928 resultados para low-energy protons
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Reported accidents involving the poisoning scorpions are still frequent in Brazil, mainly caused by Tityus serrulatus, known as yellow scorpion. Although antivenom sera are produced routinely by various government laboratories, the effectiveness of its use depends on how quickly treatment is initiated and efficiency in the production of antibodies by the immunized animals. In this study, the development of cationic polymeric nanoparticles of poly(lactic acid) aimed to create a modified delivery system for peptides and proteins of T. serrulatus venom, able to enhance the production of serum antibodies against the scorpion toxins. The cationic nanoparticles were obtained by a low energy nanoprecipitation, after study of the parameters’ variations effects over the physicochemical properties of the particles. The surface functionalization of the nanoparticles with the hyperbranched polyethyleneimine was proved by zeta potential analysis and enabled the adsorption by electrostatic interaction of different types of proteins. The protein loading efficiency of 40-80 % to bovine serum albumin (BSA) and 100 % to scorpion venom peptides evaluated by spectrophotometry and polyacrylamide gel electrophoresis confirmed the success of the selected parameters established for obtainment of nanoparticles, produced with size between 100 to 250 nm. The atomic force microscopy analysis and in vitro release showed that the spherical nanoparticles provided a sustained release profile of proteins by diffusion mechanism, demonstrating the potential for application of the nanoparticles in vivo.
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Introduction: Pelvic rami fractures in the elderly are associated with significant morbidity and mortality. Despite our rapidly aging population there is a paucity of literature dealing with fractures of the pelvic rami in this age group. The purpose of this study is report mortality rates following these injuries in the Eastern region of Newfoundland. Additionally, we aim to describe and quantify the important resultant morbidity in this vulnerable elderly population . Methods: A retrospective chart review was performed of all the pelvic fractures in individuals over the age of 60 between 2000 and 2005 in the Eastern Health region of Newfoundland and Labrador. From these patients, only those with the radiographic parameters consistent with low energy pattern pelvic ring injuries were included. Excluded from the study were those with concurrent fractures of the femur. Survival data, comorbidities, injury characteristics, hospital stay, ambulatory status, and place of residence were recorded from the chart. A surrogate control group was formulated from Statistics Canada survival data for use as a survival comparison group. Results: There were 80 fractures of the pelvis identified in patients over 60 years old from 2000-2005. Of these, 43 met our inclusion/exclusion criteria and were used in our analysis. The one and five year mortalities of these patients were 16.3% (95% CI; 7.80% to 30.3%) and 58.1% (95% CI; 43.3% to 71.6%), respectively. These were both significantly different from the point estimates from our constructed age and gender matched control group from the Statistics Canada data of 6.58% (one year mortality) and 31.3% (five year mortality). Morbidity was quantified by change in ambulatory status (independent, walker/cane assisted, wheelchair) and change in residential independence (independent, assisted living, nursing home). Post fracture, 36% of patients permanently required increased ambulatory aids and 21% of patients required a permanent increase in everyday level of care. Conclusion: This study suggests that there may be significantly increased mortality and morbidity following low energy pattern pelvic rami fractures in an elderly population compared to age and gender matched controls. In contrast to previous studies describing these injuries, there is greater homogeneity in this population with respect to age and mechanism of injury. This study generates several important hypotheses for future research and in particular highlights the need for larger prospective studies to identify factors predicting the highest risk for poor outcomes in this population.
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Limit-periodic (LP) structures exhibit a type of nonperiodic order yet to be found in a natural material. A recent result in tiling theory, however, has shown that LP order can spontaneously emerge in a two-dimensional (2D) lattice model with nearest-and next-nearest-neighbor interactions. In this dissertation, we explore the question of what types of interactions can lead to a LP state and address the issue of whether the formation of a LP structure in experiments is possible. We study emergence of LP order in three-dimensional (3D) tiling models and bring the subject into the physical realm by investigating systems with realistic Hamiltonians and low energy LP states. Finally, we present studies of the vibrational modes of a simple LP ball and spring model whose results indicate that LP materials would exhibit novel physical properties.
A 2D lattice model defined on a triangular lattice with nearest- and next-nearest-neighbor interactions based on the Taylor-Socolar (TS) monotile is known to have a LP ground state. The system reaches that state during a slow quench through an infinite sequence of phase transitions. Surprisingly, even when the strength of the next-nearest-neighbor interactions is zero, in which case there is a large degenerate class of both crystalline and LP ground states, a slow quench yields the LP state. The first study in this dissertation introduces 3D models closely related to the 2D models that exhibit LP phases. The particular 3D models were designed such that next-nearest-neighbor interactions of the TS type are implemented using only nearest-neighbor interactions. For one of the 3D models, we show that the phase transitions are first order, with equilibrium structures that can be more complex than in the 2D case.
In the second study, we investigate systems with physical Hamiltonians based on one of the 2D tiling models with the goal of stimulating attempts to create a LP structure in experiments. We explore physically realizable particle designs while being mindful of particular features that may make the assembly of a LP structure in an experimental system difficult. Through Monte Carlo (MC) simulations, we have found that one particle design in particular is a promising template for a physical particle; a 2D system of identical disks with embedded dipoles is observed to undergo the series of phase transitions which leads to the LP state.
LP structures are well ordered but nonperiodic, and hence have nontrivial vibrational modes. In the third section of this dissertation, we study a ball and spring model with a LP pattern of spring stiffnesses and identify a set of extended modes with arbitrarily low participation ratios, a situation that appears to be unique to LP systems. The balls that oscillate with large amplitude in these modes live on periodic nets with arbitrarily large lattice constants. By studying periodic approximants to the LP structure, we present numerical evidence for the existence of such modes, and we give a heuristic explanation of their structure.
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Large calcareous eolianites cover the remote island of Bermuda, accounting for more than 90% of the limestone bedrock. This study examines the sedimentology and geochemistry of these eolianites to better understand Pleistocene oceanography and the meteoric alteration of subtropical carbonate sediments. Cluster analyses reveal that the eolian carbonate sediments fall into two natural groups that represent lagoonal and reefal end members of marine sediment production. Coral fragments are uncharacteristically absent, possibly destroyed prior to their incorporation into eolian deposits by endolithic microboring organisms or broken up during transport. Sediment assemblages lead to the following interpretations of the Bermudan offshore environment: (1) the Ledge Flats reef system along the southwestern coast has been active since MIS 11, contributing coralline algal-rich sediment to the northern beaches of Sandy’s Parish and acting as an energy barrier in the south, allowing for low energy sedimentation in the quiet back- reef region; (2) on the northeastern coast, the low energy back-reef region landward of the Ledge Flats has thrived since MIS 11; (3) during MIS 5e, slightly warmer water temperatures led to the hindrance of coralline algal growth along the southern coast and in the North Lagoon. These are the first interpretations of Pleistocene marine assemblages on Bermuda. Meteoric fluids progressively transformed the pristine carbonate sediments into hardened limestones in a predictable solubility-dependent manner. The progressive alteration is coincident with: (1) divergence of δ18O and δ13C values from those similar to unaltered sediment towards those of calcrete, due to interaction with CO2-charged meteoric fluids; (2) depletion of elements with low partitioning coefficients and low meteoric concentrations, such as barium, boron, magnesium, potassium, sodium, strontium, and uranium; (3) enrichment of iron from Terra Rossa-hosted iron oxides; (4) enrichment of aluminum via detrital minerals sourced from protosol horizons; and (5) manganese concentrations that remain uncharacteristically low, owing to the lack of a consistent manganese source. Elemental correlations are useful for characterizing meteoric diagenesis, assuming the primary mineralogy is recognized, all components have been fully altered, and inter-particle cements are ubiquitous.
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This study examines the impact of ambient temperature on emotional well-being in the U.S. population aged 18+. The U.S. is an interesting test case because of its resources, technology and variation in climate across different areas, which also allows us to examine whether adaptation to different climates could weaken or even eliminate the impact of heat on well-being. Using survey responses from 1.9 million Americans over the period from 2008 to 2013, we estimate the effect of temperature on well-being from exogenous day-to-day temperature variation within respondents’ area of residence and test whether this effect varies across areas with different climates. We find that increasing temperatures significantly reduce well-being. Compared to average daily temperatures in the 50–60 °F (10–16 °C) range, temperatures above 70 °F (21 °C) reduce positive emotions (e.g. joy, happiness), increase negative emotions (e.g. stress, anger), and increase fatigue (feeling tired, low energy). These effects are particularly strong among less educated and older Americans. However, there is no consistent evidence that heat effects on well-being differ across areas with mild and hot summers, suggesting limited variation in heat adaptation.
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Direct alcohol fuel cells (DAFCs) mostly use low molecular weight alcohols such as methanol and ethanol as fuels. However, short-chain alcohol molecules have a relative high membrane crossover rate in DAFCs and a low energy density. Long chain alcohols such as butanol have a higher energy density, as well as a lower membrane crossover rate compared to methanol and ethanol. Although a significant number of studies have been dedicated to low molecular weight alcohols in DAFCs, very few studies are available for longer chain alcohols such as butanol. A significant development in the production of biobutanol and its proposed application as an alternative fuel to gasoline in the past decade makes butanol an interesting candidate fuel for fuel cells. Different butanol isomers were compared in this study on various Pt and PtSn bimetallic catalysts for their electro-oxidation activities in acidic media. Clear distinctive behaviors were observed for each of the different butanol isomers using cyclic voltammetry (CV), indicating a difference in activity and the mechanism of oxidation. The voltammograms of both n-butanol and iso-butanol showed similar characteristic features, indicating a similar reaction mechanism, whereas 2-butanol showed completely different features; for example, it did not show any indication of poisoning. Ter-butanol was found to be inactive for oxidation on Pt. In situ FTIR and CV analysis showed that OHads was essential for the oxidation of primary butanol isomers which only forms at high potentials on Pt. In order to enhance the water oxidation and produce OHads at lower potentials, Pt was modified by the oxophilic metal Sn and the bimetallic PtSn was studied for the oxidation of butanol isomers. A significant enhancement in the oxidation of the 1° butanol isomers was observed on addition of Sn to the Pt, resulting in an oxidation peak at a potential ∼520 mV lower than that found on pure Pt. The higher activity of PtSn was attributed to the bifunctional mechanism on PtSn catalyst. The positive influence of Sn was also confirmed in the PtSn nanoparticle catalyst prepared by the modification of commercial Pt/C nanoparticle and a higher activity was observed for PtSn (3:1) composition. The temperature-dependent data showed that the activation energy for butanol oxidation reaction over PtSn/C is lower than that over Pt/C.
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We report on the experimental characterisation of laser-driven ion beams using a Thomson Parabola Spectrometer (TPS) equipped with trapezoidally shaped electric plates, proposed by Gwynne et al. [Rev. Sci. Instrum. 85, 033304 (2014)]. While a pair of extended (30 cm long) electric plates was able to produce a significant increase in the separation between neighbouring ion species at high energies, deploying a trapezoidal design circumvented the spectral clipping at the low energy end of the ion spectra. The shape of the electric plate was chosen carefully considering, for the given spectrometer configuration, the range of detectable ion energies and species. Analytical tracing of the ion parabolas matches closely with the experimental data, which suggests a minimal effect of fringe fields on the escaping ions close to the wedged edge of the electrode. The analytical formulae were derived considering the relativistic correction required for the high energy ions to be characterised using such spectrometer.
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The article is focused on analysis of global efficiency of new mold for rotational molding of plastic parts, being directly heated by thermal fluid. The overall efficiency is based on several items such as reduction of cycle time, better uniformity of heating-cooling and low energy consumption. The new tool takes advantage of additive fabrication and electroforming for making the optimal manifold and cavity shell of the mold. Experimental test of a prototype mold was carried out on an experimental rotational molding machine, developed for this purpose, measuring wall temperature, and internal air temperature, with and without plastic material inside. Results were compared with conventional mold heated into an oven and to theoretical simulations done by Computational Fluid Dynamic software (CFD). The analysis represents considerable improvement of cycle time related to conventional methods (heated by oven) and better thermal uniformity to conventional procedures by direct heating of oil with external channels. In addition to thermal analysis an energetic efficiency study was done. POLYM. ENG. SCI., 52:1998-2005, 2012. © 2012 Society of Plastics Engineers Copyright © 2012 Society of Plastics Engineers.
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Les matériaux mésoporeux à base de silice sont des plateformes polyvalentes qui offrent une réponse aux besoins de domaines variés comme l’environnement, la santé et les énergies. La fonctionnalisation avec des groupements organiques en fait des matériaux hybrides qu’il est aisé d’orienter vers une application spécifique. Ainsi, afin de fournir une alternative aux procédés industriels, dommageables pour l’environnement actuellement utilisés pour l’extraction et la purification des terres rares, à savoir l’extraction liquide-liquide (ELL) majoritairement, les silices mésoporeuses ont été sollicitées à titre d’adsorbant dans l’extraction sur phase solide. Cette dernière, en opposition à l’ELL, présente de nombreux avantages dont, la suppression des solvants organiques, le contrôle de la sélectivité envers et parmi le groupe des éléments de terres rares (ÉTR) à travers l’ancrage du ligand sur un support solide et la possibilité de réutiliser plusieurs fois l’adsorbant. Les ÉTR sont des métaux qui participent à la transition vers des technologies moins coûteuses en énergie, il est donc primordial de rendre leurs procédés d’extraction plus verts. Dans le cadre de ce travail, différents types de silices ordonnées mésoporeuses, MCM-41, SBA-15 et SBA-16, ont été synthétisées, fonctionnalisées avec un ligand approprié, et leurs comportements vis à vis de ces éléments, comparés. Ces matériaux ont de nombreux points communs mais certaines caractéristiques les différencient néanmoins : la taille et la géométrie des pores, la connexion entre les pores, l’épaisseur des parois, l’accessibilité aux pores ou encore la diffusion des liquides ou gaz dans la matrice. C’est pourquoi, le but de cette étude est d’élucider l’impact de ces diverses propriétés sur l’adsorption sélective des ÉTR en condition statique et dynamique.
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Cette thèse a pour sujet le développement d’un détecteur à fibre scintillante plastique pour la dosimétrie des faisceaux de photons de basses énergies. L’objectif principal du projet consiste à concevoir et caractériser cet instrument en vue de mesurer la dose de radiation reçue au cours des examens d’imagerie diagnostique et interventionnelle. La première section est consacrée à la conception de six différents systèmes et à l’évaluation de leur performance lorsqu’ils sont exposés à des rayonnements de hautes et basses énergies. Tous les systèmes évalués présentaient un écart type relatif (RSD) de moins de 5 % lorsqu’ils étaient exposés à des débits de dose de plus de 3 mGy/s. Cette approche systématique a permis de déterminer que le tube photomultiplicateur répondait le mieux aux conditions d’exposition propres à la radiologie. Ce dernier présentait une RSD de moins de 1 % lorsque le débit de dose était inférieur à 0.10 mGy/s. L’étude des résultats permis également de suggérer quelques recommandations dans le choix d’un système en fonction de l’application recherchée. La seconde partie concerne l’application de ce détecteur à la radiologie interventionnelle en procédant à des mesures de dose à la surface d’un fantôme anthropomorphique. Ainsi, plusieurs situations cliniques ont été reproduites afin d’observer la précision et la fiabilité du détecteur. Ce dernier conserva une RSD inférieure à 2 % lorsque le débit de dose était supérieur à 3 mGy/min et d’environ 10 % au débit le plus faible (0.25 mGy/min). Les mesures sur fantôme montrèrent une différence de moins de 4 % entre les mesures du détecteur et celles d’une chambre d’ionisation lors du déplacement de la table ou du bras de l’appareil de fluoroscopie. Par ailleurs, cette différence est demeurée sous les 2 % lors des mesures de débit de dose en profondeur. Le dernier sujet de cette thèse porta sur les fondements physiques de la scintillation dans les scintillateurs plastiques. Les différents facteurs influençant l’émission lumineuse ont été analysés afin d’identifier leur contribution respective. Ainsi, la réponse du détecteur augmente de près d’un facteur 4 entre un faisceau de 20 kVp et 250 kVp. De ce signal, la contribution de la fluorescence produite dans la fibre claire était inférieure à 0.5 % lorsque les fibres étaient exposées sur 10 cm par des faisceaux de 20 à 250 kVp. Le phénomène d’extinction de la fluorescence par ionisation a également été étudié. Ainsi, l’atténuation du signal variait en fonction de l’énergie du faisceau et atteignit environ 20 % pour un faisceau de 20 kVp. En conclusion, cette étude suggère que les détecteurs à fibres scintillantes peuvent mesurer avec précision la dose de radiation reçue en imagerie diagnostique et interventionnelle, mais une calibration rigoureuse s’avère essentielle.
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In this thesis the critical dynamics of several magnetoelectric compounds at their phase transition were examined. Mostly measurements of the dielectric properties in the frequency range of below 1 Hz up to 5 GHz were employed to evaluate the critical exponents for both magnetic field and temperature-dependent measurements. Most of the materials that are part of this work show anomalous behavior, especially at very low temperatures where quantum fluctuations are of the order of or even dominate those induced thermally. This anomalous behavior manifests in different forms. In Dy2Ti2O7 we demonstrate the existence of electric dipoles on magnetic monopoles. Here the dynamics at the critical endpoint located at 0.36K and in a magnetic field of 1T parallel to the [111] direction are of special interest. At this critical endpoint the expected critical slowing down of the dynamics could not only not be observed but instead the opposite, critical speeding-up by several orders of magnitude, could be demonstrated. Furthermore, we show that the phase diagram of Dy2Ti2O7 in this field direction can be reproduced solely from the dynamical properties, for example the resonance frequency of the observed relaxation that is connected to the monopole movement. Away from this point of the phase diagram the dynamics are slowing-down with reduction of temperature as one would expect. Additional measurements on Y2Ti2O7, a structurally identical but non-magnetic material, show only slowing down with reduction of temperature and no additional features. A possible explanation for the observed critical speeding-up is a coherent movement of magnetic monopoles close to the critical field that increases the resonance frequency by reducing the damping of the process. LiCuVO4 on the other hand behaves normally at its phase transition as long as the temperature is higher than 0.4 K. In this temperature regime the dynamics show critical slowing-down analogous to classical ferroelectric materials. This analogy extends also towards higher frequencies where the permittivity displays a ‘dispersion’ minimum that is temperature-dependent but of the order of 2 GHz. Below 0.4K the observed behavior changes drastically. Here we found no longer relaxational behavior but instead an excitation with very low energy. This low energy excitation was predicted by theory and is caused by nearly gapless soliton excitations within the 1D Cu2+ chains of LiCuVO4. Finally, in TbMnO3 the dynamics of the phase transition into the multiferroic phase was observed at roughly 27 K, a much higher temperature compared to the other materials. Here the expected critical slowing-down was observed, even though in low-frequency measurements this transition into the ferroelectric phase is overshadowed by the so-called c-axis relaxation. Therefore, only frequencies above 1MHz could be used to determine the critical exponents for both temperatureand magnetic-field-dependent measurements. This was done for both the peak frequency as well as the relaxation strength. In TbMnO3 an electromagnetic soft-mode with small optical weight causes the observed fluctuations, similar to the case of multiferroic MnWO4.
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Tutkielman tavoitteena on esitellä esineiden internetin kokonaisuutta ja tutkia siellä käytettäviä langattomia verkkostandardeja sekä niiden käyttöä älykodissa. Esineiden internetin soveltamisalueet jakautuvat älykodin, teollisuuden ja yhteiskunnan osa-alueisiin. Näistä älykotia käsitellään tutkielmassa tarkemmin. Työssä selvitetään, mitkä ovat esineiden internetin yleisimmät langattomat verkkostandardit ja niiden ominaisuudet. Lisäksi selvitetään, mistä osista älykoti koostuu, mitkä ovat soveltamisalueet ja miten älykoti toimii. Vertailukohteina käytetään kahden suuren elektroniikkavalmistajan, Samsungin ja LG:n, älykotiratkaisuja. Tutkielmassa esitellään esineiden internetin määritelmä, sen historiaa ja käyttökohteita, jotta saadaan yleiskuva esineiden internetin kokonaisuudesta. Tämän jälkeen syvennytään langattomiin verkkostandardeihin, jotka ovat keskeisesti käytössä esineiden internetissä. Kyseiset verkkostandardit ovat Bluetooth, Bluetooth Low Energy, NFC, Wi-Fi, Zigbee ja 6LoWPAN. Lopuksi käsitellään älykotia ja sen ominaisuuksia. Samalla tutkitaan Samsungin ja LG:n älykotilaitteita ja pohditaan niiden toimivuutta. Lisäksi pohditaan verkkostandardien käyttöä älykodeissa sekä esineiden internetin ja älylaitteiden vaikutuksia ihmisiin. Lopputuloksena todetaan, että Wi-Fi, Bluetooth ja Zigbee ovat yleisimmät älykodin verkkostandardit ja että ainoastaan yksi verkkostandardi ei tällä hetkellä riitä monipuolisen älykodin kaikkia toimintoja varten. Vertailussa huomataan Samsungin älykotiratkaisun olevan kehityksessä LG:tä edellä.
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Résumé: Ce mémoire de maîtrise est une étude des probabilités d’interactions (sections efficaces) des électrons de basse énergie avec une molécule d’intérêt biologique. Cette molécule est le tétrahydrofurane (THF) qui est un bon modèle de la molécule constituant la colonne vertébrale de l’ADN; le désoxyribose. Étant donné la grande quantité d’électrons secondaires libérés lors du passage des radiations à travers la matière biologique et sachant que ceux-ci déposent la majorité de l’énergie, l’étude de leurs interactions avec les molécules constituant l’ADN devient rapidement d’une grande importance. Les mesures de sections efficaces sont faites à l’aide d’un spectromètre à haute résolution de pertes d’énergie de l’électron. Les spectres de pertes d’énergie de l’électron obtenus de cet appareil permettent de calculer les valeurs de sections efficaces pour chaque vibration en fonction de l’énergie incidente de l’électron. L’article présenté dans ce mémoire traite de ces mesures et des résultats. En effet, il présente et explique en détail les conditions expérimentales, il décrit la méthode de déconvolution qui est utilisée pour obtenir les valeurs de sections efficaces et il présente et discute des 4 résonances observées dans la dépendance en énergie des sections efficaces. En effet, cette étude a permis de localiser en énergie 4 résonances et celles-ci ont toutes été confirmées par des recherches expérimentales et théoriques antérieures sur le sujet des collisions électrons lents-THF. En outre, jamais ces résonances n’avaient été observées simultanément dans une même étude et jamais la résonance trouvée à basse énergie n’avait été observée avec autant d’intensité que cette présente étude. Cette étude a donc permis de raffiner notre compréhension fondamentale des processus résonants impliqués lors de collisions d’électrons secondaires avec le THF. Les valeurs de sections efficaces sont, quant à elles, très prisées par les théoriciens et sont nécessaires pour les simulations Monte Carlo pour prédire, par exemple, le nombre d’ions formées après le passage des radiations. Ces valeurs pourront justement être utilisées dans les modèles de distribution et dépôt d’énergie au niveau nanoscopique dans les milieux biologiques et ceux-ci pourront éventuellement améliorer l’efficacité des modalités radiothérapeutiques.
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Food safety has always been a social issue that draws great public attention. With the rapid development of wireless communication technologies and intelligent devices, more and more Internet of Things (IoT) systems are applied in the food safety tracking field. However, connection between things and information system is usually established by pre-storing information of things into RFID Tag, which is inapplicable for on-field food safety detection. Therefore, considering pesticide residue is one of the severe threaten to food safety, a new portable, high-sensitivity, low-power, on-field organophosphorus (OP) compounds detection system is proposed in this thesis to realize the on-field food safety detection. The system is designed based on optical detection method by using a customized photo-detection sensor. A Micro Controller Unit (MCU) and a Bluetooth Low Energy (BLE) module are used to quantize and transmit detection result. An Android Application (APP) is also developed for the system to processing and display detection result as well as control the detection process. Besides, a quartzose sample container and black system box are also designed and made for the system demonstration. Several optimizations are made in wireless communication, circuit layout, Android APP and industrial design to realize the mobility, low power and intelligence.
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Despite the high incidence of abdominal traumas, traumatic abdominal wall hernias (TAWHs) remain rare probably because of elasticity of the abdominal wall. The TAWH is due to blunt abdominal trauma with disruption of the abdominal wall muscles and fascia with intact overlying skin. TAWH can be classified into high energy injures (generally motor vehicle accidents) and low energy injures (impact on a small blunt object). Common example of the latter type is a fall onto a bicycle handlebar. The mechanism of the trauma includes sudden increase of intra-abdominal pressure and extensive shear forces applied to the abdominal wall. The diagnosis of TAWH is difficult in the Emergency Room because during the primary diagnostic process most attention is directed toward the detection of internal injures and TAWH can be missed. In this article we report a case of TAWH caused by a work accident (an heavy steel tube fallen onto the abdominal wall of the patient from a height of five meters) with delayed diagnosis.