Stroke Mimics in a Stroke Care Pathway Based on MRI Screening.

BACKGROUND: Since the use of tissue plasminogen activator for acute ischemic stroke (IS), stroke care pathways have been developed for patients with suspicion of acute stroke. The aim of this prospective observational study was to analyze the stroke mimic (SM) characteristics in patients who were part of our stroke care pathway. METHODS: All consecutive patients admitted in the code stroke within a 1-year period were prospectively enrolled in this study. Patients with a sudden onset of neurological focal deficit in a time window less than 4H30 as indicated for intravenous thrombolysis, had been accepted in the pathway by a neurologist who was directly contactable by the prehospital emergency medical service 24 h per day. Patients arrived directly on the MRI site without passing by the emergency department. A clinical neurological evaluation and a brain MRI with tri-dimensional time-of-flight magnetic resonance angiography were performed. The FAST score was calculated a posteriori. The final discharge diagnosis was concluded either immediately after both neurological examination and cerebrovascular neuroimaging or after other relevant investigations. We classified the discharge diagnosis into neurovascular diseases (NVDs) and into SM. RESULTS: There were 1,361 consecutive patients admitted for suspicion of acute stroke. Sixty-two percent (n = 840) had an NVD including IS (n = 529), transient ischemic attacks (n = 236), intracranial hemorrhages (n = 68), cerebral venous thrombosis (n = 3) and neurovascular medullar pathologies (n = 4). SM represented 38% of cases (n = 521) and the most frequent discharge diagnosis was defined as headaches (18.6%), psychological disorders (16.7%), peripheral vertigo (11.9%) and epilepsy (10.6%). The comparison between the characteristics of the NVD and those of the SM groups showed some significant differences: in the SM group, women were more represented, patients were younger and the NIHSS was lower than in the NVD group. All cardiovascular risk factors were more represented in the NVD group. Concerning the symptoms, motor deficit, speech disturbances, homonymous lateral hemianopia and head and gaze deviation were more represented in the NVD group, whereas vertigo, non-systematized visual trouble, headache, confusion, weakness, neuropsychological symptoms, seizure and chest pain were significantly more frequent in the SM group. The negative predictive value of the FAST score was 64% and the positive predictive value was 76%. CONCLUSIONS: A rate of SM up to 38% of the code stroke system confirms the difficulty to distinguish clinically a stroke from another diagnosis. In this study, using cerebral MRI in first intention was of special interest in patients with acute neurological symptoms to differentiate an NVD from an SM.

Impact of training periods in the emergency department on the motivation of health care students to learn.

OBJECTIVES: Motivation is one of the most important factors for learning and achievement. The perceived value of the task, perceptions of self-efficacy and beliefs about control of learning are the main determinants of motivation. They are highly influenced by the individual's personal history and especially by significant past experiences. We assessed the impact of training periods in the emergency department on the motivation of health care students to learn in the field of emergency medicine. METHODS: A survey was conducted in 2008 with 112 undergraduate medical students and 201 undergraduate nursing students attending an emergency medicine academic programme. At the beginning of the course, the students completed an anonymous 26-item questionnaire to assess their motivational orientations. RESULTS: Perceived task value was higher for students who had previously attended a training period in the emergency department (P = 0.002). Perceived self-efficacy was depressed when the respondent had been confronted with negative outcome events (P < 0.001). Control of learning beliefs was affected negatively in students who had attended a training period in the emergency department (P < 0.001). CONCLUSIONS: Motivation is a major contributor to the success of learning. Training periods in the emergency department can have positive and negative impacts on the learning motivation of medical and nursing students in the field of emergency medicine. Ideally, and in terms of increasing motivation, health care students should gain experiential learning in the emergency department before attending a corresponding academic course. During this period, tutors should provide appropriate supervision and feedback in order to support self-efficacy perception and learning control beliefs.

Using baseline data to address the lack of hospital beds during mass-casualty incidents.

The management of victims during mass-casualty incidents (MCIs) is improving. In many countries, physicians and paramedics are well-trained to manage these incidents. A problem that has been encountered during MCIs is the lack of adequate numbers of hospital beds to accommodate the injured. In Europe, hospitals are crowded. One solution for the lack of beds is the creation of baseline data systems that could be consulted by medical personnel in all European countries. A MCI never has occurred in northeastern Europe, but such an event remains a possibility. This paper describes how the use of SAGEC 67, a free-access, information database concerning the availability of beds should help the participating countries, initially France, Germany, and Switzerland, respond to a MCI by dispatching each patient to an appropriate hospital and informing their families and physicians using their own language. Baseline data for more than 20 countries, and for hospitals, especially those in Germany, Switzerland, and France, were collected. Information about the number of beds and their availability hour-by-hour was included. In the case of MCIs, the baseline data program is opened and automatically connects to all of the countries. In case of a necessary hospital evacuation, the required beds immediately are occupied in one of these three countries. Questions and conversations among medical staff or family members can be accomplished between hospitals through computer, secured-line chatting that automatically translates into appropriate language. During the patient evacuation phase of a MCI, respondents acknowledged that a combination of local, state, and private resources and international cooperation eventually would be needed to meet the demand. Patient evacuation is optimized through the use of SAGEC 67, a free baseline database.