[What are the crucial factors affecting the time to admission of patients with suspected stroke to the emergency department?]. / Quels sont les facteurs influençant les délais d'admission des patients arrivant aux urgences pour une suspicion d'accident vasculaire cérébral.

OBJECTIVE: To analyse the factors influencing the time of admission of patients presenting an acute ischaemic stroke (AIS) to the emergency department. PATIENTS AND METHODS: Between May 2006 and July 2007, all patients with suspected stroke admitted to the emergency department were included. Patients' characteristics and the nature and timing of the events following symptom detection were recorded in the emergency department. The symptoms observed, the person telephoning for help, the person or establishment contacted, the measures implemented (attendance of a physician, medical or paramedical intervention) and the means of transport to the hospital were noted. The overall population was analysed descriptively and patients admitted within 3 hours of symptom onset (group I) were compared with those admitted after a longer interval (group II). The final diagnosis of AIS was confirmed on patient discharge. The results were expressed as the mean (± SD) or median (interquartile range), Mann-Whitney and Chi(2) tests being used to analyse differences between the two groups (threshold of statistical significance: P<0.05). RESULTS: Among the 678 patients admitted with suspected stroke, 536 were diagnosed as having experienced an AIS, 65 a haemorrhagic stroke, 3 a cerebral venous thrombosis and 74 an event other than an acute neurovascular event. The results therefore concern 536 patients (median age: 75 years), of whom 166 (31%, group I) were admitted within 3 hours of symptom onset and 370 after a longer interval (group II). The median time between symptom onset and the call for help was 15 min (1-26) in group I and 300 min (60-960) in group II (P<0.0001). The median times to intervention of a physician (the patient's regular general practitioner, the physician on duty, or the SMUR [Mobile Emergency and Resuscitation Service] physician) ranged from 10 to 60 min. Median transport times ranged from 30 to 120 min depending on the type of transport employed. The two groups differed significantly with regard to intervention of a physician before admission to the emergency department (40% of patients in group I vs. 72% in group II, P<0.0001), initial call to the emergency medical call centre ("15" in France) (42% vs. 17%, P<0.001), presence of a relative or other person at the time of functional symptom onset (58% vs. 39%, P<0.01), and immediate transport to hospital without medical intervention (49 vs. 11%). Finally, irrespective of the time to hospital admission, 12% of the patients studied were eligible for intravenous thrombolysis. CONCLUSION: In the event of a suspected stroke, these results favour contacting the emergency medical call centre and immediate transfer of the patient to an appropriate hospital establishment without waiting for prior medical intervention.

Meningitis in adult patients with a negative direct cerebrospinal fluid examination: value of cytochemical markers for differential diagnosis.

INTRODUCTION: The objective of this study was to determine the ability of various parameters commonly used for the diagnosis of acute meningitis to differentiate between bacterial and viral meningitis, in adult patients with a negative direct cerebrospinal fluid (CSF) examination. METHODS: This was a prospective study, started in 1997, including all patients admitted to the emergency unit with acute meningitis and a negative direct CSF examination. Serum and CSF samples were taken immediately on admission. The patients were divided into two groups according to the type of meningitis: bacterial (BM; group I) or viral (VM; group II). The CSF parameters investigated were cytology, protein, glucose, and lactate; the serum parameters evaluated were C-reactive protein and procalcitonin. CSF/serum glucose and lactate ratios were also assessed. RESULTS: Of the 254 patients with meningitis with a negative direct CSF examination, 35 had BM and 181, VM. The most highly discriminative parameters for the differential diagnosis of BM proved to be CSF lactate, with a sensitivity of 94%, a specificity of 92%, a negative predictive value of 99%, a positive predictive value of 82% at a diagnostic cut-off level of 3.8 mmol/L (area under the curve (AUC), 0.96; 95% confidence interval (CI), 0.95 to 1), and serum procalcitonin, with a sensitivity of 95%, a specificity of 100%, a negative predictive value of 100%, and a positive predictive value of 97% at a diagnostic cut-off level of 0.28 ng/ml (AUC, 0.99; 95% CI, 0.99 to 1). CONCLUSIONS: Serum procalcitonin and CSF lactate concentrations appear to be the most highly discriminative parameters for the differential diagnosis of BM and VM.