High Cryptococcal Antigen Titers in Blood Are Predictive of Subclinical Cryptococcal Meningitis Among Human Immunodeficiency Virus-Infected Patients

Background High mortality rates among asymptomatic cryptococcal antigen (CrAg)–positive patients identified through CrAg screening, despite preemptive fluconazole treatment, may be due to undiagnosed cryptococcal meningitis. Methods Symptoms were reviewed in CrAg-positive patients identified by screening 19233 individuals with human immunodeficiency virus infection and CD4 cell counts <100/µL at 17 clinics and 3 hospitals in Johannesburg from September 2012 until September 2015, and at 2 hospitals until June 2016. Cerebrospinal fluid samples from 90 of 254 asymptomatic patients (35%) and 78 of 173 (45%) with headache only were analyzed for cryptococcal meningitis, considered present if Cryptococcus was identified by means of India ink microscopy, culture, or CrAg test. CrAg titers were determined with stored blood samples from 62 of these patients. The associations between blood CrAg titer, concurrent cryptococcal meningitis, and mortality rate were assessed. Results Cryptococcal meningitis was confirmed in 34% (95% confidence interval, 25%–43%; 31 of 90) of asymptomatic CrAg-positive patients and 90% (81%–96%; 70 of 78) with headache only. Blood CrAg titer was significantly associated with concurrent cryptococcal meningitis in asymptomatic patients (P 160 (sensitivity, 88.2%; specificity, 82.1%); the odds ratio for concurrent cryptococcal meningitis was 34.5 (95% confidence interval, 8.3–143.1; P < .001). Conclusions About a third of asymptomatic CrAg-positive patients have concurrent cryptococcal meningitis. More effective clinical assessment strategies and antifungal regimens are required for CrAg-positive patients, including investigation for cryptococcal meningitis irrespective of symptoms. Where it is not possible to perform lumbar punctures in all CrAg-positive patients, blood CrAg titers should be used to target those most at risk of cryptococcal meningitis

Global burden of disease of HIV-associated cryptococcal meningitis: an updated analysis.

BACKGROUND: Cryptococcus is the most common cause of meningitis in adults living with HIV in sub-Saharan Africa. Global burden estimates are crucial to guide prevention strategies and to determine treatment needs, and we aimed to provide an updated estimate of global incidence of HIV-associated cryptococcal disease. METHODS: We used 2014 Joint UN Programme on HIV and AIDS estimates of adults (aged >15 years) with HIV and antiretroviral therapy (ART) coverage. Estimates of CD4 less than 100 cells per μL, virological failure incidence, and loss to follow-up were from published multinational cohorts in low-income and middle-income countries. We calculated those at risk for cryptococcal infection, specifically those with CD4 less than 100 cells/μL not on ART, and those with CD4 less than 100 cells per μL on ART but lost to follow-up or with virological failure. Cryptococcal antigenaemia prevalence by country was derived from 46 studies globally. Based on cryptococcal antigenaemia prevalence in each country and region, we estimated the annual numbers of people who are developing and dying from cryptococcal meningitis. FINDINGS: We estimated an average global cryptococcal antigenaemia prevalence of 6·0% (95% CI 5·8-6·2) among people with a CD4 cell count of less than 100 cells per μL, with 278 000 (95% CI 195 500-340 600) people positive for cryptococcal antigen globally and 223 100 (95% CI 150 600-282 400) incident cases of cryptococcal meningitis globally in 2014. Sub-Saharan Africa accounted for 73% of the estimated cryptococcal meningitis cases in 2014 (162 500 cases [95% CI 113 600-193 900]). Annual global deaths from cryptococcal meningitis were estimated at 181 100 (95% CI 119 400-234 300), with 135 900 (75%; [95% CI 93 900-163 900]) deaths in sub-Saharan Africa. Globally, cryptococcal meningitis was responsible for 15% of AIDS-related deaths (95% CI 10-19). INTERPRETATION: Our analysis highlights the substantial ongoing burden of HIV-associated cryptococcal disease, primarily in sub-Saharan Africa. Cryptococcal meningitis is a metric of HIV treatment programme failure; timely HIV testing and rapid linkage to care remain an urgent priority. FUNDING: None

Nurses´ experiences of caring for persons with dementia in emergency care

Bakgrund: En ökad livslängd leder till att flera äldre drabbas av demenssjukdom och därmed ökar deras behov av akutsjukvård för somatiska sjukdomar och andra sjukdomar. Men en akutmiljö kan vara stressigt för både patienter och sjuksköterskor. Det drabbar särskilt patienter med demens på grund av kommunikationsbrister. Det gör att sjuksköterskor inte kan erbjuda en adekvat vård för patienter med demens eftersom de saknar tid och kunskap för att förstå dessa patienters behov.   Syfte: Att undersöka sjuksköterskors erfarenhet av att vårda patienter med demens inom akutsjukvården.   Metod: Litteraturstudie med tio kvalitativa artiklar. Databaserna CINAHL och PubMed användes för sökning. Kvalitativ innehållsanalys användes för att analysera data. Resultat: Två kategorier: Behov av personlig vård och utmaningar i vårdandet. De subkategorierna som framkom är Kommunikation och behandling, Vikten av samverkan, Organisatoriska förutsättningar, Kunskap och känslor. Slutsats: Sjuksköterskor upplever att vårdmiljöer inte är anpassad efter demenspatienter och därför är mötet med dessa patienter en utmaning. Även kunskapsbrist och brist på erfarenhet inom demensvården erkändes som en utmaning i arbetet av sjuksköterskor. Därför krävs mer forskning för att öka förståelsen kring sjuksköterskornas upplevelser och därmed förbättra vårdandet för demenspatienter.Background: An increased life expectancy leads to more elderly people suffering from dementia and thus their need for emergency care for somatic diseases and other illnesses increases. However, an emergency environment can be stressful for both patients and nurses. It particularly affects patients with dementia due to communication breakdowns between the patients and the nurse. Due to the lack of time and knowledge to understand the patients’ needs, nurses are not able to provide adequate care.  Aim: To investigate nurses´ experience of caring for patients with dementia in emergency care.  Method: Literature study with ten qualitative articles. The databases CINAHL and PubMed has been used for searching. Qualitative content analysis was used to analyse the data.  Results: Two categories: Need for personal care and challenges in care. The subcategories that emerged are Communication and treatment, the importance of cooperation, organizational conditions, knowledge and feelings.  Conclusion: Nurses feel that care environments are not adapted to dementia patients and meeting these patients is a challenge. Lack of knowledge and experience in dementia care recognised as a challenge in the work of nurses. Therefore, more research is required to increase understanding of the nurses´ experiences and improve care for dementia patients.