in her 80s in order to emphasise the importance of identifying and referring to such lesions early on. The referral delay of this lesion highlights the impact increasing awareness of this condition among both healthcare professionals and patients could have by allowing for earlier interventions.

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The spatial delays of pulmonary tuberculosis (PTB) have been less explored. In this study, a total of 151,799 notified PTB cases were included, with median patient and diagnostic delays of 15 [interquartile range (IOR), 4-35] and 2 (IOR, 0-8) days, respectively. The spatial autocorrelation analysis and spatial-temporal scan statistics were used to determine the clusters, indicating that the regions in the southwestern and northeastern parts of Zhejiang Province exhibited high rates of long-term patient delay (LPD, delay ≥ 15 days) and long-term diagnostic delay (LDD, delay ≥ 2 days). Besides, the Mantel test indicated a moderately positive correlation between public awareness of suspicious symptoms and the LPD rate in 2018 (Mantel's r = 0.4, P < 0.05). These findings suggest that PTB delays can reveal deficiencies in public health education and the healthcare system. Also, it is essential to explore methods to shift PTB knowledge towards real changes in attitude and behavior to minimize patient delay. Addressing these issues will be crucial for improving public health outcomes related to PTB in Zhejiang Province.

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BACKGROUND: Tuberculosis(TB) and Diabetes comorbidity is an emerging public health problem in India. Delays in diagnosing TB or Diabetes would lead to adverse outcomes among comorbid patients, and attempts must be made to reduce these delays. Against this background, the study has been undertaken to clarify the role of sociocultural factors in determining diagnostic delays for TB and Diabetes among comorbid patients. METHODS: A cross-sectional cultural epidemiological survey of the randomly selected 180 TB-Diabetes comorbid patients was carried out. The study examined sociocultural factors of delayed diagnosis of TB and Diabetes among urban and rural TB-Diabetes comorbid patients registered under TB-Diabetes collaborative activities under the National TB Elimination Programme (NTEP) in the Satara district of Maharashtra by using a semi-structured interview schedule. The patterns of distress (PDs) and perceived causes(PCs) of TB and Diabetes were compared with patients' and providers' diagnostic delays of TB and Diabetes based on prominence categories. In addition, the relationship between PDs and PCs as explanatory variables and TB and Diabetes diagnostic delays as outcome variables were assessed using stepwise multiple logistic regression. RESULTS: Of the 180 TB-Diabetes comorbid patients, the proportion of men was higher, and they were 4.7 times more likely to get a delayed Diabetes diagnosis. Those who reported side effects of drugs and stigma reduced social status as the PDs were 2-3 times more likely to delay reaching TB facilities/providers (patients' diagnostic delay). Those who perceived inadequate diet and mental-emotional stress as the causes of TB were about three times more likely to reach the TB providers/facilities after two weeks. Also, those who perceived TB as a cause of punishment for prior deeds were two times more likely to reach TB facilities/providers after two weeks. Patients who reported fever and chest pain as the symptoms of TB were two times more likely to delay the diagnosis of TB. Patients who reported tobacco consumption, unhealthy lifestyles, thoughts, worries, tension, and germs or infection as perceived causes of TB were about two times more likely to be diagnosed after two weeks. Patients who reported excessive thirst as a diabetes symptom were about two times more likely to get delayed >2 weeks to reach diabetes facilities/providers. Patients who perceived environmental/occupational exposure as the cause of Diabetes were two times more likely to reach the diabetes facilities/providers after two weeks. Patients who reported excessive thirst and stroke as the physical problems of Diabetes were 3.2 and 9.6 times more likely to get delayed in the diagnosis of Diabetes (providers' diagnostic delay). Patients who perceived violation of taboo or misbehaviour as the perceived cause of Diabetes were 6.7 times more likely to get a delayed diagnosis of Diabetes. CONCLUSIONS: The sociocultural factors associated with TB and Diabetes diagnostic delays among comorbid patients are essential considerations in the evolving context of implementing TB-Diabetes collaborative activities. Therefore, acknowledging sociocultural factors concerning delayed diagnosis and minimising delays would strengthen joint TB-Diabetes collaborative activities under the National framework locally and nationally.

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BACKGROUND: Tuberculosis (TB) infectiousness decreases significantly with only a few days of treatment, but delayed diagnosis often leads to late treatment initiation. We conducted a sequential explanatory mixed methods study to understand the barriers and facilitators to prompt diagnosis among people with TB. METHODS: We enrolled 100 adults who started TB treatment in the Carabayllo district of Lima, Peru, between November 2020 and February 2022 and administered a survey about their symptoms and healthcare encounters. We calculated total diagnostic delay as time from symptom onset to diagnosis. We conducted semi-structured interviews of 26 participants who had a range of delays investigating their experience navigating the health system. Interview transcripts were inductively coded for concepts related to diagnostic barriers and facilitators. RESULTS: Overall, 38% of participants sought care first from public facilities and 42% from the private sector. Only 14% reported being diagnosed with TB on their first visit, and participants visited a median of 3 (interquartile range [IQR] health facilities before diagnosis. The median total diagnostic delay was 9 weeks (interquartile range [IQR] 4-22), with a median of 4 weeks (IQR 0-9) before contact with the health system and of 3 weeks (IQR 0-9) after. Barriers to prompt diagnosis included participants attributing their symptoms to an alternative cause or having misconceptions about TB, and leading them to postpone seeking care. Once connected to care, variations in clinical management, health facility resource limitations, and lack of formal referral processes contributed to the need for multiple healthcare visits before obtaining a diagnosis. Facilitators to prompt diagnosis included knowing someone with TB, supportive friends and family, referral documents, and seeing a pulmonologist. CONCLUSIONS: Misinformation about TB among people with TB and providers, poor accessibility of health services, and the need for multiple encounters to obtain diagnostic tests were major factors leading to delays. Extending the hours of operation of public health facilities, improving community awareness and provider training, and creating a formal referral process between the public and private sectors should be priorities in the efforts to combat TB.

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This study investigated the association between serum albumin concentration and 12-weeks mortality of HIV/AIDS with late diagnosis in China. This retrospective cohort study included, 1079 inpatients diagnosis with late HIV/AIDS between January 2018 and December 2021. Disease progression was estimated based on the 12-weeks mortality rate. Cox proportional hazards regression models were used to evaluate the relationship between serum albumin levels and disease progression. The effects of serum albumin levels on mortality was estimated via Kaplan-Meier curves. The mortality risk decreased by 7% with every 1 g/L increase in serum albumin after adjustment ([HR] = 0.93, 95% CI: 0.88-0.97). Compared with that of the low (< 28 g/L) serum albumin group, the middle (28-34 g/L) group's mortality risk decreased by 70% (HR = 0.30, 95% CI: 0.15-0.59), and that of the high (≥ 34 g/L) group decreased by 40% (HR = 0.6, 95% CI: 0.29-1.23) after adjustment. Our findings suggest a positive correlation between the increase in serum albumin levels upon admission and a decrease in mortality at 12 weeks post-discharge among patients with late AIDS/HIV diagnosis. Further research is needed to characterize the role of serum albumin in 12-weeks mortality prevention in patients with a late diagnosis.

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22q11.2 deletion syndrome is a condition with complex multisystem involvement, and many clinicians will encounter patients living with the condition. 22q11.2 deletion syndrome is known to significantly increase the risk of psychosis, and there is some emerging evidence that 22q11.2 deletion syndrome may be associated with an increased risk of malignancy. We report on a case of an adolescent female who had a delayed diagnosis of 22q11.2 deletion syndrome after she developed severe psychosis at an early age. She was subsequently diagnosed in late adolescence with papillary thyroid carcinoma. This case contributes to the limited body of evidence regarding the treatment of psychosis secondary to 22q11.2 deletion syndrome and the potential increased risk of malignancy associated with the genetic condition.

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AIM: The study aims to identify factors influencing referral patterns and delays in rheumatoid arthritis (RA) patients across clinical settings in India. MATERIALS AND METHODS: A prospective, multicenter, observational study collected data from eight centers using the Indian Rheumatology Association (IRA) database. Patient-related factors and referral factors were determined based on patient narration. The modified PRASAD scale categorized patients' socioeconomic status. RESULTS: The study included 4,643 RA patients from eight centers. Data from 35 patients were excluded due to inconsistent reporting of diagnosis and delay. Lack of awareness was the predominant factor causing the delay in referral. Approximately, 39% of patients were referred to the rheumatology specialty within 6 months of disease onset, while 26% reported later, and 34% reported over 2 years. Referral delays were linked to socioeconomic factors in Madhya Pradesh (21.43%) and West Bengal (28.57%). Lack of awareness about the disease and rheumatology specialty was highest in West Bengal (100%), followed by Delhi and Rajasthan (93.70%). Misconceptions about modern medicine, reluctance to refer patients to the rheumatologist, and previous treatment by other specialities were other factors influencing referral delay. Primary care clinicians' unawareness of the rheumatology specialty was the primary reason for referral delay in Gujarat (33.56%) and Delhi and Rajasthan (25.18%). CONCLUSION: Both patient and healthcare professional-related factors contribute to referral delays in RA patients. Major factors causing referral delays include reluctance to refer and inadequate knowledge about rheumatology among primary care physicians and the general public. Patients' education and occupation also influence the timing of referrals to specialty care.

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This reflective piece deals with the challenges of healthcare delivery in a resource-constrained setting. The narrative is set in an emergency room and the story follows a doctor's desperate efforts to save a young girl suffering from disseminated tuberculosis, whose condition is exacerbated by economic hardships and delayed diagnosis. This story is a compelling commentary on the inequities in healthcare, and the urgent need for systemic change to ensure that all individuals, regardless of their economic status, have access to quality healthcare and health as a fundamental right of the people is established.

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