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Background Meningitis causes significant mortality in regions with high comorbid HIV and TB. Improved outcomes are hindered by limited understanding of factors that delay adequate care. Methods In-depth interviews of patients admitted to the University Teaching Hospital with suspected meningitis, their caregivers, doctors and nurses were conducted. Patient/caregiver interviews explored meningitis understanding, treatment prior to admission and experiences since admission. Provider interviews addressed current and prior experiences with meningitis patients and hospital barriers to care. A conceptual framework based on the Three Delays Model identified factors that delayed care. Results Twenty-six patient/caregiver, eight doctor and eight nurse interviews occurred. Four delays were identified: in-home care; transportation to a health facility; clinic/first-level hospital care; and third-level hospital. Overcrowding and costly diagnostic testing delayed outpatient care; 23% of patients began with treatment inside the home due to prior negative experiences with biomedical care. Admission occurred after multiple clinic visits, where subsequent delays occurred during testing and treatment. Conclusions Delays in care from home to hospital impair quality meningitis care in Zambia. Interventions to improve outcomes must address patient, community and health systems factors. Patient/caregiver education regarding signs of meningitis and indications for care-seeking are warranted to reduce treatment delays. [ABSTRACT FROM AUTHOR]

Introduction Epilepsy affects 50 million people worldwide, and 80% of them live in the developing world. (1) An individual with epilepsy suffers recurrent seizures unprovoked by acute brain insults or [...], Objective To describe the magnitude and variation of the epilepsy treatment gap worldwide. Methods We conducted a systematic review of the peer-reviewed literature published from 1 January 1987 to 1 September 2007 in all languages using PubMed and EMBASE. The purpose was to identify population-based studies of epilepsy prevalence that reported the epilepsy treatment gap, defined as the proportion of people with epilepsy who require but do not receive treatment. Negative binomial regression models were used to assess trends and associations. Findings The treatment gap was over 75% in low-income countries and over 50% in most lower middle- and upper middle- income countries, while many high-income countries had gaps of less than 10%. However, treatment gaps varied widely both between and within countries. They were significantly higher in rural areas (rate ratio, RR: 2.01; 95% confidence interval, Cl: 1.40-2.89) and countries with lower World Bank income classification (RR: 1.55; 95% Cl: 1.32-1.82). There was no significant trend in treatment gap over time (RR: 0.92; 95% Cl: 0.79-1.07). Conclusion There is dramatic global disparity in the care for epilepsy between high- and low- income countries, and between rural and urban settings. Our understanding of the factors affecting the treatment gap is limited; future investigations should explore other potential explanations of the gap. Objectif Decrire I'ampleur et les variations de I'insuffisance du traitement de I'epilepsie dans le monde. Methodes A I'aide de PubMed et d'EMBASE, nous avons realise une revue systematique de la litterature examinee par des pairs et publiee entre le 1 er janvier 1987 et le 1 er septembre 2007 dans toutes les langues. L'objectif etait d'identifier des etudes en population de la prevalence de I'epilepsie indiquant l'insuffisance du traitement de cette maladie, definie comme la proportion des personnes epileptiques ayant besoin d'etre traitees, mais ne recevant pas de traitement. Des modeles par regression binomiale negative ont ete utilises pour evaluer les tendances et les associations. Resultats L'insuffisance du traitement de I'epilepsie depassait 75% dans les pays a faible revenu et 50% dans la plupart des pays a revenu moyen inferieur et moyen superieur, alors que dans de nombreux pays a revenu eleve, cette insuffisance etait inferieure a 10%. Neanmoins, l'insuffisance du traitement variait fortement d'un pays a I'autre et au sein d'un meme pays. Elle etait significativement plus importante dans les zones rurales (risque relatif, RR : 2,01 ; intervalle de confiance a 95%, IC : 1,40-2,89) et dans les pays appartenant a la classe de revenu inferieure de la Banque mondiale (RR : 1,55 ; IC a 95 % : 1,32-1,82). On n'a releve aucune tendance significative de l'insuffisance du traitement de I'epilepsie au cours du temps (RR : 0,92 ; IC a 95 % : 0,79-1,07). Conclusion II existe a travers le monde des disparites considerables dans les soins dispenses aux epileptiques, et notamment entre les pays a revenu faible et eleve et entre les environnements ruraux et urbains. Notre comprehension des facteurs influant sur I'insuffisance du traitement est limitee : dans le cadre d'investigations futures, li conviendrait d'etudier d'autres explications possibles de cette insuffisance. Objetivo Describir la magnitud y las diferencias de la brecha de tratamiento de la epilepsia a nivel mundial. Metodos Atraves de PubMed y EMBASE, se hizo una revision sistematica de los articulos revisados por homologos publicados entre el 1 de enero de 1987 y el 1 de septiembre de 2007. La finalidad era encontrar estudios poblacionales sobre la prevalencia de la epilepsia que informaran acerca de la brecha de tratamiento de esa enfermedad, definida como la proporcion de personas afectadas que necesitan pero no reciben tratamiento. Las tendencias y relaciones se evaluaron mediante modelos de regresion binomial negativa. Resultados La brecha terapeutica era superior al 75% en los paises de ingresos bajos, y superior al 50% en la mayoria de los paises de ingresos medios bajos y medios altos, mientras que muchos paises de ingresos altos presentaban brechas inferiores al 10%. Sin embargo, la magnitud de la brecha terapeutica diferia ampliamente tanto entre los paises como en cada pais. Era significativamente mayor en las zonas rurales (razon de tasas, RT: 2,01, intervalo de confianza del 95%: 1,40-2,89) y en los paises incluidos en la categoria de ingresos bajos dei Banco Mundial (RT: 1,55, IC95%: 1,32-1,82). No se observo ninguna tendencia significativa de la brecha a lo largo dei tiempo (RT: 0,92, IC95%: 0,79-1,07). Conclusion En lo referente ai tratamiento de la epilepsia, existe una enorme disparidad mundial entre los paises de altos y de bajos ingresos, y entre las zonas rurales y las urbanas. Nuestros conocimientos sobre los factores que determinan esa brecha terapeutica son limitados, y en las investigaciones futuras se deberian estudiar otras posibles explicaciones de la misma.

Background: Cerebral malaria (CM) results in significant paediatric death and neurodisability in sub-Saharan Africa. Several different alterations to typical Transcranial Doppler Ultrasound (TCD) flow velocities and waveforms in CM have been described, but mechanistic contributors to these abnormalities are unknown. If identified, targeted, TCD-guided adjunctive therapy in CM may improve outcomes. Methods: This was a prospective, observational study of children 6 months to 12 years with CM in Blantyre, Malawi recruited between January 2018 and June 2021. Medical history, physical examination, laboratory analysis, electroencephalogram, and magnetic resonance imaging were undertaken on presentation. Admission TCD results determined phenotypic grouping following a priori definitions. Evaluation of the relationship between haemodynamic, metabolic, or intracranial perturbations that lead to these observed phenotypes in other diseases was undertaken. Neurological outcomes at hospital discharge were evaluated using the Paediatric Cerebral Performance Categorization (PCPC) score. Results: One hundred seventy-four patients were enrolled. Seven (4%) had a normal TCD examination, 57 (33%) met criteria for hyperaemia, 50 (29%) for low flow, 14 (8%) for microvascular obstruction, 11 (6%) for vasospasm, and 35 (20%) for isolated posterior circulation high flow. A lower cardiac index (CI) and higher systemic vascular resistive index (SVRI) were present in those with low flow than other groups (p < 0.003), though these values are normal for age (CI 4.4 [3.7,5] l/min/m2, SVRI 1552 [1197,1961] dscm-5m2). Other parameters were largely not significantly different between phenotypes. Overall, 118 children (68%) had a good neurological outcome. Twenty-three (13%) died, and 33 (19%) had neurological deficits. Outcomes were best for participants with hyperaemia and isolated posterior high flow (PCPC 1–2 in 77 and 89% respectively). Participants with low flow had the least likelihood of a good outcome (PCPC 1–2 in 42%) (p < 0.001). Cerebral autoregulation was significantly better in children with good outcome (transient hyperemic response ratio (THRR) 1.12 [1.04,1.2]) compared to a poor outcome (THRR 1.05 [0.98,1.02], p = 0.05). Conclusions: Common pathophysiological mechanisms leading to TCD phenotypes in non-malarial illness are not causative in children with CM. Alternative mechanistic contributors, including mechanical factors of the cerebrovasculature and biologically active regulators of vascular tone should be explored. [ABSTRACT FROM AUTHOR]