That experienced clinicians have different ap- proaches to clinical problems is found throughout medicine. The differences often are not based on available medical knowledge but rather on one’s practice experience. Dr. Coplan is a developmental pediatrician in an academic center where he evalu- ates children referred for a variety of developmental problems. Drs. Parker and Feldman, although both practice and teach in academic centers, have a pri- mary care clinician’s perspective. Throughout medi- cine, the specialist is an expert in the numerator of disease frequency, and the generalist is the expert in the denominator! This difference, in part, is respon- sible for the different perspectives among the com- mentators. In addition, the primary care clinician typically works under the assumption that continu- ity of care is assured. The uncertain or equivocal diagnosis at one office visit can be followed up in a designated time interval with a degree of assurance. The specialist, who evaluates a child as a consultant, may not be comfortable withholding a diagnostic study or therapeutic intervention when continuity of care is less clear.
There are several potential limitations to this study. As mentioned before, firstly, toddlers were clinically diagnosed as either ASD or DLD by a child and adolescent psychia- trist, but ADOS and ADI-R were not used to confirm the diagnosis. Secondly, a smaller number of toddlers were di- agnosed with DLD when compared to the number diag- nosed with ASD. Lastly, since the study was a cross-sec- tional comparison, it is not certain that the difference in expressive language abilities were more apparent in tod- dlers between 20 and 29 months was due to a particular pattern that could be observed during this specific period. Longitudinal studies examining various language-related measures are necessary. However, to the best of our knowl- edge, this study provided valuable results since it is the one of first studies examining language development in toddlers with ASD.
difficulties that causes functional impairment in everyday life and is associated with poor prognosis. DLD should be used when the language disorder is not associated with a known biomedical etiology. It was also agreed that: 1) presence of risk factors (neurobiological or environmental) does not pre- clude a diagnosis of DLD; 2) DLD can co-occur with other neurodevelopmental disorders (eg, ADHD); and 3) DLD does not require a mismatch between verbal and nonverbal ability. The Catalise consortium also stated that some children need language interventions because they have a different mother tongue than the language spoken in the surrounding commu- nity and have been exposed to and used the majority language too little to master it. These children do not have language disorder or DLD, unless there is evidence that they have the same difficulties in all their languages. 8,9
Nasopharyngeal Carcinoma A Delay in Diagnosis ORIGINAL ARTICLE Nasopharyngeal Carcinoma A Delay in Diagnosis U Prasad, FRCSE*, K C Pua, M S (ORL)**, *Department of Otorhinolaryngology, Faculty of Medi[.]
This study evaluates the reliability of two differently constructed screening instruments for lan- guage delay. Only few studies have addressed the question of early identification at population level. Data for this article were drawn from a Finnish cohort study, entitled the Steps to the Healthy Development and Well-Being of Children (the STEPS study, N = 9.936). The MacArthur Communicative Development Inventories (CDI-T), based on parent reported vocabulary, was used for screening at 24 months. At 36 months, child’s language skills were screened with the Fox Lan- guage Inventory (FLI) carried out by a clinical nurse. The Renfrew Word Finding Vocabulary Test and Reynell Developmental Language Scales III (language comprehension), served as outcome measures at 36 months. Receiver operating characteristic-analysis (ROC) was used to examine the cost and benefit of the two screening methods in decision making at 36 months. We found that ex- pressive vocabulary at 24 months, can already foretell later language development. However, to reach even better predictivity, screening based on a structured language battery and age point of 36 months would be a valuable addition to clinical assessment. Further studies are needed to ad- dress to what extend early screening is able to predict atypical language during later preschool- years.
A major challenge in elucidating the biology underlying autism spectrum disorder (ASD) is its genetic hetero- geneity. Endophenotypes, heritable characteristics which share genetic liability with a disorder and which are measurable regardless of a disorder’ s state or stage (i.e., state-independent) [1, 2], are therefore especially inform- ative for resolving the complex, polygenic genetic architec- ture of ASD. By definition, endophenotypes demonstrate several criteria involving inheritance among family mem- bers with and without the disorder. These criteria include co-segregating, or being inherited more commonly, in affected versus unaffected family members and aggregat- ing, or occurring with increased frequency, in unaffected family members versus the general population, which is at lower genetic risk [1, 2]. The occurrence of these familial patterns in the context of a heritable trait substantiates the relationship between an endophenotype and genetic factors for a given disorder. Because endophenotypes can be inferred to reflect causal pathways of a disorder and can be reliably measured in individuals with and without the disorder [1, 2], they enhance the sensitivity to determine contributory genes and, by extension, the underlying biology. The common co-occurrence of ASD and persistent language impairments , which may include deficits in aspects of structural language, such as vocabulary and grammar, as well as pragmatics, the appropriate use of language, has prompted the long-standing question of whether language deficits represent an endophenotype of ASD [4, 5]. Like ASD, language disorders are heritable [6–9], with evidence of genetic influence from early in development [10, 11]. Further, as expected for an endophenotype, both autistic symptoms and language abil- ity appear to behave as quantitative traits which are herit- able across a range of competency encompassing unimpaired and impaired individuals [9, 12–15]. Multiple family studies have
In the most common form of the EBC procedure, termed single-cue delay EBC, a conditioned stimulus (CS; e.g., 400 ms tone) is paired with a co-terminating unconditioned stimulus (US; e.g., 50 ms corneal airpuff). Repeated CS- US pairings elicit the development of an adaptive conditioned blink response (CR), which occurs in healthy individuals just prior to the US. The delay EBC procedure appears to be the purest assay of the functional integrity of the cerebellum, with the circuitry and synaptic mechanisms being well studied and identi- fied in nonhumans (Kim and Thompson 1997; Steinmetz 2000; Christian and Thompson 2003) compared to other forms of EBC, such as trace conditioning (Christian and Thompson 2003). In addition, the cerebellar networks mediating this form of associative learning appear to be conserved across mammals (rat: (Rogers et al. 2001); human: (Gerwig et al. 2007)). The single-cue delay procedure has been used to examine developmental and clinical conditions associated with cerebellar abnormali- ties and motor disruptions, such as aging (e.g., (Woodruff- Pak and Thompson 1988; Woodruff-Pak et al. 1999)), autism(Sears et al. 1994), schizophrenia (e.g., (Brown et al. 2005)) and drug abuse (Skosnik et al. 2008). In their study of children with autism ages 7 – 22 years, Sears et al. (1994) report that affected children differed from controls with faster rates of conditioning at a young age and maintained that rate as age increased whereas control subjects showed increasingly fast rates of conditioning with age. In addition, the autism group showed a more rapid and significant decline in the amplitudes of condi- tioned responses during an extinction phase. The topog- raphy of the conditioned responses of the autism group differed from the control group. Overall, the patterns of motor learning associated with cerebellar functioning differentiated the children with autism from the control group.
The aim of this study is to investigate the use of multimedia technology by speech and lan- guage therapists in developing their own digital material on diagnostic and therapeutic proce- dures. Undergraduate fourth-year students were motivated to use various multimedia editing and authoring tools for diagnosis and therapy procedures in building social skills deficits. The research questions concern students’ accomplishments on intergrading multimedia technology in speech and languagediagnosis and therapy, and the effectiveness of the digital environment they created.
The questionnaire included sociodemographic charac- teristics, risk factors of TB, comorbidity, and TB know- ledge and attitudes. Follow-up data included history of TB treatment, such as a detailed description of diagnos- tic investigation process, first symptoms perceived by the patient, and health seeking actions. The patients were also asked to complete a number of questions measuring psychosocial aspects, for example, feeling ashamed about having TB, fear of social isolation and stigma. In addition, patient medical cards were reviewed for TB diagnostic information, such as date of diagnosis, date of treatment initiation, and laboratory results.
Our study found two key results. First, patients consult- ing a non-neurological specialist experience a longer delay in diagnosis, compared to patients who initially consulted a neurologist or a GP. Second, for women, the diagnostic delay was even longer than for men. Our data showed that there was no difference in time to diagnosis when initially either a neurologist or a GP was consulted. Interestingly, first consulting another subspe- cialty resulted in a significant diagnostic delay compared to a neurologist or a GP. In Germany, the choice is left to the patient as to whether a GP or a specialist serves as the primary contact. Other health care systems allow access to a specialist only after consultation with a GP. Leaving the patient with the decision to choose a medi- cal subspecialist as the primary point of contact with the medical profession has profound effects on the diag- nostic course. Our data support the usefulness of a sys- tem that first requires the consultation of a GP, followed by assignment to a specialist. The GP appeared to be well qualified by training to direct the patient to the correct subspecialty.
ably the biggest weakness with using the concept of doubling time to defend a delayed diagnosis case is that it runs counter to the message of the medi- cal, public health, and cancer survivor communities that early diagnosis and treatment are the keys to cure. The idea that earlier discovery of a cancer would not affect outcome—the basis of the doubling time defense—contradicts the logic of widely publicized cancer screen- ing campaigns promoting breast self- examinations, regular mammograms, Pap smears, and colonoscopies. The equation of early treatment with greater chances for cure is ﬁ rmly implanted in the minds of most jurors. A defense expert faces an uphill battle to convince jurors that earlier is not early enough. Plaintiff Uses of Doubling Time Plaintiff s can and do use the doubling time theory to their advantage. The fol- lowing medical negligence case alleges a negligent delay in the diagnosis of cervi- cal cancer. The plaintiff ’s causation wit- ness, a gynecologic oncologist, relied on the theory of doubling time to bolster his opinion.
CNREP: Children's test of non-word repetition; CELF-P2: Clinical evaluation of language fundamentals- preschool edition 2; CI: Confidence interval; CTOPP: Comprehensive test of phonological processing; dB HL: Decibels hearing loss; ELVS: Early language in victoria study; GSV: Growth scale value; HUI: Health utilities index; IQ: Intelligence quotient; KBIT-2: Kaufman brief intelligence test second edition; LGAs: Local government areas; M&CH: Maternal & child health; NHMRC: National health and medical research council; NCEs: Normal curve equivalents; PPVT-4: Peabody picture vocabulary test; PedsQL: Pediatric quality of life inventory; QALYs: Quality- adjusted life years; RCT: Randomised controlled trial; RACV: Royal automobile club of victoria; SLI: Specific language impairment; SD: Standard deviations; SDQ: Strengths and difficulties questionnaire; SPAT-R: Sutherland phonological awareness test – revised: modified; WRAT: Wide range achievement test.
With regard to treatment planning, ﬁ ndings further substantiate the im- portance of considering both nonverbal intelligence and social communication, potentially supporting use of inter- vention strategies for these children that focus on the development of social cognition strategies (eg, perspective taking/theory of mind). Further re- search into the impact of these inter- ventions on the development of spoken language is warranted. In addition, results uniquely suggest that the level of intellectual ability is a critical consid- eration. Speci ﬁ cally, concerning age at phrase speech acquisition, the most meaningful distinction was between children with normal (ie, $ 1 SD of the mean) nonverbal intelligence from those who fall below 1 SD of the mean. Whereas children with both intellectual disability and normal nonverbal in- telligence gained phrase speech, those falling below the 1-SD mark were delayed in their acquisition of phrase speech by ∼ 6 months. Although there was also an independent effect of social impairment on age at phrase speech acquisition, the effect was more uniform across symptom sever- ity. As such, treatment expectations may be adjusted for lower functioning children (ie, children with nonverbal IQ falling in the low-average to borderline- impaired range and with notable social
low-up DAC visit at 3 years of age, Jose demon- strated marked delays in all areas on the McCarthy Scales of Children’s Abilities, and mild deficits were seen on the Vineland Adaptive Behavior Scales. He was able to indicate “yes” and “no” with gestures only, and he understood fewer than 10 words. His mother reported that at times he would not use words for hours at home, and she felt that he was actually losing some of the improvements in speech that he had previously made. His diagnosis was now global developmental delay with possible autistic spectrum disorder. Subsequent evaluations were negative, including a neurologic assessment and ge- netics consultation, a magnetic resonance image of the brain, a Fragile X DNA molecular probe, and high-resolution chromosome analysis.
In demonstrating our methods we have investigated how diagnosis delays vary with patient ethnicity among MSM in London, finding substantially greater delays to diagnosis in non-white individuals. This finding is con- sistent with those reported based on a crude definition of late diagnosis of CD4 count <350 within 3 months of diagnosis , and a similar pattern of differences was observed when we used CD4 back-estimation for comparison in our analysis. However, the average diag- nosis delay for all groups was found to be lower when it was estimated using a survival model pooled across patients. Explicit estimation of the diagnosisdelay distri- bution in subgroups of interest could be very useful for public health monitoring and in the planning of inter- ventions such as targeted outreach testing. We should note that we have analysed a selected cohort with inclu- sion conditional on enrolment into the UK CHIC study and availability of a treatment-naïve viral sequence, and so the findings that we have observed cannot be used for any specific public health conclusions without further research.
Another important issue in this context concerns mor- tality. The role of mortality is not negligible and related information would be useful to provide more precise inci- dence estimates; features speciﬁc to ALS disease led many researchers to use mortality to indirectly estimate inci- dence (see e.g., : death percentages due to ALS as ﬁrst death cause vary from about 34% to 92%. The relation between incidence and mortality is obviously bidirec- tional; a strong correlation between these two measures is present for the elderly. Given that the ALS diagnosis is diﬃcult to be recognized in the elderly (due to the poten- tial presence of comorbidities), this selection mechanism could lead to underestimate mortality; in this sense, sur- vival analysis stratiﬁed by age or age groups would be important. The NRRD contains information about the date of death but this variable is not reliable since it is not compulsory and the corresponding information is only rarely recorded. Should the quality of mortality informa- tion be improved through permanent link with census archives, it could be possible to consider the observed (registered) removals to provide more precise incidence and prevalence estimates. In particular, it could be pos- sible to register the number of people aﬀected by ALS having a certain onset date but lost due to death/ migra- tion and remove them to get more reliable prevalence measures. Should a link with Death causes survey (DCS) be possible, we could also try to understand how many incident units have not been registered by the NRRD but died of ALS, or with ALS registered as a comorbidity. This could help get a more reliable incidence measure as well. A probabilistic record linkage could be carried out between NRRD and survey of causes of death (DCS) by using appropriate matching variables; however this has not been possible yet due to privacy reasons (individual data can not be joined). Mortality can aﬀect incidence and be aﬀected by changes in health services which may lead to overestimation of death cases; improvements over recent years in ALS diagnosis may, at least hypothetically, explain the rise in death rates (see ) with ageing of the population.
In total, 1,560 adults with reported CD were invited to participate, with 65 males and females randomly selected from each five-year interval from 20 years of age and above (20-24, 25-29,..., 70-74, and 75 years or older). Out of 1,122 responders, 1,031 (66%) were eligible for the study. A reported CD diagnosis based on medical exper- tise was required for inclusion. As this information was lacking in the society’s register, when respondents stated that they had CD, questionnaire information was used to assess how their CD was diagnosed (blood sample, biopsy, and/or diet change), and if a medical professional had recommended adherence to a gluten-free diet. Ninety-one members did not meet eligibility require- ments, and they comprised three criteria groups; i) they did not have CD (n = 34), ii) CD diagnosis uncertain (n = 33), and iii) age and/or sex not consistent based on regis- ter information and questionnaire responses (n = 24). Those with uncertain CD were those reporting a self- diagnosis or that a gluten-free diet had not been recom- mended by a medical professional. Of eligible responders, 52% (n = 536) were females and the mean age was 52 years (Table 1).
But this delay was found to be shorter than the patient and diagnosis delays that are obvious at the National Institute of Oncology with a new department specialized in gynecologic cancer in partnership with “Lalla Salma Fondation- Cancers Prevention and Treatment”. Many efforts have been taken in terms of infrastructure, Investigation, medication and follow up. Furthermore, Lalla Salma Foundation to support and encourage patients to access to treatment created “Houses of life” dedicate to house poor women who live far from treatment centers[41, 42].
One of the main objectives of tuberculosis control programs is to reduce tuberculosis transmission in the community through early detection of smear-positive cases and rapid administration of a full course of treatment  . It is estimated that about one-third of the world's population is infected with mycobacterium tuberculosis  . Among the communicable diseases, TB is the second leading cause of death worldwide, killing nearly two million people each year  . Early diagnosis of the disease and prompt initiation of treatment are essential for an effective tuberculosis control program. Delay in the diagnosis may worsen the disease, increase the risk of death and enhance tuberculosis transmission in the community.
What can be suggested for reducing Health care system delay in Iran on the basis of the results of this study? First, many of health care providers (mostly doctors) should become suspicious to TB when several symptoms (especially severe ones such as haemoptysis and chest pain) appear in patients and as we know it means that patient (and / or) previous health care providers delays have been longer. This shows the necessity of training & retraining of health care providers on TB at regular intervals. Second, for patient’s whose illness continues in spite of having a negative sputum smear result for AFB, the sputum smear exam should be repeated. It means that patients should be encouraged to return if symptoms persist; however, our impression is that health care providers fail to do this. Therefore, an emphasis on repetition of sputum smear for these circumstances should be done during the training / retraining courses for health care providers. Although we do not think that increased use of Chest X-ray in first visit is indicated; however, we do suggest that there are cases for more liberal utilization of Chest X-ray such as in repeat visitors with negative AFB results. Third, as in 67% of the cases, the type of first health care system which attended by patients was private