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.

Analgesic efficacy of orodispersible paracetamol in patients admitted to the emergency department with an osteoarticular injury.

INTRODUCTION: Acute pain still persists in patients under treatment after admission to emergency departments (ED). The objective of this study was to determine the efficacy of 1 g of paracetamol in patients presenting an osteoarticular injury. MATERIALS AND METHODS: This prospective study included all patients admitted to the ED with an osteoarticular injury and a pain score above 30 on the visual analogue scale (VAS). Patients were selected on admission by the reception nurse and given paracetamol within 5 min of admission. VAS scores were recorded 30 and 60 min after admission. On discharge from the ED, the patients underwent a further VAS assessment and were asked a question about pain relief (yes/no answer). The primary endpoint was the VAS score at 60 min. The secondary endpoint was the pain relief expressed by the patient on discharge from the ED. RESULTS: Five hundred and seventy-one patients were included. The median stay in the ED was 90 min (75-120 min). The diagnoses at discharge were sprain or dislocation (ankle, knee, and wrist) for 287 patients, fracture for 102 patients, and other injury for 182 patients. In 69% of the patients, the injured limb was immobilized. The median VAS score on admission was 57. A significant difference was seen between the median VAS on admission and at 1 h after admission (57+/-18 vs. 30+/-18; P<0.0001), and between the median VAS score at admission and the score at discharge from the ED (57+/-18 vs. 26+/-18, P<0.0001). Finally, 81% of the patients expressed pain relief. On discharge from the ED, a gain of 20 mm on the VAS had a positive predictive value of 93% [area under curve (AUC): 89; CI: 86-92; P=0.001], for the endpoint 'patients stating pain relief'. CONCLUSION: A simple and easily applicable protocol of pain management permits the achievement of satisfactory analgesia during a patient's stay in the ED.

Conversion of prevalence survey data on nosocomial infections to incidence estimates: a simplified tool for surveillance?

We calculated the incidence of nosocomial infection in 2 intensive care units (ICUs) on the basis of prevalence data recorded from 1997 through 2002 and compared these estimates to cumulative incidences measured in the 2 ICUs during the same period to investigate the feasibility and the reliability of converting prevalence data to incidence estimates. Decreases in the calculated and measured incidences over time in the ICUs were found to be statistically significantly related.

[Troponin I values during rhabdomyolysis in elderly patients admitted to the emergency department]. / Valeurs de la troponine I au cours des rhabdomyolyses chez les personnes âgées admises aux urgences.

OBJECTIVE: The objective of this study was to assess the utility of determining serum cardiac troponin I (TcI) levels in the elderly. METHODS: During the nine-month study period, all patients older than 70 years admitted to the emergency department presenting rhabdomyolysis (defined by creatine kinase>500 IU/L) were included in this prospective descriptive study, except for those with acute coronary syndrome or pulmonary embolism. Patients were classified into two groups according to their serum TcI level:>0.15 or0.15 ng/mL group and 37 in the other group. Clinical and laboratory indicators were similar in the two groups. In contrast, significantly more patients in the TcI>0.15 ng/mL group had been treated with a curative dose of heparin (14 versus 2, p=0.01). This difference between the two groups was noted in both the emergency department and other hospital units. Serum TcI levels were not correlated with creatine kinase levels. Concordance between emergency department diagnosis and discharge diagnosis was 95%. No patient was discharged with a diagnosis of acute coronary syndrome; one patient, with a serum TcI level0. 15 ng/mL group versus 8% in the other group). Mortality at six months was higher among patients with an elevated serum TcI level, but the difference was not significant (23% versus 8%, p=0.07). CONCLUSION: This study indicated a trend toward higher mortality among patients with elevated serum TcI levels, although the factors underlying these increased concentrations remain unclear.