This study demonstrates an unexpectedly high percentage of patients with heart failure fulfilling current echocardiographic criteria for LVNC. This might be explained by a hitherto underestimated cause of heart failure, but the comparison with controls suggests that current diagnostic criteria are too sensitive, particularly in black individuals.

IntroductionCryptococcal meningitis (CCM) is one of the leading causes of early mortality among HIV-infected patients. This study was a part of clinical audit [1] aimed at improving care for patients with CCM at an urban district hospital in South Africa.MethodsClinical records of all patients (age>13 years) admitted to the hospital with a diagnosis of CCM (based on a positive India ink, positive cryptococcal latex agglutination test (CLAT) or a positive culture of Cryptococcus neoformans) between June 2011 and December 2012 were retrospectively reviewed. Descriptive statistics and Chi-square analysis were generated with Epi Info 7.1.2.0. 95% confidence intervals were reported where appropriate.ResultsOf the 127 patients admitted with CCM, only 97 (76.4%) knew their HIV status. Only 44.8% (43/96) of those who knew they were HIV positive were on antiretroviral therapy (ART). Seventeen out of 25 patients (68%) previously treated for CCM had defaulted fluconazole and only 60% (15/25) were on ART. Acute mortality (death within 14 days of CCM diagnosis) was 55.9% (71/127). The median time to death from diagnosis was four days (IQR 2–9). The association between CSF WBC count<20cells/mL and increased risk of death within 14 days was statistically significant (OR 2.2; 95% CI 1.1–4.6, p=0.03). Patients with heavy cryptococcal burden (reported as numerous yeasts seen on microscopy) at diagnosis were three times more likely to die within 14 days of diagnosis of CCM (OR 3.2; 95% CI 0.9–10.7, p=0.06). Even though a CD4 count<100cells/mm3 was associated with a 1.6 times increased acute mortality risk, the association was not statistically significant (OR 1.6; 95% CI 0.6–4.6, p=0.3). The role of elevated CSF opening pressure at diagnosis was not assessed because only two (1.6%) patients had their baseline opening pressure measured.ConclusionsAcute CCM-related mortality remains high. The number of patients who do not know their HIV status, the number of HIV positive patients not on ART, the high level of non-adherence to fluconazole and the proportion of patients not on ART after at least one previous CCM episode all point to the need of developing comprehensive strategies aimed at encouraging HIV testing and improving patient's retention in HIV care and support.

Ectopic pregnancies can be very difficult to diagnose at initial admission. This paper reviewed the morbidity and mortality associated with misdiagnosis of ectopic gestation over a 15-year period (1985-99) at Ile-Ife, Nigeria. There were 380 confirmed ectopic pregnancies of 35 857 live births, giving an incidence of 10.5 per 1000 live births. Of the 380 cases, 38 (10%) were misdiagnosed initially at presentation. Mistaken diagnoses include pelvic inflammatory diseases, cholera, acute appendicitis, typhoid enteritis, incomplete septic abortion, uterine fibroid with menorrhagia, malaria, gastroenteritis, peptic ulcer and intestinal obstruction. There were five maternal deaths among the 38 misdiagnosed cases compared to two maternal deaths among the 342 initially correctly diagnosed cases. Significant morbidity included prolonged hospital stay, increased hospital costs and an enterocutaneous fistula. To improve the chances of correct diagnosis at initial admission, accurate menstrual and sexual history should be obtained. Facilities for improved diagnosis such as serum beta HCG and transvaginal ultrasonography should be provided. Colleagues from other specialities should be educated to increase their suspicion of ectopic pregnancy in any woman of childbearing age and perform the appropriate investigations.

BackgroundDespite the development of context-specific guidelines, cryptococcal meningitis (CCM) remains a leading cause of death amongst HIV-infected patients. Results from clinical audits in routine practice have shown critical gaps in clinicians’ adherence to recommendations regarding the management of CCM.AimThe aim of this study was to review the acute management of CCM at an urban district hospital in KwaZulu-Natal, South Africa with a view to making recommendations for improving care.SettingAn urban district hospital in KwaZulu-Natal, South Africa.MethodsA retrospective audit was performed on clinical records of all patients (age > 13 years) admitted to the hospital with a diagnosis of CCM between June 2011 and December 2012.ResultsMeasurement of cerebrospinal fluid opening pressure at initial lumbar puncture (LP) was done rarely and only 23.4% of patients had therapeutic LPs. The majority of patients (117/127; 92.1%) received amphotericin B, however, only 19 of the 117 patients (16.2%) completed the 14-day treatment target. Amphotericin B-toxicity monitoring and prevention was suboptimal; however, in-patient referral for HIV counselling and testing was excellent.ConclusionsThe quality of care of CCM based on selected process criteria showed gaps in routine care at the hospital despite the availability of context-specific guidelines. An action plan for improving care was developed based on stakeholders’ feedback. A repeat audit should be conducted in the future in order to evaluate the impact of this plan and to ensure that improvements are sustained.

Background: Cryptococcal meningitis (CCM) is one of the leading causes of early mortality in human immunodeficiency virus (HIV)-infected patients. This study was part of a clinical audit aimed at improving care for patients with CCM at an urban district hospital in South Africa. Method: The clinical records of patients (age > 13 years) admitted to the hospital with a diagnosis of CCM between June 2011 and December 2012 were retrospectively reviewed. Descriptive statistics and chi-square analysis were generated with EpiInfo™ 7.1.2.0. Ninety-five per cent confidence intervals were reported, where appropriate. Results: Of the 127 patients admitted with CCM, only 97 (76.4%) knew their HIV status. Only 44.8% (43/96) of those who knew that they were HIV-positive were on antiretroviral therapy (ART). Seventeen of the 25 patients (68%) previously treated for CCM had defaulted on their fluconazole treatment and only 60% (15/25) were on ART. CCM-related mortality at two weeks was 55.9% (71/127). A high cerebrospinal fluid (CSF) fungal load, CD4 count < 100 cells/mm 3 and poor CSF inflammatory response were associated with increased mortality risk. However, only the association between poor CSF inflammatory response and mortality was statistically significant (p = 0.03). Conclusion: Acute CCM-related mortality remains high. The number of patients who do not know their HIV status, the number of HIV-positive patients who are not on ART, the high level of nonadherence to their fluconazole medication and the proportion of patients who are not on ART after at least one previous CCM episode indicate that there is a need to develop comprehensive strategies aimed at encouraging HIV testing and improving the retention of patients with regard to HIV care and support.