A systematic review of delays in seeking medical attention after transient ischaemic attack.

BACKGROUND: Prompt assessment and investigation of transient ischaemic attack (TIA) followed by early initiation of secondary prevention is effective in reducing recurrent stroke. Nevertheless, many patients are slow to seek medical advice after TIA. A systematic review was undertaken to examine potential factors associated with delay in seeking medical review after TIA. METHODS: The electronic databases MEDLINE, EMBASE, and Science Citation Index were searched for observational studies assessing patient delay in presentation after TIA. The search was restricted to studies published between December 1995 and September 2008. RESULTS: The electronic search yielded nine studies with data on presentation delay in patients with TIA; variations existed in study size, population and methodology. One study included patients with TIA only (n = 241), whereas the remaining eight studies recruited both stroke and TIA patients. Overall, TIA patients (n = 821) made up only a small proportion of the total number of patients in this analysis (n = 3,202). Length of delay varied greatly across all studies. In most studies, patients with TIA who attended an emergency department arrived there within hours. Where patients first presented to their general practitioner, 50% attended within 24 hours whereas 25% waited 2 days or more. Recognition of symptoms as stroke/TIA did not reduce the delay. CONCLUSIONS: The majority of delay in seeking assessment after TIA is due to a lack of response by the patient-many patients do not recognise the symptoms of stroke/TIA, and even when they do, many fail to seek emergency medical attention. The public needs educating on the importance of contacting the emergency medical services or attending an emergency department immediately after TIA.

Pneumococcal disease in HIV-infected Malawian adults: acute mortality and long-term survival.

OBJECTIVE: HIV-infected patients in Africa are vulnerable to severe recurrent infection with Streptococcus pneumoniae, but no effective preventive strategy has been developed. We set out to determine which factors influence in-hospital mortality and long-term survival of Malawians with invasive pneumococcal disease. DESIGN, SETTING AND PATIENTS: Acute clinical features, inpatient mortality and long-term survival were described among consecutively admitted hospital patients with S. pneumoniae in the blood or cerebrospinal fluid. Factors associated with inpatient mortality were determined, and patients surviving to discharge were followed to determine their long-term outcome. RESULTS: A total of 217 patients with pneumococcal disease were studied over an 18-month period. Among these, 158 out of 167 consenting to testing (95%) were HIV positive. Inpatient mortality was 65% for pneumococcal meningitis (n = 64), 20% for pneumococcaemic pneumonia (n = 92), 26% for patients with pneumococcaemia without localizing signs (n = 43), and 76% in patients with probable meningitis (n = 17). Lowered consciousness level, hypotension, and age exceeding 55 years at presentation were associated with inpatient death, but not long-term outcome in survivors. Hospital survivors were followed for a median of 414 days; 39% died in the community during the study period. Outpatient death was associated with multilobar chest signs, oral candidiasis, and severe anaemia as an inpatient. CONCLUSION: Most patients with pneumococcal disease in Malawi have HIV co-infection. They have severe disease with a high mortality rate. At discharge, all HIV-infected adults have a poor prognosis but patients with multilobar chest signs or anaemia are at particular risk.

Chloramphenicol-resistant bacterial meningitis in Malawi.

Three recent cases of chloramphenicol-resistant pyogenic meningitis are reported from Malawi. The implications of the emergence of antibiotic-resistant strains of Streptococcus pneumoniae and Haemophilus influenzae type b causing childhood meningitis are discussed.

Three cases of bacteremia caused by Vibrio cholerae O1 in Blantyre, Malawi.

We report three fatal cases of bacteremia (two adults, one neonate) caused by Vibrio cholerae O1 (Ogawa), which occurred in the context of a community outbreak of cholera diarrhea in Blantyre, Malawi. Only four cases of invasive disease caused by V. cholerae O1 have previously been reported. We describe the clinical features associated with these rare cases and discuss their significance.