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The purpose was to study the outcomes and factors affecting the survival of esophageal atresia in our center. A retrospective analysis of 86 cases of esophageal atresia (EA) over a 10-year period was performed with 46 boys and 42 girls. Demographic data, birth weight, gestational age, consanguinity, incidence of associated anomalies, place of delivery, history of feeding, and outcomes were studied. EA with distal tracheoesophageal fistula (TEF) was the commonest type with 58/86 (67%). The percentage of patients with at least one associated anomaly was 52/86 (60%), with 7/86 (8%) who are from consanguineous parents; most commonly associated anomalies were cardiac 13/86 (15%). The average gestational age and birth weight were 36 ± 2 weeks and 2300 ± 570 g, respectively. Survival rates for the patients according to the Waterston classification was 80% in group A, 58% in group B, and 25% in group C (three patients died before surgery). Prematurity, the gap between the two ends of the esophagus, and preoperative respiratory status were the most significant factors affecting the survival. Late complication of EA/TEF include respiratory symptoms, especially in the first year, associating tracheomalacia and bronchopulmonary infections in about 24/45 (53%), recurrence of TEF 3/45 (7%), esophageal stricture 26/45 (58%), and gastroesophageal reflux 22/45 (49%). The high incidence of delayed diagnosis, low birth weight, and lack of advanced neonatological management are important contributory factors to the poor outcome. The frequency of late complications highlights the need for multidisciplinary clinics to follow these children's., (© 2014 International Society for Diseases of the Esophagus.)

Childhood cancer is a leading cause of childhood mortality in developed countries though ranks lower than infections in developing countries. Most patients with malignancies present late to hospital with consequent adverse outcome. Early diagnosis, therefore, is an important requirement in pediatric oncology as delayed diagnosis is associated with poor prognosis and huge economic cost. The study aims to identify factors associated with delay in the diagnosis of childhood cancer at University of Nigeria Teaching Hospital, Enugu.Children aged 0-17 years with admitting diagnosis of cancer which was histologically confirmed were reviewed prospectively over a 3-year period. An interviewer structured questionnaire was administered to patients or parents/caregivers to obtain information on patients' biodata, their symptoms as well as visit to health professionals or alternative health care providers before presentation at this hospital.Ninety patients were confirmed to have cancer. Overall median lag time (LT) was 15.7 weeks. Major contributors to delay were parents and the type of cancer patients presented with. Acute lymphoblastic leukemia (ALL) had the shortest median LT of 4.2 weeks while Hodgkin's disease had the longest median LT of 53.6 weeks (p = 0.01, Mann-Whitney test, 2-tailed). The median parent's delay was 12.3 weeks and health system delay was 3.6 weeks showing a significant difference in the two categories of delay (p < 0.0001, Mann-Whitney test, 2-tailed). The median treatment delay was 5 days.Public awareness and health system reform is imperative in reducing the delay in diagnosis of childhood cancer in our environment.

Background: In industrialized nations a curative therapy of retinoblastoma can be achieved in a large number of patients due to timely diagnosis and therapy. In developing countries the survival rates are much lower and very little data have been published especially from Africa., Objectives: This study was performed to investigate the survival and prognostic factors of retinoblastoma patients admitted to Kenyatta National Hospital, the national referral hospital in Kenya., Material and Methods: In this study all records of patients admitted with retinoblastoma from January 2000 to December 2004 were reviewed. Demographic data, clinical presentation, intraoperative findings and histology reports were recorded and the patients or their relatives were contacted during follow-up to investigate the outcome and survival., Results: Files of 160 patients (86 males and 74 females) were retrieved for this study. Data on 3-year survival could be acquired from 105 patients and the cumulative 3-year survival rate was 26.6 %. Factors significantly influencing survival were age at presentation less than 12 months, early disease at presentation (leukocoria only), no extraocular growth and total delay of management ≤ 5 months. Proptosis and tumor recurrence were associated with a 3-year mortality of 100 %., Conclusion: The main reasons for poor outcome were late presentation and recurrent disease after initial treatment elsewhere, extraocular growth and delay between initial presentation and treatment. Awareness of the public and of healthcare workers should be increased in order to reduce the time delay until diagnosis and treatment.

In childhood cancer patients, early diagnosis may have an impact on survival that reduces the potential morbidity. This study aimed to identify the factors associated with delay in diagnosis in children with cancer in southeastern Turkey. The clinical records of 682 patients with childhood cancer were evaluated. Study variables were classified as factors related to the patient, their disease, and the health care system. The median parental delay, physician delay, and total delay were determined as 20, 23, and 60 days, respectively. There was a significant relationship between parental delay, physician delay, and total delay and age at diagnosis (P = .005, P = .008, and P = .004, respectively). Long parental delay was least frequent in children younger than 1 year (P = .001). Parental, physician, and total delay were longer in patients with solid tumors than in patients with leukemias (P = .007, P = .000, and P = .000, respectively). Patients with tumors of the genitalia had longer physician delay and total delay than patients with other solid tumors (P = .001 and P = .000, respectively). Patients with solid tumor and early-stage disease had longer physician delay and total delay (P = .016 and P = .013, respectively). According to the first physician contacted, long physician delay was less frequent among pediatricians (P = .003). Delayed diagnosis was associated with age, type/localization and stage of tumor, the first physician consulted, and area of residence. A sustained effort should be made to raise the level of awareness of childhood cancer among parents and to sensitize all physicians, especially those who treat pediatric patients infrequently, with regard to the warning signs of the disease.

Background: The UK has poor lung cancer survival rates and high early mortality, compared to other countries. We aimed to identify factors associated with early death, and features of primary care that might contribute to late diagnosis., Methods: All cases of lung cancer diagnosed between 2000 and 2013 were extracted from The Health Improvement Network database. Patients who died within 90 days of diagnosis were compared with those who survived longer. Standardised chest X-ray (CXR) and lung cancer rates were calculated for each practice., Results: Of 20,142 people with lung cancer, those who died early consulted with primary care more frequently prediagnosis. Individual factors associated with early death were male sex (OR 1.17; 95% CI 1.10 to 1.24), current smoking (OR 1.43; 95% CI 1.28 to 1.61), increasing age (OR 1.80; 95% CI 1.62 to 1.99 for age ≥80 years compared to 65-69 years), social deprivation (OR 1.16; 95% CI 1.04 to 1.30 for Townsend quintile 5 vs 1) and rural versus urban residence (OR 1.22; 95% CI 1.06 to 1.41). CXR rates varied widely, and the odds of early death were highest in the practices which requested more CXRs. Lung cancer incidence at practice level did not affect early deaths., Conclusions: Patients who die early from lung cancer are interacting with primary care prediagnosis, suggesting potentially missed opportunities to identify them earlier. A general increase in CXR requests may not improve survival; rather, a more timely and appropriate targeting of this investigation using risk assessment tools needs further assessment., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Acral melanoma (AM) is an uncommon melanoma subtype occurring on the palms, soles and nail apparatus. It often lacks the typical features of primary melanoma resulting in delayed diagnosis., Objective: This article aims to raise awareness of AM and promote a high index of clinical suspicion to enable early diagnosis and improve outcomes for patients with AM., Discussion: The diagnosis of AM is often delayed because its presentation mimics other benign conditions such as fungal infections and ulcers. When lesions that were thought to be benign fail to respond to appropriate therapies, biopsy is critically important to exclude AM or other malignant pathology. Clinician awareness of the diversity of AM presentations, maintaining AM as part of their differential diagnosis and facilitating early biopsy are essential for early diagnosis and improving outcomes in patients with AM.

Background: The biliary atresia (BA) is the end result of a destructive and idiopathic inflammatory process affecting the intrahepatic and extrahepatic bile ducts, leading to fibrosis and biliary cirrhosis. The objective was to identify factors associated with mortality in children with BA., Methods: Observational, longitudinal, analytical and retrospective study carried out in patients with biliary atresia treated between 2008 and 2012 in a tertiary care hospital from the Instituto Mexicano del Seguro Social., Results: A total of 66 patients with BA; 49 were girls (74.2 %), 47 underwent hepatic portoenterostomy (or Kasai procedure: KP), the age at delivery was 4.5 months. When comparing the groups with and without KP, the lower age at the time of delivery, the age of diagnosis, a lower score on the PELD score and the Child-Pugh for the group with Kasai were statistically significant. Patients who died had a PELD score statistically higher (median 20) than those who lived (median 13), p = 0.004. The factor directly related with the mortality was the history of KP with an OR of 0.17 (95 % CI 0.04-0.71, p = 0.016)., Conclusions: The prognosis of children with BA remains gloomy because they are diagnosed in late stages. The most important factor associated with mortality in these patients is to perform KP.

Background: Reconfiguration of the Irish Health Service has diverted of large numbers of acutely ill medical patients to a reduced number of hospitals and may have caused in delays in treatment. Although prompt care improves outcomes for patients with acute myocardial infarction, stroke, infection and shock, there is surprisingly little evidence for its value in other conditions., Methods: The time of admission and time patients waited to be seen and clerked by a doctor was reviewed on all medical patients admitted to Nenagh Hospital prior to service reconfiguration (i.e. from 17 February 2000 to 6 March 2004)., Results: Over the study period of 1442,days 9435 patients were admitted (i.e. 6.5 patients per day or 0.3 per hour) and waited 37.6 SD 53.1min after admission before they were seen by a doctor. The peak time of admission is in the late afternoon and early evening and there was a liner correlation between the delay before seeing a doctor and the time of admission. The 1095 patients who waited 80min or more to be seen and clerked by a doctor (median delay 120min) were more likely to die (odds ratio 1.36 95% CI 1.03-1.81, p <0.03)., Conclusion: Waiting to be seen by a doctor may increase the risk of death to some patients. For these patients it is probably safer to be seen quickly by any doctor, rather than travel many miles and wait several hours to see a better one., (Copyright © 2014 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Objectives: Spontaneous bacterial peritonitis (SBP) is associated with high mortality. Early paracentesis (EP) is essential for rapid diagnosis and optimal treatment. The aim of the study is to compare the outcomes of patients with SBP who received EP vs. delayed paracentesis (DP)., Methods: Consecutive patients who were diagnosed with SBP (ascites neutrophil count ≥250 cells/mm(3) and clinical evidence of cirrhosis) <72 h from the first physician encounter at two centers were identified. EP was defined by receiving paracentesis <12 h and DP 12-72 h from hospitalization. Primary outcome was in-hospital mortality., Results: The mean age of 239 patients with SBP was 53±10 years; mean Model for End-Stage Liver Disease (MELD) score was 22±9. In all, 98 (41%) patients who received DP had a higher in-hospital mortality (27% vs. 13%, P=0.007) compared with 141 (59%) who received EP. Furthermore, DP group had longer intensive care days (4.0±9.5 vs. 1.3±4.1, P=0.008), hospital days (13.0±14.7 vs. 8.4±7.4, P=0.005), and higher 3-month mortality (28/76, 37% vs. 21/98, 21%; P=0.03) compared with the EP group. Adjusting for MELD score ≥22 (adjusted odds ratio (AOR)=5.7, 95% confidence interval (CI)=1.8-18.5) and creatinine levels ≥1.5 mg/dl (AOR=3.2, 95% CI=1.4-7.2), DP was associated with increased in-hospital mortality (AOR=2.7, 95% CI=1.3-4.8). Each hour delay in paracentesis was associated with a 3.3% (95% CI=1.3-5.4%) increase in in-hospital mortality after adjusting for MELD score and creatinine levels., Conclusions: Hospitalized patients with SBP who received DP had a 2.7-fold increased risk of mortality adjusting for MELD score and renal dysfunction. Diagnostic paracentesis performed <12 h from hospitalization in patients with cirrhosis and ascites may improve short-term survival.

Background: The number of imported malaria cases in Poland compared with other European countries remains low. However, in view of the high mortality and the large proportion of severe clinical forms, a better understanding of the problem is required., Methods: Data reported to the surveillance system in Poland between 2003 and 2011 were reviewed retrospectively. All cases were laboratory confirmed as outlined by the EU case definition. Statistical analysis was performed using Epi Info 3.5.3 and STATA 10., Results: A total of 189 confirmed malaria cases, including 5 that were fatal, were reported in Poland during the study period. All cases were imported: 72% came from Africa. Among cases with a species-specific diagnosis, 118 (73%) were caused by Plasmodium falciparum. The median age of individuals afflicted was 36 years and 74% were males. Most cases occurred among work-related travelers (40%) or tourists (38%). Individuals born in malaria-endemic countries constituted 12% of all cases. The severe malaria form was identified in 23% of all cases and was more frequent among cases caused by P. falciparum (32%), in people older than 50 years (39%), and in cases when diagnosis was delayed (36%). The severe form occurred only in 9% of cases originating from malaria-endemic countries and there were no fatalities in this group. Fatal outcomes were associated with a delay in diagnosis (fatality = 10.5%) and falciparum malaria (fatality = 4%). Most of the delays resulted from a delay in seeking medical care, and less frequently due to misdiagnosis., Conclusions: Tourists and work-related travelers make up most of the malaria patients in Poland and they are at a greater risk of the severe form of malaria and consequently death, possibly due to the lack of immunity. Delayed diagnosis is associated with mortality, implying low awareness of the threat that malaria poses, both among patients and doctors., (© 2014 International Society of Travel Medicine.)

The objectives were to describe times to diagnosis and initiation of treatment in pediatric ALL in Ontario from 1997 to 2007, and to measure their impact on OS and EFS. In 1000 children, the median times to diagnosis and treatment were both 1 day (IQR = 1-2). Those who began treatment >3 days after diagnosis had inferior OS (AHR = 2.49; 95% CI = 1.40-4.43; p = 0.002), and inferior EFS (AHR = 1.73; 95% CI = 1.01-2.96; p = 0.047) compared to those who began treatment ≤ 3 days after diagnosis. There was no statistically significant relationship between time to diagnosis and survival. Longer time to treatment was associated with worse survival in pediatric ALL; reasons for this relationship may be multi-factorial., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: To determine whether there was an association between delayed medical emergency team calls and mortality after a medical emergency team review., Design: This was a prospective observational study., Setting: A university-affiliated tertiary referral hospital in Porto Alegre, Brazil., Patients: All patients were reviewed by the medical emergency team from July 2008 to December 2009., Interventions: None., Measurements and Main Results: There were 1,481 calls for 1,148 patients. Delayed medical emergency team calls occurred for 246 patients (21.4%). The criterion associated with delay was typically the same criterion for the subsequent medical emergency team call. Physicians had a greater prevalence of delayed medical emergency team calls (110 of 246 [44.7%]) than timely medical emergency team calls (267 of 902 [29.6%]; p < 0.001). The mortality at 30 days after medical emergency team review was higher among patients with delayed medical emergency team activation (152 [61.8%]) than patients receiving timely medical emergency team activation (378 [41.9%]; p < 0.001). In a multivariate analysis, delayed medical emergency team calls remained significantly associated with higher mortality., Conclusions: Delayed medical emergency team calls are common and are independently associated with higher mortality. This result reaffirms the concept and need for a rapid response system.

Objective: Often, as diabetes mellitus type 2 (T2DM) evolves insidiously, prevention is commenced late and diagnosis is made when vascular damage has been set. Hence, our hypothesis is that T2DM awareness may influence the outcome of atherothrombotic events., Methods: A consecutive cohort of patients manifesting ST-elevation myocardial infarction (MI) was classified according to the presence and awareness of the diagnosis of T2DM: known diabetes (kT2DM, n = 72), unknown diabetes (uT2DM, n = 80) and no diabetes (ND, n = 333). Medical history, laboratory data, and angiographic findings including myocardial blush grade (MBG) were prospectively obtained. The primary endpoint was in-hospital death and secondary endpoint was major adverse cardiac events (MACE) defined as sudden cardiac death, fatal MI and nonfatal MI that occurred from 30 days of study entry onwards., Results: With the exception of glycated hemoglobin (p = 0.001) and triglycerides (p = 0.04), no differences were found between groups for all other biochemical, clinical or angiographic admission characteristics. Myocardial tissue reperfusion defined as MBG 3 was observed in 62% in the ND group, 50% in the kT2DM group and 23% in the uT2DM group (p = 0.01). All-cause in-hospital mortality was higher in uT2DM (16.7%) than in kT2DM (8.4%) and both groups had a higher mortality rate as compared with the ND group (3.8%, p = 0.01). During follow-up (653 ± 26 days), the incidence of MACE was higher in uT2DM than in kT2DM and in both compared to the ND group (p = 0.002)., Conclusion: Unawareness of T2DM diagnosis is strongly associated with a poor short- and long-term outcome after MI.

Background: Early diagnosis is considered a key factor in improving the outcomes in cancer therapy; it remains unclear, however, whether long pre-diagnostic patient pathways influence clinical outcomes negatively. The aim of this study was to assess the association between the length of the diagnostic interval and the five-year mortality for the five most common cancers in Denmark while addressing known biases., Methods: A total of 1128 patients with colorectal, lung, melanoma skin, breast or prostate cancer were included in a prospective, population-based study in a Danish county. The diagnostic interval was defined as the time from the first presentation of symptoms in primary care till the date of diagnosis. Each type of cancer was analysed separately and combined, and all analyses were stratified according to the general practitioner's (GP's) interpretation of the presenting symptoms. We used conditional logistic regression to estimate five-year mortality odds ratios as a function of the diagnostic interval using restricted cubic splines and adjusting for comorbidity, age, sex and type of cancer., Results: We found increasing mortality with longer diagnostic intervals among the approximately 40% of the patients who presented in primary care with symptoms suggestive of cancer or any other serious illness. In the same group, very short diagnostic intervals were also associated with increased mortality. Patients presenting with vague symptoms not directly related to cancer or any other serious illness had longer diagnostic intervals and the same survival probability as those who presented with cancer suspicious/serious symptoms. For the former, we found no statistically significant association between the length of the diagnostic interval and mortality., Conclusion: In full coherence with clinical logic, the healthcare system instigates prompt investigation of seriously ill patients. This likely explains the counter-intuitive findings of high mortality with short diagnostic intervals; but it does not explain the increasing mortality with longer diagnostic intervals. Thus, the study provides further evidence for the hypothesis that the length of the diagnostic interval affects mortality negatively., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: To identify the independent variables associated with death within 4 days after the first sepsis-induced organ dysfunction., Methods: In this prospective observational study, severe sepsis and septic shock patients were classified into 3 groups: Group 1, survivors; Group 2, late non-survivors; and Group 3, early non-survivors. Early death was defined as death occurring within 4 days after the first sepsis-induced organ dysfunction. Demographic, clinical and laboratory data were collected and submitted to univariate and multinomial analyses., Results: The study included 414 patients: 218 (52.7%) in Group 1, 165 (39.8%) in Group 2, and 31 (7.5%) in Group 3. A multinomial logistic regression analysis showed that age, Acute Physiology and Chronic Health Evaluation II score, Sepsis-related Organ Failure Assessment score after the first 24 hours, nosocomial infection, hepatic dysfunction, and the time elapsed between the onset of organ dysfunction and the sepsis diagnosis were associated with early mortality. In contrast, Black race and a source of infection other than the urinary tract were associated with late death. Among the non-survivors, early death was associated with Acute Physiology and Chronic Health Evaluation II score, chronic renal failure, hepatic dysfunction Sepsis-related Organ Failure Assessment score after 24 hours, and the duration of organ dysfunction., Conclusion: Factors related to patients' intrinsic characteristics and disease severity as well as the promptness of sepsis recognition are associated with early death among severe septic patients.

Objectives: Understanding the situation of cancer awareness which doctors give to patients might lead to prognostic prediction in cases of of colorectal cancer (CRC)., Methods: Subsets of 10,779 CRC patients were used to screen the risk factors from the Cancer Registry in Pudong New Area in cancer awareness, age, TNM stage, and gender. Survival of the patients was calculated by the Kaplan-Meier method and assessed by Cox regression analysis. The views of cancer awareness in doctors and patients were surveyed by telephone or household., Results: After a median observation time of 1,616 days (ranging from 0 to 4,083 days) of 10,779 available patients, 2,596 of the 4,561 patients with cancer awareness survived, whereas 2,258 of the 5,469 patients without cancer awareness and 406 of the 749 patients without information on cancer awareness died of the disease. All-cause and cancer- specific survival were poorer for the patients without cancer awareness than those with (P < 0.001 for each, log- rank test). Cox multivariate regression analysis showed that cancer concealment cases had significantly lower cancer-specific survival (hazard ratio (HR) = 1.299; 95 % confidence interval (CI): 1.200-1.407)and all-cause survival (HR = 1.324; 95 % CI: 1.227-1.428). Furthermore, attitudes of cancer awareness between doctors and patients were significantly different (P < 0.001)., Conclusion: Cancer concealment, not only late-stage tumor and age, is associated with a poor survival of CRC patients.

Background: Delayed diagnosis of squamous cell carcinoma (SCC) increases recurrence, metastatic potential, and management costs. This study aims to identify risk factors of patient-related delayed presentation in cutaneous SCC., Patients and Methods: A total of 513 patients, who first sought care for cutaneous lesions that were subsequently removed and histologically confirmed as SCCs, were included. Attitude to symptoms, psychosocial profile, and reasons for delayed presentation were obtained via a structured questionnaire-based interview. First presentation > 3 months from the onset of symptoms was considered as delayed., Results: Mean presentation time was 3.90 ± 2.05 months, while 186 patients delayed presentation. Multivariate logistic regression analysis revealed that serious co-morbidity (p = 0.003), low education level (p < 0.001), non-recognition of the seriousness of symptoms (p < 0.001), a 'wait and see' attitude (p < 0.001), and fatalism (p = 0.005) were independent determinants of significantly higher risk for delayed presentation. In contrast, female sex (p = 0.006), new lesion (p = 0.012), accessible topography (p = 0.019), size increase (p = 0.002), color change (p = 0.017), non-healing wound (p = 0.048), and presence of social support/advice (p < 0.001) were independent determinants significantly associated with early presentation., Conclusion: Recognition of symptom seriousness and elimination of factors hindering self-referral may increase awareness and promote early patient presentation and diagnosis of cutaneous SCC., (© 2013 S. Karger GmbH, Freiburg.)

Objective: To determine the predictors of death in Malaysian HIV-infected patients undergoing antiretroviral therapy (ART)., Methods: Data from 845 HIV-infected patients aged ≥ 20 years on ART in a large teaching hospital in Malaysia from 1989 to 2009 were analyzed using Kaplan-Meier and Cox regression analyses., Results: 72.7% of the patients survived. Multivariate Cox regression showed that significant predictors of death were age ≥ 50 years (HR 1.76; 95% CI 1.18-2.64), secondary education (HR 3.57; 95% CI 1.12-11.37), tertiary education (HR 3.57; 95% CI 1.09-11.70), being unemployed (HR 1.49; 95% CI 1.07-2.09), AIDS on initial presentation (HR 5.75; 95% CI 3.29-10.07), single-drug ART (HR 1.84; 95% CI 1.27, 2.66), double-drug ART (HR 1.63; 95% CI 1.19-2.25) and inability to achieve viral load ≤ 50 copies/ml (HR 10.22; 95% CI 7.26-14.37)., Conclusion: Every effort needs to be made to ensure that all HIV patients have access to triple drug ART, to lower viral load to ≤ 50 copies/ml and to treat HIV patients before they progress to AIDS as these are significant modifiable predictors of death in Malaysian HIV patients., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The purpose of this study is to estimate the survival probability of patients following their first admission for the treatment of AIDS to an infectious disease reference hospital in Belo Horizonte, Brazil, during 2005. Study subjects were monitored during a 12-month period to identify factors associated with survival probability. Late diagnosis was recorded among many of the 250 study subjects: almost half (44.8%) were diagnosed less than 30 days prior to or during their hospitalization. A high mortality rate was also detected: 39.6% of the subjects died during the 12 months of monitoring. The cumulative survival probability of the cohort group was estimated at 68.0% after 3 months and at 61.2% after 12 months. However, certain patient subgroups analyzed had even lower cumulative survival probabilities after 12 months of monitoring: if diagnosed during hospitalization, it was estimated at only 48.0% and those with no record of antiretroviral treatment had a 48.5% cumulative survival probability. Patients with severe anemia had the lowest survival probability, similar among the two lymphocyte count groups (<1000 mm(3) and ≥1000 mm(3)), the former with a 45.5% survival probability and the latter with a 46.7% one. The proportional death risk was 2.5-fold higher for men residing in other area than the capital city of the State of Minas Gerais and greater metropolitan region when compared with women residing there. The findings of this study highlight the importance of early diagnosis for predicting patient survival and reinforce the necessity of facilitating HIV diagnosis.

Objectives: To estimate life expectancy for people with HIV undergoing treatment compared with life expectancy in the general population and to assess the impact on life expectancy of late treatment, defined as CD4 count <200 cells/mm(3) at start of antiretroviral therapy., Design: Cohort study., Setting: Outpatient HIV clinics throughout the United Kingdom. Population Adult patients from the UK Collaborative HIV Cohort (UK CHIC) Study with CD4 count ≤ 350 cells/mm(3) at start of antiretroviral therapy in 1996-2008., Main Outcome Measures: Life expectancy at the exact age of 20 (the average additional years that will be lived by a person after age 20), according to the cross sectional age specific mortality rates during the study period., Results: 1248 of 17,661 eligible patients died during 91,203 person years' follow-up. Life expectancy (standard error) at exact age 20 increased from 30.0 (1.2) to 45.8 (1.7) years from 1996-9 to 2006-8. Life expectancy was 39.5 (0.45) for male patients and 50.2 (0.45) years for female patients compared with 57.8 and 61.6 years for men and women in the general population (1996-2006). Starting antiretroviral therapy later than guidelines suggest resulted in up to 15 years' loss of life: at age 20, life expectancy was 37.9 (1.3), 41.0 (2.2), and 53.4 (1.2) years in those starting antiretroviral therapy with CD4 count <100, 100-199, and 200-350 cells/mm(3), respectively., Conclusions: Life expectancy in people treated for HIV infection has increased by over 15 years during 1996-2008, but is still about 13 years less than that of the UK population. The higher life expectancy in women is magnified in those with HIV. Earlier diagnosis and subsequent timely treatment with antiretroviral therapy might increase life expectancy.

Rationale: Idiopathic pulmonary fibrosis is often initially misdiagnosed. Delays in accessing subspecialty care could lead to worse outcomes among those with idiopathic pulmonary fibrosis., Objectives: To examine the association between delayed access to subspecialty care and survival time in idiopathic pulmonary fibrosis., Methods: We performed a prospective cohort study of 129 adults who met American Thoracic Society criteria for idiopathic pulmonary fibrosis evaluated at a tertiary care center. Delay was defined as the time from the onset of dyspnea to the date of initial evaluation at a tertiary care center. We used competing risk survival methods to examine survival time and time to transplantation., Measurements and Main Results: The mean age was 63 years and 76% were men. The median delay was 2.2 years (interquartile range 1.0–3.8 yr), and the median follow-up time was 1.1 years. Age and lung function at the time of evaluation did not vary by delay. A longer delay was associated with an increased risk of death independent of age, sex, forced vital capacity, third-party payer, and educational attainment (adjusted hazard ratio per doubling of delay was 1.3, 95% confidence interval 1.03 to 1.6). Longer delay was not associated with a lower likelihood of undergoing lung transplantation., Conclusions: Delayed access to a tertiary care center is associated with a higher mortality rate in idiopathic pulmonary fibrosis independent of disease severity. Early referral to a specialty center should be considered for those with known or suspected interstitial lung disease.

Background: The purpose of this study was to examine the relationship between perceived social support and patient delay (PD) among female and male cancer patients., Methods: A population-based study with register-sampled cancer patients was designed. Patient delay was defined as the time interval between the patient's experience of the first symptom and the first contact with a health-care professional. Both dates were provided by the patients (n=910). The patients completed a purpose-designed questionnaire, which assessed the patient's perceptions of how the partner reacted ('Partner Avoidance' and 'Partner Support') and how others in the social network responded ('Other Avoidance' and 'Other Support') to the patient's worries about the symptoms. The associations between the social support subscales and PD were analysed separately for men and women., Results: In female patients, Partner Support and Other Support were associated with shorter PD, whereas Other Avoidance was associated with longer PD. In the multivariate analysis, Other Avoidance remained associated with longer PD. Moreover, disclosure of symptoms to someone reduced the likelihood of a long PD in female patients. In male patients, none of the social support scales significantly increased or decreased the risk of a long PD in the univariate analysis, but Partner Support significantly decreased risk of a long PD in the multivariate analysis., Conclusions: The results of this study suggest that social support and avoidance from network members influence length of PD differently in male and female cancer patients. This gender difference may explain previous mixed findings obtained in this field.

Infants affected with severe combined immunodeficiency (SCID) are susceptible to severe and recurrent infections and do not survive unless provided with immune reconstituting treatments. In the absence of population-based newborn screening, infants with SCID who do not have an affected older relative are ascertained only after they have developed infections. However, only limited data are available from the perspective of patients and families to indicate what proportion of SCID cases might benefit from earlier detection by pre-symptomatic screening, whether adequate treatment facilities are available, and how screening could improve SCID treatment outcomes. A survey of parents of children with SCID evaluated family history, pre- and post-diagnosis events, outcomes, and impact of SCID on families. Affected infants diagnosed with SCID as neonates had better survival, demonstrating the potential benefit of universal newborn screening., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Background: Gastric carcinoma is usually characterized with significant morbidity and mortality mainly because of late presentation. Late presentation of gastric carcinoma is a prominent feature in developing and poor countries., Aim of Study: The purpose of this study is to present our experience with the pattern and outcome of gastric tumors at the University of Benin Teaching Hospital, Benin City, Nigeria; with emphasis on late presentation of the patients., Patients and Methods: The case files of the patients that were managed at the University of Benin Teaching Hospital for gastric tumors over a 5-year period (January 2004 to December 2006) were analyzed for biodata, symptoms and signs of disease, findings at operation, treatment offered, and outcome of treatment., Results: The male/female ratio was 2.3:1, with the youngest patient being 38 years while the oldest patient was 76 years old. Upper abdominal pain and a palpable mass per abdomen were the commonest symptoms and signs, respectively. Alcohol ingestion was the commonest identifiable risk factor. Only 30.4% of the patients presented within a year of the onset of symptoms. The gastric antrum was affected in over 78% of the cases, and adenocarcinoma was found in about 90% of the patients. Partial gastrectomy with gastrojejunostomy was the commonest procedure carried out. The mortality rate was 39.1%, and of the patients that died, 66.7% occurred within a year from time of diagnosis., Conclusion: Most of the cases of gastric carcinoma presented in this study presented late with associated significant mortality. Health education is advised with a view to encouraging early presentation.

Objective: To identify a definition of presentation after clinical or immunological disease progression that will reliably identify an individual at high risk of mortality over the first 3 months after HIV diagnosis and that can be adopted as a basis for comparing over time and regions., Design: An observational cohort study., Methods: Individuals seen for the first time at a UK Collaborative HIV Cohort study clinic from 1996 to 2006 were identified. Two immunological (CD4 cell count < 200 cells/microl and CD4 cell count <50 cells/microl) and two clinical (AIDS and severe/moderate AIDS) criteria for presentation with advanced HIV disease were compared, as well as combinations of them. The predictive ability of each diagnosis for identifying individuals who died in the first 3 months after HIV diagnosis was assessed., Results: Fifteen thousand seven hundred and seventy-four patients were included, of whom 1495 (9.5%), 4231 (26.8%), 1523 (9.7%) and 379 (2.4%) had a CD4 cell count below 50 cells/microl, CD4 cell count below 200 cells/microl, AIDS or severe/moderate AIDS at diagnosis; CD4 cell counts were unavailable for 2264 (14.4%) patients. Two hundred and six (1.3%) patients died within the first 3 months. Sensitivities of the individual criteria ranged from 18.0% (severe/moderate AIDS) to 50.5% (CD4 cell count < 200 cells/microl) with specificities ranging from 73.5% (CD4 < 200 cells/microl) to 97.8% (severe/moderate AIDS). Combinations of clinical and immunological criteria increased the sensitivity but decreased the specificity., Conclusion: We propose that presentation with 'advanced HIV disease' is presentation with a CD4 cell count below 200 cells/microl or AIDS, whereas 'late' presentation is defined as presentation when the CD4 cell count is below that when treatment should be initiated (currently CD4 cell count < 350 cells/microl or AIDS).

This paper presents a geostatistical approach to incorporate individual-level data (e.g. patient residences) and area-based data (e.g. rates recorded at census tract level) into the mapping of late-stage cancer incidence, with an application to breast cancer in three Michigan counties. Spatial trends in cancer incidence are first estimated from census data using area-to-point binomial kriging. This prior model is then updated using indicator kriging and individual-level data. Simulation studies demonstrate the benefits of this two-step approach over methods (kernel density estimation and indicator kriging) that process only residence data.

The article is devoted to the problems of the well-timed diagnosis of autoimmune liver diseases, such as autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis and overlap-syndromes. It has been shown that diagnosis verification influences on the course of these conditions and the patient's longevity. The causes of last diagnosis and clinical and laboratory data have been analyzed. The authors based on literature facts, obtained results and their experience have advised the number of recommendations to improve the diagnosis of autoimmune liver disease. The well-timed diagnosis permits to elevate the longevity and to advance the quality of life.