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UNLABELLED: Following the publication practice guidelines for multiple sclerosis by a group of neurologists (multiple sclerosis study group [GRESEP]), the primary objective of this study was to compare the reality of practice to the guidelines according to the targeted clinical audit (TCA) method. The study was conducted at 17 neurology sites and was administered during two periods of MS care (diagnostic - TCA-DIAG, and disease course - TCA-EVOL). Two complementary surveys were done on the record keeping and the root causes of the deviations. The percentages of compliance ranged from 8 to 98% for the TCA-DIAG, and from 15 to 99% for the TCA-EVOL, with wide disparity between sites. The audits were able to identify causes of the flaws in traceability or accessibility. At the end of the study, despite its limitations, we think that the sharing of the results from different sites provided interesting approaches for the use of the assessment criteria defined by GRESEP in a complete audit cycle. This study is to our knowledge the first report of an experiment in which guidelines were created, and subsequently followed by the development of assessment criteria and then the performance of targeted clinical audits using them, all by the same participants. CONTEXT: Clinical practice guidelines (CPGs) are intended to help practitioners and patients make informed treatment choices, but their integration into actual practice remains problematic. This study was done immediately following the publication of CPGs for multiple sclerosis (MS) by the multiple sclerosis study group [GRESEP]. The primary objective was to generate quality criteria, to test them within the same group, and to analyze the observed deviations. MATERIALS AND METHODS: The study was conducted in the 17 voluntary departments that had participated in the development of the CPGs. The targeted clinical audit method was administered during two periods of MS care (diagnostic - TCA-DIAG, and disease course - TCA-EVOL). All the files were evaluated by a clinical research technician using digital format, which ensured thoroughness of the collection. Two complementary surveys were done on the record keeping and the potential causes of the deviations. RESULTS: The percentages of compliance to the criteria ranged from 8 to 98% (out of 240 files) for the TCA-DIAG, and from 15 to 99% (221 files) for the TCA-EVOL, with wide disparity between sites (interquartile distance ranges: TCA-DIAG between 0% and 55%; TCA-EVOL between 0% and 70%). The mean percentage of compliance with all the criteria as measured by the TCA-DIAG was 83.9% for the sites with digital files vs. 76.4% for those with only paper files (P<0.01). For the TCA-EVOL, the difference was not significant. Explanations for the observed deviations were suggested (1 to 9 according to the participants). DISCUSSION AND CONCLUSION: The quantified results could not be compared to other studies given the unique nature of the experiment. The importance of the traceability of practices in the patient files was discussed and assessed with regard to continuity and safety of care, as well as the medical-legal perspectives. Causes of lack of compliance were suggested (particularly the absence of reminders, the lack of means and/or time). Despite the limitations of the study, we think it is advisable that when a group becomes involved in the development of CPGs that they follow with the development of assessment criteria in order to evaluate the validity as well as their character as intermediate indicators of the quality of practices.

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INTRODUCTION: Patients who receive care in a dedicated stroke unit are more likely to survive and become independent. Specific guidelines describe evidence-based care practices. We examined the results of a French audit validation campaign to determine whether the presence of a stroke unit had an influence on the implementation of these recommendations. METHODS: Eleven hospital centers volunteered for self-evaluation. Care delivered to patients in the emergency room and in the hospital unit (dedicated stroke unit or not) was assessed with the clinical audit method. RESULTS: Compared with non-dedicated units, care delivered in stroke units was significantly more compliant with published recommendations. All aspects of acute stroke care were concerned: initial evaluation, acute phase treatment, screening for complications and their treatment, multidisciplinary team coordination, discharge preparation. Care delivered in dedicated stroke units was more reproducible, protocols were more widely used, acute phase risks were better prevented, and acute and postacute care was better coordinated between professionals. A second audit one year later showed increased quality of care in both dedicated and non-dedicated units, with more items improved in the latter. CONCLUSION: Although statistical bias cannot be excluded, this study suggests that recommendations are applied better in dedicated stroke units. A second audit showed better compliance with recommendations, especially in non-dedicated units.

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The traditional theories according to which deprivation of the visual channel is directly responsible for every disturbance observed in children born blind or partially sighted prove to be unsatisfactory; they fail to answer why, given the same visual defect, some children develop in a healthy way while others present a typical picture of infantile psychosis. The authors put forward the following hypotheses: infantile psychosis is always both a sign of and a response to trauma, in the sense developed by Freud in Beyond the Pleasure Principle, which has struck the mother-child dual unit; the high frequency of psychotics among children born blind indicates that blindness is a particularly charged trauma. The traumatic neurosis of the parents and especially of the mother is catastrophic for the child; it is therefore necessary to understand why and how its works, how it can be avoided or dealth with. The authors present a detailed clinical description of the various possible mother-child constellations and regarding unfavourable outcomes, propose preventive measures.

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A new case of pseudo-Cockett syndrome is reported. Both the clinical picture and the anatomic characteristics were unusual. Apparently, no similar cases have been reported in the medical literature. The relation between the cause of venous compression and it's results (thrombosis upstream and embolism downstream) could not be stated from data reviewed in the literature. No well-defined plan of management has been described. However, in the case reported here, therapeutic decisions gave satisfactory results.

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The authors report the case of a 34 year old woman admitted to hospital for attacks of atrial tachycardia inducing very poorly tolerated junctional tachycardia at 260 beats/min. The attacks were always induced by swallowing and could be reproduced at will. Electrophysiological studies could only be undertaken after the administration of large doses of amiodarone. An exclusively retrograde rapidly conducting paranodal accessory pathway was demonstrated with triggering of runs of reentrant tachycardia. No underlying gastro-oesophageal or cardiac disease apart from thromboembolism was found. Swallowing-induced supraventricular tachycardia is rare and possible mechanisms are discussed. The arrhythmia may be triggered by direct mechanical stimulation, by changes in vagosympathetic tone, or by an association of the two phenomena. Previously published reports describe similar clinical situations resulting from a variety of different mechanisms.

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In reviewing a series of twelve cases treated surgically for deep venous thrombosis, with an admittedly short follow up (2 months to 2 years), the authors stress the beneficial effects of venous surgery. The postoperative mortality rate was zero and the morbidity rate marginal. They underline the importance of phlebographic exploration leading to earlier diagnosis, and list the therapeutic indications which vary according to the case and may include a supporting heparinotherapy and fibrinolytic treatment in a specialized center. They advocate venous surgery which has the twofold merit of preventing embolic complications and attenuating postphlebitic sequelae.

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This critical review of the literature concerns the electrophysiological studies of sleep applied to depressed patients. While the (phenomenological) studies confirm the actual sleep disturbances in most patients and at certain stages of the depressive episodes, the (parallelistic) studies failed to evidence any strict correlation between quantified sleep data and nosographical classifications of depressions. The reductionistic) studies, searching into sleep measurements indices of specific biochemical disturbances also lead to contradictory and questionable conclusions. The explanation of this negative assessment is not to be found in methodological deficiencies but must be searched at the level of the theoretical approach of the problem.

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The case of a child under continuous anticonvulsant medication, especially barbiturate, since the age of 8 months for atypical seizures is reported. Medication was withdrawn when the child was 7.7 years old. The child was then under care in a Day Hospital with an autistic-like syndrome associated with important disturbances of sleep-waking regulation, complete learning incapability and major EEG abnormalities. The EEG paroxysmal discharges observed in the waking and all-night sleep records gradually decreased and then disappeared as the withdrawal was pursued over a period of several months. During the same period, the child's behaviour markedly improved and his sleep disturbances disappeared. The possibility of iatrogenic effects of early and continuous anti-convulsant therapies is discussed, even though the drug plasma levels remain within ranges generally considered as non-toxic.

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Three biotelemetric examinations and a whole night sleep recording were carried out in an 8-year-old child whose behaviour alternated between excitation and autism with stereotypes. The EEG showed 5 c/sec temporo-parietal sharp wave discharges lasting from 1 sec to 20 min. These discharges were at times unilateral and predominantly right sided, at other times bilateral, without any clinical sign of epilepsy. The chronological distribution of right, left and bilateral discharges during the successive 1 min epochs was computed and related to corresponding 'behavioural states' of the child. The paroxysmal discharges predominated when the child was awake but not involved in any relational activity; during sleep, they mostly appeared during light NREM sleep (stage I) and paradoxical sleep. The significance of these paroxysmal discharges is discussed in relation to stereotyped behaviour, vigilance and early disorganization of biological rhythms.

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From four cases studied both clinically and with the help of repeated and prolonged electroencephalograms, the problems raised by the association psychosis-epilepsy in children are reconsidered. The difficulties in evaluating: the actual weight of the "epilepsy" component; the role of the epileptic discharge for the subject's psychic economy; the role of drug therapies, are particularly underlined.

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Potentials in relation to eye movements were studied by means of direct recording of the striate cortex in a waking man. In a lighted environment, the usual evoked potential--lambda response--was obtained and was clearly visible after each eye movement. In complete darkness no individual potential was observable by means of visual analysis after each eye movement, but a slow potential of low amplitude could be obtained by superimposition and averaging of the cortical striate activity time-locked to the start of a series of eye movements. This eye-movement potential showed a longer latency and a lower amplitude than the lambda response. These data are discussed in reference to those obtained in the cat and the monkey; the significance of this eye-movement potential in darkness as a 'corollary discharge' is considered.

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Pulmonary embolism and preventive anticoagulant therapy of ederly patients in hospital. Statistical survey of their respective risks. The incidence of pulmonary embolism as a cause of death seems the higher as its strikes old people (above 60) affected by cardiovascular diseases and who are bed tied; the interest of preventive anticoagulant treatment (PAT) remains controversial. This matter has been studied over a period of 5 years from the files of a geriatric cardiology department; 455 anatomo-clinical documents have been set up. This survey confirms the frequency of mortality by pulmonary embolism (23,9 %) and its diminution under long-term preventive anticoagulant treatment 6,6 %). The anticoagulant therapy does not increase the risk of haemorrhagic accidents, from the point of view of frequency, but slightly increases it if one considers the number of days spent in hospital. As a conclusion, the preventive anticoagulant treatment seems positive insofar as contra-indications are strictly observed, in particular the digestive ones. The mechanism of some hemorrhagic accidents with or without PAT remains sometimes difficult to explain.

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The afternoon sleep of 12 children aged 7-9 was studied; its electrophysiological indices and sequential organization were described and compared to those of afternoon sleep of adults and to those of night sleep of adults and children. The EEG indices which differentiate sleep patterns of children from adults' were the following: abundance of slow rhythms from onset of sleep; absence of low voltage fast activity at sleep onset and during REM sleep; early appearance of a large amount of transitory potentials in the form of sharp rolandic waves and sharp occipital waves. Moreover, either focal or generalized paroxysmal discharges occasionally occurred. Even when it covers a complete sleep cycle, the afternoon sleep of children appears shorter than both that of adults and the first cycle of night sleep in children of the same age. The organization of sleep components does not allow identification of the classical stages defined in adults nor to describe homogeneous stages which are specific to children. The very atypical character of REM sleep also makes it difficult to differentiate unequivocally the classical slow and paradoxical sleeps. The significance of rolandic and occipital sharp transients is discussed; the role of maturation and the influence of the time of occurrence within the circadian rhythm are considered, in order to explain the phenomenological and temporal characteristics of day sleep in children.

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