Medicine and Health Sciences Commons^™

Reducing Hospital Utilizations For Urinary Tract Infections Through Education, Tiffany Ulmer Msn, Rn, Ccm, Danielle Adam Bsn, Rn, Amb-Bc

Posters & Presentations

Poster was presented at Parkview Nursing Research Symposium, 2023.

Population Health is a department within Parkview Health that uses care coordination services to improve patient outcomes, quality care, and patient satisfaction while reducing overall healthcare costs.

The purpose of this evidence-based project (EBP) was to identify or develop an educational tool to be used within the Population Health department to educate older adults at risk for developing UTIs. •The first goal was to increase awareness of early UTI symptoms and when to seek medical treatment. •The second goal was to increase awareness of the different evidence-based prevention strategies and other …

Skin Safety Bootcamp: Empowering Nurses To Own Hapi Prevention: A Quality Improvement Initiative, Brooke Randol Msn, Rn, Agcns-Bc, Cmsrn, Cws, Michelle Wood Msn, Rn-Bc

Posters & Presentations

Poster presented at Parkview Nursing Research Symposium, 2023

Question: For inpatient cardiovascular nurses, does implementing a skin safety bootcamp improve the use of pressure injury prevention interventions compared to preintervention, resulting in a decrease in hospital-acquired pressure injuries?

Enhancing Diabetes Care With Peer Mentorship And Support Groups, Barry Mccann Bsn, Rn

Posters & Presentations

Poster presented at the Parkview Nursing Research Symposium, 2023.

Continued increase in prevalence of type 2 diabetes indicates need for more effective interventions to support lifestyle and behavior changes (ADA 2018).

• Evidence indicates attending diabetes self management education programs can improve diabetes outcomes, unfortunately they are often under referred and underutilized (Powers et al. 2015, Boakye et al. 2018).

• Limited class times, locations, and capacities can make attendance for all patients difficult and vulnerable populations are less likely to participate (Boakye et al. 2018).

• Diabetes education programs often lack culturally and individually relevant guidance, provide no long-term …

Evaluating Effects Of Academic-Practice Partnerships A Literature Review, Katherine M. Edwards Msn, Rn, Ccrn-K

Posters & Presentations

Poster was presented at Parkview Nursing Research Symposium, 2023

Purpose of Project: ♦ Stakeholder satisfaction and benefits evaluated to understand what effects academic-practice partnership programs have on healthcare systems and nursing students ♦ Literature review was the method utilized to examine the effects of partnership programs for healthcare system and nursing student satisfaction

Raccoon Spatial Ecology In The Rural Southeastern United States, Jacob E. Hill, Madison L. Miller, James L. Helton, Richard B. Chipman, Amy Gilbert, University Of Georgia, Guha Dharmarajan, Olin E. Rhodes Jr.

United States Department of Agriculture Wildlife Services: Staff Publications

The movement ecology of raccoons varies widely across habitats with important implications for the management of zoonotic diseases such as rabies. However, the spatial ecology of raccoons remains poorly understood in many regions of the United States, particularly in the southeast. To better understand the spatial ecology of raccoons in the southeastern United States, we investigated the role of sex, season, and habitat on monthly raccoon home range and core area sizes in three common rural habitats (bottomland hardwood, upland pine, and riparian forest) in South Carolina, USA. From 2018–2022, we obtained 264 monthly home ranges from 46 raccoons. Mean …

Charting And Checking For Suicidality In A Family Medicine Residency Clinic, Bridget Murphy, Stacy Ogbeide

Journal of Human Services Scholarship and Interprofessional Collaboration

Suicide is a leading cause of death in the United States, and many individuals who die by suicide are likely to have seen a primary care physician (PCP) within the month of their death. Thus, the goal of this quality improvement (QI) project was to examine suicidality documentation practices of interprofessional clinicians within a Family Medicine residency clinic, thus providing rationale for continued research and a template for other clinics to emulate. The QI project used the Plan-Do-Study-Act cycle to survey 28 Family Medicine residents, faculty, and trainees for the Plan stage of the cycle in 2022 and assessed their …

A Novel Machine-Learning Framework Based On A Hierarchy Of Dispute Models For The Identification Of Fish Species Using Multi-Mode Spectroscopy, Mitchell Sueker, Amirreza Daghighi, Alireza Akhbardeh, Nicholas Mackinnon, Gregory Bearman, Insuck Baek, Chansong Hwang, Jianwei Qin, Amanda M Tabb, Jiahleen B Roungchun, Rosalee S Hellberg, Fartash Vasefi, Moon Kim, Kouhyar Tavakolian, Hossein Kashani Zadeh

Faculty, Staff and Student Publications

Seafood mislabeling rates of approximately 20% have been reported globally. Traditional methods for fish species identification, such as DNA analysis and polymerase chain reaction (PCR), are expensive and time-consuming, and require skilled technicians and specialized equipment. The combination of spectroscopy and machine learning presents a promising approach to overcome these challenges. In our study, we took a comprehensive approach by considering a total of 43 different fish species and employing three modes of spectroscopy: fluorescence (Fluor), and reflectance in the visible near-infrared (VNIR) and short-wave near-infrared (SWIR). To achieve higher accuracies, we developed a novel machine-learning framework, where groups of …

Medication Review Project For The Aspiring Ma Iii, Marie Millan

Articles, Abstracts, and Reports

No abstract provided.

Recent Incarceration, Substance Use, Overdose, And Service Use Among People Who Use Drugs In Rural Communities, Daniel B. Hoover, P. Todd Korthuis, Elizabeth Needham Waddell, Canyon Foot, Caitlin Conway, Heidi M. Crane, Peter D. Friedmann, Vivian F. Go, Mai T. Pho, Milan F. Satcher, Adams Sibley, Ryan P. Westergaard, April M. Young, Ryan Cook

Dartmouth Scholarship

Importance Drug use and incarceration have a substantial impact on rural communities, but factors associated with the incarceration of rural people who use drugs (PWUD) have not been thoroughly investigated.

Objective To characterize associations between recent incarceration, overdose, and substance use disorder (SUD) treatment access among rural PWUD.

Design, Setting, and Participants For this cross-sectional study, the Rural Opioid Initiative research consortium conducted a survey in geographically diverse rural counties with high rates of overdose across 10 US states (Illinois, Wisconsin, North Carolina, Oregon, Kentucky, West Virginia, Ohio, Massachusetts, New Hampshire, and Vermont) between January 25, 2018, and March 17, …

Global Variation In Diabetes Diagnosis And Prevalence Based On Fasting Glucose And Hemoglobin A1c, Ncd Risk Factor Collaboration (Ncd-Risc), Bin Zhou, Kate E. Sheffer, James E. Bennett, Edward W. Gregg, Goodarz Danaei, Rosie K. Singleton, Jonathan E. Shaw, Gladys Maestre, Jesus D. Melgarejo

School of Medicine Publications

Fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) are both used to diagnose diabetes, but these measurements can identify different people as having diabetes. We used data from 117 population-based studies and quantified, in different world regions, the prevalence of diagnosed diabetes, and whether those who were previously undiagnosed and detected as having diabetes in survey screening, had elevated FPG, HbA1c or both. We developed prediction equations for estimating the probability that a person without previously diagnosed diabetes, and at a specific level of FPG, had elevated HbA1c, and vice versa. The age-standardized proportion of diabetes that was previously undiagnosed …

Social Activity Restriction And Psychological Health Among Caregivers Of Older Adults With And Without Dementia, Elliane Irani, Kylie Meyer, Scott Emory Moore, Kedong Ding

Faculty Scholarship

Objectives: We examined associations between social activity restriction and psychological distress and well-being for caregivers of older adults with and without dementia, and if the identified associations are different for the two groups. Methods: Using data from the 2017 National Study of Caregiving, we identified caregivers of older adults with (N = 541) and without (N = 1701) dementia. Linear regression models were estimated, adjusting for caregivers’ age, gender, race, education, relationship to care recipient, and self-rated health. Results: Restriction in visiting friends and family and attending religious services were associated with higher distress in dementia caregivers. Restriction in visiting …

Left Juxtaposition Of The Right Atrial Appendage: Pitfalls In Diagnosis, Kanya Singhapakdi, Wesam Sourour, Thomas Kimball

School of Medicine Faculty Publications

Several congenital anomalies of the right atrial appendage (RAA) have been described including aneurysm, herniation (in association with a pericardial defect), and left juxtaposition. The left juxtaposition of the RAA (LJRAA), first described by Birmingham in 1893 and subsequently introduced by Dixon in 1954, is usually associated with complex cardiac malformations such as obstruction of the left ventricular outflow tract. In this case report, we will describe an unusual variant of LJRAA in the absence of any other cardiac defects, which was initially misinterpreted as an aortic dissection. The correct diagnosis was made after careful reinterpretation and the use of …

Designing For Community Engagement: User-Friendly Refugee Wellness Center Planning Process And Concept, A Health Design Case Study, Ellen Solomon, Brandon Joa, Shandon Coffman, Billie Faircloth, Marc Altshuler, Bon Ku

Department of Family & Community Medicine Faculty Papers

BACKGROUND: Refugee and immigrant populations have diverse cultural factors that affect their access to health care and must be considered when building a new clinical space. Health design thinking can help a clinical team evaluate and consolidate these factors while maintaining close contact with architects, patients' community leaders, and hospital or institutional leadership. A diverse group of clinicians, medical students, community leaders and architects planned a clinic devoted to refugee and immigrant health, a first-of-its-kind for South Philadelphia.

METHODS: The planning process and concept design of this wellness center is presented as a design case study to demonstrate how principles …

Raccoon Spatial Ecology In The Rural Southeastern United States, Jacob E. Hill, Madison L. Miller, James L. Helton, Richard B. Chipman, Amy T. Gilbert, James C. Beasley, Guha Dharmarajan, Olin E. Rhodes Jr.

United States Department of Agriculture Wildlife Services: Staff Publications

The movement ecology of raccoons varies widely across habitats with important implications for the management of zoonotic diseases such as rabies. However, the spatial ecology of raccoons remains poorly understood in many regions of the United States, particularly in the southeast. To better understand the spatial ecology of raccoons in the southeastern US, we investigated the role of sex, season, and habitat on monthly raccoon home range and core area sizes in three common rural habitats (bottomland hardwood, upland pine, and riparian forest) in South Carolina, USA. From 2018–2022, we obtained 264 monthly home ranges from 46 raccoons. Mean monthly …

The Influence Of Psychosocial Factors On Opioid Decision-Making For Cancer-Related Pain Among Breast Cancer Survivors: A Mixed Method Study, Melody Nichole Chavez

USF Tampa Graduate Theses and Dissertations

Introduction: Breast cancer is the most frequently reported malignancy among women in the United States. Cancer-related pain is highly prevalent occurrence and is often the most fearful side effect following curative intent treatment. Opioid pain management is considered a standard of care and can be of great benefit to treat moderate to severe pain. However, undertreatment of pain remains a significant issue affecting the patient’s physical function, psychological well-being, and overall quality of life. Barriers to adequate pain management are multifactorial and often attributed to patients’ beliefs and attitudes revolving around opioid pain management. In addition, the opioid epidemic has …

Interdisciplinary Involvement In Htn Management, Kirsten Curcio, Maurice N. Tran, Estera Ianciuc

Articles, Abstracts, and Reports

No abstract provided.

Cd46-Adc Reduces The Engraftment Of Multiple Myeloma Patient-Derived Xenografts, Michael J Vanwyngarden, Zachary J Walker, Yang Su, Olivia Perez De Acha, Brett M Stevens, Peter A Forsberg, Tomer M Mark, William Matsui, Bin Liu, Daniel W Sherbenou

Faculty, Staff and Student Publications

An antibody-drug conjugate (ADC) targeting CD46 conjugated to monomethyl auristatin has a potent anti-myeloma effect in cell lines in vitro and in vivo, and patient samples treated ex vivo. Here, we tested if CD46-ADC may have the potential to target MM-initiating cells (MM-ICs). CD46 expression was measured on primary MM cells with a stem-like phenotype. A patient-derived xenograft (PDX) model was implemented utilizing implanted fetal bone fragments to provide a humanized microenvironment. Engraftment was monitored via serum human light chain ELISA, and at sacrifice via bone marrow and bone fragment flow cytometry. We then tested MM regeneration in PDX by …

Appendiceal Neoplasms In Patients Treated With Antibiotics For Acute Appendicitis: Secondary Analysis Of The Coda Randomized Clinical Trial, Writing Group For The Coda Collaborative

Faculty, Staff and Student Publications

No abstract provided.

Mechanopathology Of Biofilm-Like Mycobacterium Tuberculosis Cords, Richa Mishra, Melanie Hannebelle, Vishal P Patil, Anaëlle Dubois, Cristina Garcia-Mouton, Gabriela M Kirsch, Maxime Jan, Kunal Sharma, Nicolas Guex, Jessica Sordet-Dessimoz, Jesus Perez-Gil, Manu Prakash, Graham W Knott, Neeraj Dhar, John D Mckinney, Vivek V Thacker

Faculty, Staff and Student Publications

Mycobacterium tuberculosis (Mtb) cultured axenically without detergent forms biofilm-like cords, a clinical identifier of virulence. In lung-on-chip (LoC) and mouse models, cords in alveolar cells contribute to suppression of innate immune signaling via nuclear compression. Thereafter, extracellular cords cause contact-dependent phagocyte death but grow intercellularly between epithelial cells. The absence of these mechanopathological mechanisms explains the greater proportion of alveolar lesions with increased immune infiltration and dissemination defects in cording-deficient Mtb infections. Compression of Mtb lipid monolayers induces a phase transition that enables mechanical energy storage. Agent-based simulations demonstrate that the increased energy storage capacity is sufficient for the formation …

Is The Direct Fixation Of Displaced Quadrilateral Plates In Acetabular Fractures Necessary?, Beom-Soo Kim, Ki-Cheor Bae, Chul-Hyun Cho, Kyung-Jae Lee, In Gyu Lee, Min-Gyu Lee, Byung-Woo Min

Faculty, Staff and Student Publications

Quadrilateral plate fractures represent a heterogeneous group of acetabular fractures. Accurate reduction is required to prevent post-traumatic arthritis. The purpose of this study is to determine the reduction effect of the direct fixation of quadrilateral plates in acetabular fractures, and to evaluate the strength of direct fixation compared to indirect fixation. Between 2005 and 2021, 49 patients underwent surgery for open reduction and internal fixation in acetabular fractures with severely displaced quadrilateral plates. Twenty-nine patients comprised the indirect fixation group, and twenty patients comprised the direct fixation group. In a comparison of primary outcome between two groups, 10 out of …

Predicting Multiple Sclerosis Severity With Multimodal Deep Neural Networks, Kai Zhang, John A Lincoln, Xiaoqian Jiang, Elmer V Bernstam, Shayan Shams

Faculty, Staff and Student Publications

Multiple Sclerosis (MS) is a chronic disease developed in the human brain and spinal cord, which can cause permanent damage or deterioration of the nerves. The severity of MS disease is monitored by the Expanded Disability Status Scale, composed of several functional sub-scores. Early and accurate classification of MS disease severity is critical for slowing down or preventing disease progression via applying early therapeutic intervention strategies. Recent advances in deep learning and the wide use of Electronic Health Records (EHR) create opportunities to apply data-driven and predictive modeling tools for this goal. Previous studies focusing on using single-modal machine learning …

Deep Histopathology Genotype-Phenotype Analysis Of Focal Cortical Dysplasia Type Ii Differentiates Between The Gator1-Altered Autophagocytic Subtype Iia And Mtor-Altered Migration Deficient Subtype Iib, Jonas Honke, Lucas Hoffmann, Roland Coras, Katja Kobow, Costin Leu, Tom Pieper, Till Hartlieb, Christian G Bien, Friedrich Woermann, Thomas Cloppenborg, Thilo Kalbhenn, Ahmed Gaballa, Hajo Hamer, Sebastian Brandner, Karl Rössler, Arnd Dörfler, Stefan Rampp, Johannes R Lemke, Sara Baldassari, Stéphanie Baulac, Dennis Lal, Peter Nürnberg, Ingmar Blümcke

Faculty, Staff and Student Publications

Focal cortical dysplasia type II (FCDII) is the most common cause of drug-resistant focal epilepsy in children. Herein, we performed a deep histopathology-based genotype–phenotype analysis to further elucidate the clinico-pathological and genetic presentation of FCDIIa compared to FCDIIb. Seventeen individuals with histopathologically confirmed diagnosis of FCD ILAE Type II and a pathogenic variant detected in brain derived DNA whole-exome sequencing or mTOR gene panel sequencing were included in this study. Clinical data were directly available from each contributing centre. Histopathological analyses were performed from formalin-fixed, paraffin-embedded tissue samples using haematoxylin–eosin and immunohistochemistry for NF-SMI32, NeuN, pS6, p62, and vimentin. Ten …

Venetoclax Abrogates The Prognostic Impact Of Splicing Factor Gene Mutations In Newly Diagnosed Acute Myeloid Leukemia, Jayastu Senapati, Samuel Urrutia, Sanam Loghavi, Nicholas J Short, Ghayas C Issa, Abhishek Maiti, Hussein A Abbas, Naval G Daver, Naveen Pemmaraju, Sherry Pierce, Kelly S Chien, Koji Sasaki, Tapan M Kadia, Danielle E Hammond, Gautam Borthakur, Keyur Patel, Farhad Ravandi, Hagop M Kantarjian, Guillermo Garcia-Manero, Courtney D Dinardo

Faculty, Staff and Student Publications

Mutations in splicing factor (SF) genes SRSF2, U2AF1, SF3B1, and ZRSR2 are now considered adverse risk in the European LeukemiaNet 2022 acute myeloid leukemia (AML) risk stratification. The prognostic impact of SF mutations in AML has been predominantly derived from younger patients treated with intensive (INT) therapy. We evaluated 994 patients with newly diagnosed AML, including 266 (27%) with a SFmut. Median age was 67 years overall, with patients with SFmut being older at 72 years. SRSF2 (n = 140, 53%) was the most common SFmut. In patients treated with INT, median relapse-free survival (RFS) (9.6 vs 21.4 months, P …

Mucopolysaccharidosis Iva: Current Disease Models And Drawbacks, Andrés Felipe Leal, Carlos Javier Alméciga-Díaz, Shunji Tomatsu

Department of Pediatrics Faculty Papers

Mucopolysaccharidosis IVA (MPS IVA) is a rare disorder caused by mutations in the N-acetylgalactosamine-6-sulfate-sulfatase (GALNS) encoding gene. GALNS leads to the lysosomal degradation of the glycosaminoglyccreasans keratan sulfate and chondroitin 6-sulfate. Impaired GALNS enzymes result in skeletal and non-skeletal complications in patients. For years, the MPS IVA pathogenesis and the assessment of promising drugs have been evaluated using in vitro (primarily fibroblasts) and in vivo (mainly mouse) models. Even though value information has been raised from those studies, these models have several limitations. For instance, chondrocytes have been well recognized as primary cells affected in MPS IVA and responsible for …

Association Of Interleukin-6 And Interleukin-18 With Cardiovascular Disease In Older Adults: Atherosclerosis Risk In Communities Study, Xiaoming Jia, Leo Buckley, Caroline Sun, Mahmoud Al Rifai, Bing Yu, Vijay Nambi, Salim S Virani, Elizabeth Selvin, Kunihiro Matsushita, Ron C Hoogeveen, Josef Coresh, Amil M Shah, Christie M Ballantyne

Faculty, Staff and Students Publications

AIMS: Interleukin-6 (IL-6) and interleukin-18 (IL-18), important cytokines implicated in atherosclerosis and inflammaging, were assessed for associations with global cardiovascular disease (CVD), atrial fibrillation (AF), and death in older adults.

METHODS AND RESULTS: Participants from Atherosclerosis Risk in Communities study Visit 5 (mean age 75.4 ± 5.1 years) with IL-6 and IL-18 measurements were included (n = 5672). Cox regression models were used to assess associations of IL-6 and IL-18 with coronary heart disease (CHD), ischaemic stroke, heart failure (HF) hospitalization, global CVD (composite of CHD, stroke, and HF), AF, and all-cause death. Over a median follow-up of 7.2 years, …

Staphylococcus Aureus Α-Toxin Impairs Early Neutrophil Localization Via Electrogenic Disruption Of Store-Operated Calcium Entry, Fan Yang, Mingyi Suo, Homayemem Weli, Mason Wong, Alex Junidi, Celeste Cummings, Ryan Johnson, Kiara Mallory, Annie Y Liu, Zev J Greenberg, Laura G Schuettpelz, Mark J Miller, Cliff J Luke, Gwendalyn J Randolph, Bernd H Zinselmeyer, Juliane Bubeck Wardenburg, Regina A Clemens

2020-Current year OA Pubs

The pore-forming S. aureus α-toxin (Hla) contributes to virulence and disease pathogenesis. While high concentrations of toxin induce cell death, neutrophils exhibit relative resistance to lysis, suggesting that the action of Hla may not be solely conferred by lytic susceptibility. Using intravital microscopy, we observed that Hla disrupts neutrophil localization and clustering early in infection. Hla forms a narrow, ion-selective pore, suggesting that Hla may dysregulate calcium or other ions to impair neutrophil function. We found that sub-lytic Hla did not permit calcium influx but caused rapid membrane depolarization. Depolarization decreases the electrogenic driving force for calcium, and concordantly, Hla …

Treatment Patterns For Patients Initiating Novel Acute Migraine Specific Medications (Namsms) In The Context Of Monoclonal Antibodies (Mabs) Targeting The Calcitonin Gene-Related Peptide (Cgrp) Pathway, Zifan Zhou, Robert Urman, Karminder Gill, Andrew S Park, Fiston Vuvu, Leah B Patel, Jingsong Lu, Rolin L Wade, Lindsay Frerichs, Mark E Bensink

2020-Current year OA Pubs

BACKGROUND: New acute and preventive migraine medications are available, but data on current treatment patterns are limited. This study describes migraine treatment patterns among patients initiating novel acute migraine specific medications (nAMSMs), overall and by prior use of anti-calcitonin gene-related peptide (CGRP) pathway monoclonal antibodies (mAbs).

METHODS: In this retrospective cohort study using IQVIA open-source pharmacy and medical claims data, we identified patients with ≥ 1 claim for a nAMSM (ubrogepant, rimegepant, lasmiditan) between 01/01/2020 and 09/30/2020 (index period). Patients were indexed on their first nAMSM claim and stratified into 2 cohorts: patients with prior mAb use (≥ 1 claim …

A Retrospective Analysis Of Hearing Screening Outcomes In Infants Whose Mothers Were Covid-19 Positive During Pregnancy, Sangamanatha Ankmnal Ankmnal Veeranna, Charles G. Marx, Hwanseok Choi, Clinton White, Kimberly Ward

Journal of Early Hearing Detection and Intervention

Background: This study examined hearing screening referral rates over a three-year period, including testing performed pre-pandemic (2019) and during the first two years (2020 and 2021) of the onset of the spread of COVID-19.

Methods: This study conducted a retrospective analysis of 8,130 hearing screening referral records from 2019 – 2021, obtained from a large regional level II trauma center. These records were generated from the universal hearing screening process which utilized automated auditory brainstem response devices.

Results: There was no significant change in the number of infants screened for hearing loss and hearing screening outcomes between the pre-pandemic and …

Sociodemographic Factors Influencing Pandemic-Era Ehdi Use And Access, Nicole Perez, David Adkins, Marissa Schuh, Jennifer B. Shinn, Lori Travis, Matthew L. Bush

Journal of Early Hearing Detection and Intervention

Objective: The COVID-19 pandemic impact on Early Hearing Detection and Intervention (EHDI) programs is unknown. This research evaluated sociodemographic factors influencing adherence to EDHI diagnostic testing and the incidence of infant hearing loss during the pandemic.

Method: We evaluated EHDI adherence and incidence of hearing loss in Kentucky before and during the COVID-19 pandemic. Using univariate and multivariate analysis, we evaluated the association of these outcomes to sociodemographic variables.

Results: There were 71,206 births and 1,385 referred infant hearing screening tests during the study period. Infants during the pandemic had a 24% lower odds of hearing testing adherence (OR …

Factors Contributing To Late Identification Of Deaf/Hard Of Hearing Children In Louisiana, Danielle D. Mercer, Tri Tran, Dawne Mccabe, Terri Ibieta, Dana Hubbard

Journal of Early Hearing Detection and Intervention

To ensure children who are Deaf/Hard of Hearing (D/HH) receive supports they need to reach their full potential, it is imperative that they be identified as early as possible. Early Hearing Detection and Intervention benchmarks stipulate children who are D/HH be enrolled in early intervention no later than 6 months of age. A major barrier to early enrollment is late identification. We reviewed records of children identified as D/HH in Louisiana after 6 months of age for 2015-2020 birth cohorts to determine factors contributing to the late identification. Cases were examined in-depth after it was determined that a diagnosis was …