Diagnostic delay of sarcoidosis: an integrated systematic review.

BACKGROUND: Sarcoidosis is a chronic inflammatory granulomatous disease of unknown cause. Delays in diagnosis can result in disease progression and poorer outcomes for patients. Our aim was to review the current literature to determine the overall diagnostic delay of sarcoidosis, factors associated with diagnostic delay, and the experiences of people with sarcoidosis of diagnostic delay. METHODS: Three databases (PubMed/Medline, Scopus, and ProQuest) and grey literature sources were searched. Random effects inverse variance meta-analysis was used to pool mean diagnostic delay in all types of sarcoidosis subgroup analysis. Diagnostic delay was defined as the time from reported onset of symptoms to diagnosis of sarcoidosis. RESULTS: We identified 374 titles, of which 29 studies were included in the review, with an overall sample of 1531 (694 females, 837 males). The overall mean diagnostic delay in all types of sarcoidosis was 7.93 months (95% CI 1.21 to 14.64 months). Meta-aggregation of factors related to diagnostic delay in the included studies identified three categories: (1) the complex and rare features of sarcoidosis, (2) healthcare factors and (3) patient-centred factors. Meta-aggregation of outcomes reported in case studies revealed that the three most frequent outcomes associated with diagnostic delay were: (1) incorrect diagnosis, (2) incorrect treatment and (3) development of complications/disease progression. There was no significant difference in diagnostic delay between countries with gatekeeper health systems (where consumers are referred from a primary care clinician to specialist care) and countries with non-gatekeeper systems. No qualitative studies examining people's experiences of diagnostic delay were identified. CONCLUSION: The mean diagnostic delay for sarcoidosis is almost 8 months, which has objective consequences for patient management. On the other hand, there is a paucity of evidence about the experience of diagnostic delay in sarcoidosis and factors related to this. Gaining an understanding of people's experiences while seeking a diagnosis of sarcoidosis is vital to gain insight into factors that may contribute to delays, and subsequently inform strategies, tools and training activities aimed at increasing clinician and public awareness about this rare condition. TRIAL REGISTRATION: PROSPERO Registration number: CRD42022307236.

Diagnostic delay of sarcoidosis: Protocol for an integrated systematic review.

INTRODUCTION: Sarcoidosis is a rare systemic inflammatory granulomatous disease of unknown cause. It can manifest in any organ. The incidence of sarcoidosis varies across countries, and by ethnicity and gender. Delays in the diagnosis of sarcoidosis can lead to extension of the disease and organ impairment. Diagnosis delay is attributed in part to the lack of a single diagnostic test or unified commonly used diagnostic criteria, and to the diversity of disease manifestations and symptom load. There is a paucity of evidence examining the determinants of diagnostic delay in sarcoidosis and the experiences of people with sarcoidosis related to delayed diagnosis. We aim to systematically review available evidence about diagnostic delay in sarcoidosis to elucidate the factors associated with diagnostic delay for this disease in different contexts and settings, and the consequences for people with sarcoidosis. METHODS AND ANALYSIS: A systematic search of the literature will be conducted using PubMed/Medline, Scopus, and ProQuest databases, and sources of grey literature, up to 25th of May 2022, with no limitations on publication date. We will include all study types (qualitative, quantitative, and mixed methods) except review articles, examining diagnostic delay, incorrect diagnosis, missed diagnosis or slow diagnosis of all types of sarcoidosis across all age groups. We will also examine evidence of patients' experiences associated with diagnostic delay. Only studies in English, German and Indonesian will be included. The outcomes we examine will be diagnostic delay time, patients' experiences, and factors associated with diagnostic delay in sarcoidosis. Two people will independently screen the titles and abstracts of search results, and then the remaining full-text documents against the inclusion criteria. Disagreements will be resolved with a third reviewer until consensus is reached. Selected studies will be appraised using the Mixed Methods Appraisal Tool (MMAT). A meta-analysis and subgroup analyses of quantitative data will be conducted. Meta-aggregation methods will be used to analyse qualitative data. If there is insufficient data for these analyses, a narrative synthesis will be conducted. DISCUSSION: This review will provide systematic and integrated evidence on the diagnostic delay, associated factors, and experiences of diagnosis delay among people with all types of sarcoidosis. This knowledge may shed light on ways to improve diagnosis delays in diagnosis across different subpopulations, and with different disease presentations. ETHICS AND DISSEMINATION: Ethical approval will not be required as no human recruitment or participation will be involved. Findings of the study will be disseminated through publications in peer-reviewed journals, conferences, and symposia. TRIAL REGISTRATION: PROSPERO Registration number: CRD42022307236. URL of the PROSPERO registration: https://www.crd.york.ac.uk/PROSPEROFILES/307236_PROTOCOL_20220127.pdf.

Nurse staffing and inpatient mortality in the English National Health Service: a retrospective longitudinal study.

OBJECTIVE: To examine the impact of nursing team size and composition on inpatient hospital mortality. DESIGN: A retrospective longitudinal study using linked nursing staff rostering and patient data. Multilevel conditional logistic regression models with adjustment for patient characteristics, day and time-invariant ward differences estimated the association between inpatient mortality and staffing at the ward-day level. Two staffing measures were constructed: the fraction of target hours worked (fill-rate) and the absolute difference from target hours. SETTING: Three hospitals within a single National Health Service Trust in England. PARTICIPANTS: 19 287 ward-day observations with information on 4498 nurses and 66 923 hospital admissions in 53 inpatient hospital wards for acutely ill adult patients for calendar year 2017. MAIN OUTCOME MEASURE: In-hospital deaths. RESULTS: A statistically significant association between the fill-rate for registered nurses (RNs) and inpatient mortality (OR 0.9883, 95% CI 0.9773 to 0.9996, p=0.0416) was found only for RNs hospital employees. There was no association for healthcare support workers (HCSWs) or agency workers. On average, an extra 12-hour shift by an RN was associated with a reduction in the odds of a patient death of 9.6% (OR 0.9044, 95% CI 0.8219 to 0.9966, p=0.0416). An additional senior RN (in NHS pay band 7 or 8) had 2.2 times the impact of an additional band 5 RN (fill-rate for bands 7 and 8: OR 0.9760, 95% CI 0.9551 to 0.9973, p=0.0275; band 5: OR 0.9893, 95% CI 0.9771 to 1.0017, p=0.0907). CONCLUSIONS: RN staffing and seniority levels were associated with patient mortality. The lack of association for HCSWs and agency nurses indicates they are not effective substitutes for RNs who regularly work on the ward.

An extremely rare case of multiple small bowel intussusceptions in a 20-year-old female.

Intussusception, which is characterized by the invagination of one portion of the gastrointestinal tract into an adjacent segment, is an uncommon cause of abdominal pain in adults. Given that it is typically associated with identifiable pathological abnormalities, intussusception can pose a diagnostic challenge in adults due to its rarity and nonspecific symptomatology. This report presents a unique case of multiple small bowel intussusceptions in a 20-year-old female, which emphasizes the importance of clinical suspicion and advanced imaging for an accurate diagnosis.

Light-Responsive Molecular Release from Cubosomes Using Swell-Squeeze Lattice Control.

Stimuli-responsive materials are crucial to advance controlled delivery systems for drugs and catalysts. Lyotropic liquid crystals (LLCs) have well-defined internal structures suitable to entrap small molecules and can be broken up into low-viscosity dispersions, aiding their application as delivery systems. In this work, we demonstrate the first example of light-responsive cubic LLC dispersions, or cubosomes, using photoswitchable amphiphiles to enable external control over the LLC structure and subsequent on-demand release of entrapped guest molecules. Azobenzene photosurfactants (AzoPS), containing a neutral tetraethylene glycol head group and azobenzene-alkyl tail, are combined (from 10-30 wt %) into monoolein-water systems to create LLC phases. Homogenization of the bulk LLC forms dispersions of particles, ∼200 nm in diameter with internal bicontinuous primitive cubic phases, as seen using small-angle X-ray scattering and cryo-transmission electron microscopy. Notably, increasing the AzoPS concentration leads to swelling of the cubic lattice, offering a method to tune the internal nanoscale structure. Upon UV irradiation, AzoPS within the cubosomes isomerizes within seconds, which in turn leads to squeezing of the cubic lattice and a decrease in the lattice parameter. This squeeze mechanism was successfully harnessed to enable phototriggerable release of trapped Nile Red guest molecules from the cubosome structure in minutes. The ability to control the internal structure of LLC dispersions using light, and the dramatic effect this has on the retention of entrapped molecules, suggests that these systems may have huge potential for the next-generation of nanodelivery.

Förster Resonance Energy Transfer in Luminescent Solar Concentrators.

Luminescent solar concentrators (LSCs) are an emerging technology to collect and channel light from a large absorption area into a smaller one. They are a complementary technology for traditional solar photovoltaics (PV), particularly suitable for application in urban or indoor environments where their custom colors and form factors, and performance under diffuse light conditions may be advantageous. Förster resonance energy transfer (FRET) has emerged as a valuable approach to overcome some of the intrinsic limitations of conventional single lumophore LSCs, such as reabsorption or reduced quantum efficiency. This review outlines the potential of FRET to boost LSC performance, using highlights from the literature to illustrate the key criteria that must be considered when designing an FRET-LSC, including both the photophysical requirements of the FRET lumophores and their interaction with the host material. Based on these criteria, a list of design guidelines intended to aid researchers when they approach the design of a new FRET-LSC system is presented. By highlighting the unanswered questions in this field, the authors aim to demonstrate the potential of FRET-LSCs for both conventional solar-harvesting and emerging LSC-inspired technologies and hope to encourage participation from a diverse researcher base to address this exciting challenge.

Perfil dos usuários de uma unidade especializada do Paraná sobre profilaxia pré-exposição ao HIV/AIDS / Profile of users of a specialized unit in Paraná on HIV/AIDS pre-exposure prophylaxis / Perfil de los usuarios de una unidad especializada en Paraná en profilaxis preexposición al VIH/SIDA

Objetivo: conhecer o perfil dos usuários do Centro de Testagem e Aconselhamento cadastrados para utilizar a profilaxia pré exposição ao HIV/Aids no município de Maringá.Métodos:estudo exploratório e descritivo, de abordagem qualitativa, realizado em prontuários do Centro de Testagem e Aconselhamento de Maringá. Cinquenta e dois usuários aderiram a nova estratégia de prevenção a profilaxia pré-exposição ao HIV no município. Os dados foram coletados em abril de 2020. Para a análise das entrevistas, foi utilizada a análise estatística descritiva.Resultados: A grande maioria dos participantes da pesquisa foramdo sexo masculino, de cor branca, solteiros, com nível superior e possuíamfaixa etária entre 21 e 40 anos. Quanto ao perfil da população-chave, apenas um é transexual, dois são profissionais do sexo. 34,62% se caracterizam como casais sorodiferentes e 84,62% são homens que fazem sexo com homens.Conclusão: Foi possível identificar o perfil dos usuários que utilizam a profilaxia pré exposição ao HIV/Aids, o qual tem se mostrado como uma ferramenta de prevenção combinada, principalmente entre homens que fazem sexo com homens. Mais estudos epidemiológicos com outras populações-chave, como mulheres, transexuais e profissionais do sexo, são necessários.

Objective: to know the profile of users of the Testing and Counseling Center registered to use HIV/AIDS pre-exposure prophylaxis in the city of Maringá.Methods:exploratory anddescriptive study, with a qualitative approach, carried out in medical records from the Testing and Counseling Center in Maringá. Fifty-two users adhered to the new HIV pre-exposure prophylaxis prevention strategy in the municipality. Data were collected in April 2020. Descriptive statistical analysis was used to analyze the interviews.Results:The vast majority of research participants are male, white, single, with higher education and aged between 21 and 40 years. As for the profile of the key population, only one is transsexual, two are sex workers. 34.62% are characterized as serodifferent couples and 84.62% are men who have sex with men.Conclusion:It was possible to identify the profile of users who use pre-exposure prophylaxis to HIV/AIDS, which has been shown to be a combined prevention tool, especially among men who have sex with men. More epidemiological studies with other key populations, such as women, transsexuals and sex workers, are needed.

Objetivo: conocer el perfil de los usuarios del Centro de Pruebas y Consejería registrados para utilizar la profilaxis preexposición al VIH/SIDA en la ciudad de Maringá.Métodos:estudio exploratorio y descriptivo, con abordaje cualitativo, realizado en prontuarios del Centro de Pruebas y Consejería de Maringá. Cincuenta y dos usuarios adhirieron a la nueva estrategia de prevención de profilaxis preexposición al VIH en el municipio. Los datos fueron recolectados en abril de 2020. Se utilizó análisis estadístico descriptivo para analizar las entrevistas.Resultados:La gran mayoría de los participantes de la investigación son hombres, blancos, solteros, con educación superior y con edades entre 21 y 40 años. En cuanto al perfil de la población clave, solo uno es transexual, dos son trabajadoras sexuales. El 34,62% se caracterizan por ser parejas serodiferentes y el 84,62% son hombres que tienen sexo con hombres.Conclusión:Se logró identificar el perfil de los usuarios que utilizan la profilaxis preexposición al VIH/SIDA, la cual ha demostrado ser una herramienta de prevención combinada, especialmente entre hombres que tienen sexo con hombres. Se necesitan más estudios epidemiológicos con otras poblaciones clave como mujeres, transexuales y trabajadoras sexuales.

Divided by choice? For-profit providers, patient choice and mechanisms of patient sorting in the English National Health Service.

This paper studies patient choice of provider following government reforms in the 2000s, which allowed for-profit surgical centers to compete with existing public National Health Service (NHS) hospitals in England. For-profit providers offer significant benefits, notably shorter waiting times. We estimate the extent to which different types of patients benefit from the reforms, and we investigate mechanisms that cause differential benefits. Our counterfactual simulations show that, in terms of the value of access, entry of for-profit providers benefitted the richest patients twice as much as the poorest, and white patients six times as much as ethnic minority patients. Half of these differences is explained by healthcare geography and patient health, while primary care referral practice plays a lesser, though non-negligible role. We also show that, with capitated reimbursement, different compositions of patient risks between for-profit surgical centers and existing public hospitals put public hospitals at a competitive disadvantage.

Light-responsive self-assembly of a cationic azobenzene surfactant at high concentration.

The formation of high-concentration mesophases by a cationic azobenzene photosurfactant is described for the first time. Using a combination of polarised optical microscopy and small-angle X-ray scattering, optically anisotropic, self-assembled structures with long-range order are reported. The mesophases are disrupted or lost upon UV irradiation.

The impacts of private hospital entry on the public market for elective care in England.

This paper examines reforms that enabled private hospitals to compete with public hospitals for elective patients in England. Studying hip replacements, we compare changes in outcomes across areas differentially exposed to private hospital entry, instrumenting hospital entry with the pre-reform location of private hospitals. We find private hospital entry increased the number of publicly funded hip replacements by 12% but did not reduce volumes at incumbent public hospitals, and had no impact on readmission rates. This suggests new entrants exerted little competitive pressure on incumbents. Instead, the market expanded with more marginal patients receiving treatment at an earlier point in time, resulting in a fall in average patient severity. Additional publicly funded volumes were not associated with reduced privately funded volumes, while impacts of provider entry did not vary by local deprivation. These findings indicate the reform increased publicly funded capacity but did not improve quality at existing public hospitals.

A single-component photorheological fluid with light-responsive viscosity.

Viscoelastic fluids whose rheological properties are tunable with light have the potential to deliver significant impact in fields relying on a change in flow behavior, such as in-use tuning of combined efficient heat-transfer and drag-reduction agents, microfluidic flow and controlled encapsulation and release. However, simple, single-component systems must be developed to allow integration with these applications. Here, we report a single-component viscoelastic fluid, capable of a dramatic light-sensitive rheological response, from a neutral azobenzene photosurfactant, 4-hexyl-4'butyloxymonotetraethylene glycol (C6AzoOC4E4) in water. From cryo-transmission electron microscopy (TEM), small-angle X-ray scattering (SAXS) and rheology measurements, we observe that the photosurfactant forms an entangled network of wormlike micelles in water, with a high viscosity (28 Pa s) and viscoelastic behaviour. UV irradiation of the surfactant solution creates a less dense micellar network, with some vesicle formation. As a result, the solution viscosity is reduced by four orders of magnitude (to 1.2 × 10-3 Pa s). This process is reversible and the high and low viscosity states can be cycled several times, through alternating UV and blue light irradiation.

Effects of an Aging Population and Racial Demographics on Eye Disease Prevalence: Projections for Georgia Through 2050.

PURPOSE: To provide a state-level prediction of the future burden of visual impairment and its causes in adults in the state of Georgia through 2050, accounting for age and race demographics. DESIGN: A population prevalence projection study. METHODS: Population data were obtained from the Georgia Governor's Office of Planning and Budget, stratified by age and race and applied to the Prevent Blindness America eye disease prevalence values. Prevalence of overall vision impairment and of blindness were calculated, in addition to the most common diseases. RESULTS: In Georgia in 2050, there will be an estimated 226,000 visually impaired persons, and nearly 100,000 will be blind. Of those who are visually impaired or blind, 65% will be age 80 or older. There will be a greater than 350% projected increase in visual impairment in those 80 and older by 2050. A projected 1.7 million cases of cataract, 2.3 million of refractive error, over 250,000 cases of glaucoma, and 117,000 cases of macular degeneration will be present. The total caseload of diabetic retinopathy in adults age 40 and older is expected to increase by 150% between 2015 and 2040. CONCLUSION: The aging population and racial demographics impact projections for future eye disease burden, causing state-level projections to vary from national levels. As the demand for eye services increases, states must have individualized projections to evaluate the unique challenges they will face and prepare for enhanced service delivery, educational campaigns, and advocacy that match the need for their state.

Probing the dynamic self-assembly behaviour of photoswitchable wormlike micelles in real-time.

Understanding the dynamic self-assembly behaviour of azobenzene photosurfactants (AzoPS) is crucial to advance their use in controlled release applications such as drug delivery and micellar catalysis. Currently, their behaviour in the equilibrium cis- and trans-photostationary states is more widely understood than during the photoisomerisation process itself. Here, we investigate the time-dependent self-assembly of the different photoisomers of a model neutral AzoPS, tetraethylene glycol mono(4',4-octyloxy,octyl-azobenzene) (C8AzoOC8E4) using small-angle neutron scattering (SANS). We show that the incorporation of in situ UV-Vis absorption spectroscopy with SANS allows the scattering profile, and hence micelle shape, to be correlated with the extent of photoisomerisation in real-time. It was observed that C8AzoOC8E4 could switch between wormlike micelles (trans native state) and fractal aggregates (under UV light), with changes in the self-assembled structure arising concurrently with changes in the absorption spectrum. Wormlike micelles could be recovered within 60 seconds of blue light illumination. To the best of our knowledge, this is the first time the degree of AzoPS photoisomerisation has been tracked in situ through combined UV-Vis absorption spectroscopy-SANS measurements. This technique could be widely used to gain mechanistic and kinetic insights into light-dependent processes that are reliant on self-assembly.

End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported.

Although end-of-life medical spending is often viewed as a major component of aggregate medical expenditure, accurate measures of this type of medical spending are scarce. We used detailed health care data for the period 2009-11 from Denmark, England, France, Germany, Japan, the Netherlands, Taiwan, the United States, and the Canadian province of Quebec to measure the composition and magnitude of medical spending in the three years before death. In all nine countries, medical spending at the end of life was high relative to spending at other ages. Spending during the last twelve months of life made up a modest share of aggregate spending, ranging from 8.5 percent in the United States to 11.2 percent in Taiwan, but spending in the last three calendar years of life reached 24.5 percent in Taiwan. This suggests that high aggregate medical spending is due not to last-ditch efforts to save lives but to spending on people with chronic conditions, which are associated with shorter life expectancies.

Poverty dynamics and parental mental health: Determinants of childhood mental health in the UK.

Using data from the British Millennium Cohort Study (MCS), an ongoing longitudinal study of a cohort of 18,827 children born in the UK in 2000-2001, we investigate important correlates of mental health issues during childhood. MCS respondents were sampled at birth, at age 9 months, and then when they were 3, 5, 7 and 11 years old. Each sweep contains detailed information on the family's SES, parenting activities, developmental indicators, parental relationship status, and indicators of parental mental health. The Strengths and Difficulties Questionnaire (SDQ) and the related Rutter scale were used to identify behavioral and emotional problems in children. In this paper, childhood problems are separated into four domains: hyperactivity, emotional symptoms, conduct problems, and peer problems. We focus on two aspects of this relationship at ages 5 and 11-the role of temporary and persistent poverty and the role of temporary and persistent mental health problems of mothers and fathers. At ages 11 and 5, without other controls in the model, persistent and transitory poverty have strong estimated associations with all four domains, with somewhat stronger estimated effects for persistent poverty. After a set of controls are added, we document that both persistent levels of poverty and transitions into poverty are strongly associated with levels of and transitions into childhood mental health problems. Similarly, sustained levels and transitions into mothers' mental health problems are strongly associated with levels and transitions into children's mental health problems. This is much less so for fathers.

Relação radiologista-paciente no exame ultrassonográfico obstétrico sob o enfoque bioético / Radiologist-patient relationship in the obstetrics ultrasound exam under bioethics? view

Este trabalho objetivou conhecer a relação radiologista-paciente durante os exames de ultrassonografia obstétrica sob os pontos de vista materno e do radiologista, com enfoque do principialismo. Com abordagem qualitativa, exploratória e transversal foram entrevistadas 10 gestantes e 10 radiologistas, mediante entrevista semi-estruturada, gravada e transcrita literalmente. As diretrizes metodológicas do Discurso do Sujeito Coletivo (DSC) foram utilizadas para a seleção das ideias centrais e das expressães-chave. Foram identificadas as seguintes representaçães sociais por parte das gestantes:-informaçães sobre o feto-, -dia do parto-,-orientação sobre o exame-, -expectativa negativa superada-, -bondade-,-tratar bem-,-pouca expectativa- e -atenção-. E por parte dos radiologistas: -tranquilizar a paciente-,-administrar situaçães-, -tratar bem- e -atenção, respeito, confiança e carinho- para com a paciente. Constatou-se que na relação radiologista-paciente os conhecimentos técnicos específicos, o relacionamento humano e os cuidados com a gestante são imprescindíveis para a valorização da vida humana e dos preceitos bioéticos.

Arterial switch with full-flow cardiopulmonary bypass and limited circulatory arrest: neurodevelopmental outcome.

OBJECTIVES: Neonatal cardiac surgery has been associated with unfavorable neurodevelopmental events. We investigated a patient cohort operated on predominantly with full-flow cardiopulmonary bypass (150 mL x kg(-1) x min(-1), alpha-stat, alpha-blockade, median arrest = 6 minutes, temperature of 22 degrees C) as the major support strategy for neonatal arterial switch operations (transposition of the great arteries and intact ventricular septum). METHODS: Seventy-four patients and "best-friend" control subjects were assessed 109 months (range, 48-166 months) postoperatively with general medical and neurologic evaluation, IQ testing, formal movement scores, and detailed parent-teacher behavioral-social reports. Fetal, neonatal, and perioperative data were collated. RESULTS: The prevalence of perioperative seizures was 6.8% (4/5 cases occurring preoperatively). The incidence of all perioperative neurologic abnormalities was 20%. Patients who had a neurologic event were (as a group) older at the time of operation and had a lower arterial blood pH before the operation. Selected perioperative factors (not related directly to cardiopulmonary bypass variables) predicted early (before discharge) neurologic outcome in a multivariate model. At late assessment, patients were more likely than control subjects to have a mild neurologic abnormality (P = 0.002). Full-scale IQ scores (Wechsler Preschool and Primary Scale of Intelligence and Wechsler Intelligence Scale for Children-Third Edition) were higher in control subjects (101.9 [SD = 13] vs 108.6 [SD = 12], P =.0007), with both groups having scores greater than the population-based test means. Full-scale IQ scores related most significantly to years of paternal education (beta = 1.51, P =.0078) but were also influenced by perioperative neurologic abnormalities, birth weight, and circulatory arrest time. Patients had higher motor impairment scores (Movement Assessment Battery) than control subjects (P =.0004). Parents (Achenbach Child Development Checklist) assigned higher total social-behavioral competence scores to control subjects (P =.05). Teachers (Achenbach Teacher Report Form) suggested that patients were more likely to be perceived as having various speech and expressive language problems, as well as minor behavioral problems. CONCLUSION: With the perioperative strategies used, not all survivors can be considered (neurodevelopmentally) normal at late follow-up, although the risk of important impairment is low. Perioperative events might have long-term prognostic value. On the basis of this study and published data regarding other strategies, continued application of full-flow cardiopulmonary bypass is justified, with the proviso that further investigation is required.