The practical impact of postgraduate leadership education on Registered Nurses' practice: a narrative inquiry.

When diagnosed, tuberculous meningitis (TBM) has an inpatient mortality rate of up to 50% in HIV1 (HIV)-endemic areas of sub-Saharan Africa []. The global burden of adult TBM was estimated to be 164 000 cases in 2019, with 23% of cases occurring in people with HIV (PWH) []. Currently recommended diagnostic testing on cerebrospinal fluid (CSF) has sensitivity limitations. As a result, cases are missed, and patients are treated empirically with minimal objective data for guidance. Complete diagnostic autopsy (CDA) is the gold standard to determine cause of death. Worldwide, because of multiple factors including advances in diagnostic technology, reduced accreditation requirements, cost, and difficulty obtaining consent [, ]. In settings of high HIV prevalence, additional barriers to CDA include cultural taboo of desecrating the body, religious beliefs, and the need to initiate burial in a timely manner []. Alternatively, organ-specific minimally invasive tissue sampling (MITS) has recently been used in sub-Saharan Africa with promising results []. MITS of the brain has shown utility in the diagnosis of infectious causes of mortality []. Suboccipital and transethmoidal brain biopsy along with large volume postmortem CSF provide invaluable diagnostic information. The diagnosis of TBM remains hindered by the lack of a true diagnostic gold standard test due to the risks of obtaining a biopsy from the brain or meninges in living patients and infrequent CDA in deceased individuals. The World Health Organization has endorsed CSF Xpert MTB/RIF Ultra (Xpert Ultra), an automated polymerase chain reaction platform, as the first-line test to diagnose TBM []. However, it has never been compared to a pathological diagnosis. In addition, there is a sizeable and well-documented group of meningitis patients that do not undergo lumbar puncture (LP) in sub-Saharan Africa due to patient/family refusal, procedural stigma, or provider discomfort associated with the procedure []. These patients are omitted from epidemiological studies, as antemortem CSF sampling is not feasible, leading to underestimation of the true TBM burden, a gap that MITS can help address.