Efficiency of Sensorimotor Networks: Posture and Gait in Young and Older Adults.

Background/Study context: Posture and gait are complex sensorimotor functions affected by age. These difficulties are particularly apparent when performing cognitively demanding tasks. Characterizing the functional organization of brain networks involved in these associations remains a challenge because of the incompatibility of brain imagery techniques with gross body movements. The present study aimed at testing whether resting-state functional connectivity of sensorimotor networks is associated with posture and gait performance recorded offline, in young and older adults. METHODS: Young (n = 12, mean = 24.1 y/o) and older (n = 14, mean = 65.6 y/o) healthy adults were tested for stability of their posture and gait. Four hours later, anatomical and functional brain imaging data were collected with Magnetic Resonance Imaging (MRI). Bilateral precentral and postcentral gyri were used as seeds in a graph theory analysis focused on global and local efficiency. The possible association between these data and posture and gait performance was examined. RESULTS: Both samples presented similar sensorimotor graphs, but with different global and local efficiencies (small world properties). The association between the networks' graph measures and posture and gait performance also differed across groups: local efficiency was correlated with gait stability in challenging conditions in older adults, but not in young adults. CONCLUSION: This exploratory study suggests that combining analyses of functional networks and offline body movement may provide important information about motor function. In older adults, the association between graph properties of the sensorimotor network and gait performance in challenging conditions may be indicative of compensatory processes. Prospective studies involving more subjects with a larger age range are warranted.

[The role of inhibition in obsessional-compulsive disorders]. / Place de l'inhibition dans le trouble obsessionnel-compulsif.

INTRODUCTION: The nature of neuropsychological mechanisms underlying the clinical picture of obsessions and compulsions has not been clearly determined. A number of studies has emphasized the role of cognitive deficits, but diversity of methodology and overlapping of clinical sub-groups have not established a specific cognitive functioning of these patients. The studies carried out on executive functions have, however, helped to identify the important role that both inhibition and cognitive flexibility play in obsessive-compulsive (OC) symptoms. Most of them have found that a deficit of inhibition and alteration of cognitive flexibility could explain inflexibility and repetitive thoughts and actions typical of all types of OC disorders. The aim of the paper is to present the published data supporting the hypothesis of a specific role played by a deficit of inhibition and cognitive inflexibility. In the first, theoretical part, we present the neuropsychological approach emphasizing inhibition and lack of flexibility as a promising explanation of the functioning of OC disorders. In the second part, we will present studies using various measurements of inhibition and the results of which, therefore, support this hypothesis. ARGUMENTS AND DISCUSSION: On the theoretical level, it is the model of attention that was used in explaining the OCD hypothesis. In the model of attention control of action, described by Norman, Shallice and Burgess, three systems were emphasized: one that takes care of routine actions, and the second that takes over the first in situations where automatic activities must stop in order to establish an attention control and therefore inhibit automatic responses. When selection of everyday and automatic activities is not sufficient to accomplish a task, it is the third system, that of cognitive control, which takes over. This supervisory attentional system operates in non-routine and ambiguous activities. The cognitive control is charged with detecting potential or emitted cognitive errors and resolving ambiguous situations. Neurocognitive studies show that cingular anterior cortex and prefrontal lateral cortex are engaged in ambiguous and conflicting situations. These two regions are considered essential for inhibition of routine actions, adjustment to change and, more generally, for an efficient and flexible behaviour. Repetitive nature of verification rituals in OCD could be explained in terms of lack of relationship between two systems, leaving in action the one that regulates automatic activities. Therefore, the rituals are considered to be under particular influence of the system which, being in charge of automatic actions, has a deficit in disengagement. Another model of attention, described by Posner, gives a further explanation of OCD. Mental inhibition has the capacity to treat information, either by applying strategies to control it (i.e. trying not to remember an unpleasant event) or leaving it to automatic control (i.e. incapacity to experience an emotion in relation to a particular event). In this way, the effort to suppress an intrusive thought is considered as controlled and deliberate cognitive treatment of emotionally charged information. In OCD, in the context of heightened anxiety, the assumed negative valence of information would influence habitual suppression of thought during controlled treatment. As a result, controlled efforts to suppress obsessions in emotionally stressful situations, would lead to the production of repetitive thoughts, as controlled treatment of information has failed in this action. On a clinical and experimental level, these studies have led to a better understanding and conceptualization of OCD. In spite of some conflicting results, there are concordant data in favour of hypotheses of the role of sub-cortical and frontal regions and their function in inhibition/desinhibition implied in the onset and maintenance of OCD. Functional neuroimagery anomalies are also in favour of the role of sub-cortical-frontal region in clinical manifestations of OCD. They are often associated with low performance in cognitive tasks, especially those implying frontal functions, which are, in turn, dependent on a necessary level of attention in order to guide or inhibit motor and cognitive programs.

Prevention of overweight in preschool children: results of kindergarten-based interventions.

OBJECTIVE: Given the increasing prevalence of pediatric obesity, we evaluated two kindergarten-based strategies for reducing overweight in preschool children in the Haute-Garonne Department in France. METHODS: Kindergartens (n=79) were randomly assigned to one of the two strategies and followed for 2 years. In the first group (Epidémiologie et prévention de l'obésité infantile, EPIPOI-1), parents and teachers received basic information on overweight and health, and children underwent screening to identify those with overweight (body mass index (BMI) > or = 90th percentile) or at risk for overweight (BMI between 75 and 90th percentile), who were then followed up by their physicians. EPIPOI-2 children, in addition, received kindergarten-based education to promote healthy practices related to nutrition, physical activity and sedentary behaviors. Data on control children from non-intervention kindergartens (n=40) were retrieved from medical records at the Division of School Health. RESULTS: At baseline, groups differed significantly on age and school area (underprivileged/not). Owing to a significant interaction between school area and group, analyses were stratified by school area. At baseline, groups did not differ on overweight prevalence and BMI z-scores for any school area. After intervention, prevalence of overweight, BMI z-score and change in BMI z-score were significantly lower in intervention groups compared with controls in underprivileged areas. Using multilevel analysis adjusted for potential confounders, a significant effect on overweight prevalence at the end of the study was noted for EPIPOI-1 in underprivileged areas only (odds ratio and 95% confidence interval: 0.18 (0.07-0.51). In non-underprivileged areas, the gain in BMI z-score was lower in EPIPOI-2 group compared with control and EPIPOI-1. CONCLUSION: Our results suggest that simple measures involving increasing awareness on overweight and health, and periodic monitoring of weight and height with follow-up care when indicated, could be useful to reduce overweight in young children from underprivileged areas. A reinforced strategy with an education component, in addition, may be indicated in children in non-underprivileged areas.

Two-levels mini-open transforaminal lumbar interbody fusion: technical note.

OBJECTIVE: Mini-open transforaminal lumbar interbody fusion (oTLIF), previously described by Mummaneni et al., is a well-established technique that uses tubular dilators and retractors for treatment of single-level lumbar spinal stenosis. TECHNIQUE: We describe eight patients with two-level spinal stenosis who were operated on with minimally invasive spinal arthrodesis via a transforaminal route with the use of tubular retractors. This approach allowed us to obtain double-level cages insertion in all patients, with direct visualization of pedicular entry points and no screw malpositioning. CONCLUSION: The oTLIF represents a good compromise in patients with two-level lumbar degenerative disease deserving surgery. Compared to standard open TLIF, it is associated with less postoperative muscular trauma, and faster recovery. This seems to be more evident in that category of patients in whom open approaches need longer incisions and more muscular fiber splitting. Compared to percutaneous TLIF (pTLIF), it allows for bilateral root decompression in every case. Bilateral cage insertion was also possible with this technique.

[Age and management decisions in patients with primary lung cancer]. / Age et décision de prise en charge des patients atteints d'un cancer pulmonaire primitif.

INTRODUCTION: Therapeutic decisions are difficult in elderly patients because of the heterogeneity of this population. Our objective was to evaluate the role of age in the management of patients suffering from primary lung cancer seen in the department of respiratory diseases of the Limoges regional teaching hospital between 2002 and 2004. METHODS: A cross sectional study analysed the management of 363 patients suffering from primary lung cancer. The patients were divided into two groups according to their age (less than seventy or seventy and over). A comparison was made between the management of the two groups. RESULTS: The comparisons according to age produced evidence of reduced activity, greater dependence, an increased Charlson score, less frequently administered radiotherapy and chemotherapy, and more frequent symptomatic treatment in the elderly group (p<0.001). CONCLUSIONS: The geriatric assessment of patients suffering from primary lung cancer should make allowance for the physiological age of the patient and adapt the management to ensure the best quality of life.

Relationship between Rh-o(D) zygosity and red cell Rh-o(D) antigen content in family members.

The red cells of 63 members of 11 families were tested with (125)I-labeled anti-Rh(0)(D). Families with a history of hemolytic disease of the newborn due to fetomaternal Rh incompatibility were selected for study. In such families it was possible to determine the antibody binding to the Rh(0)(D) heterozygous red cells of the children and to compare within each family this value with the antibody bound to the father's Rh(0)(D)-positive red cells and the mother's Rh(0)(D)-negative red cells. The fathers in all the families studied could be assigned to two classes on the basis of the quantity of antibody bound to their red cells. One group bound about the same quantity of antibody to their cells as did their children, indicating that they were heterozygous for the Rh(0)(D) antigen. The other bound about twice as much antibody to their cells as did their children, indicating that they were homozygous for the antigen. The Rh genotype of the father in all 11 families could be ascertained by using the children in each family as a reference point. The members of two families showed a poor correspondence between antibody binding and zygosity. In one family an Rh heterozygous child (R(1)r) took up 85% of the antibody bound to the father's homozygous cells (R(1)R(1)), and in the other family an Rh heterozygous child (R(1)r) took up 20% more antibody than did the cells of her father, which were of the same Rh phenotype (Rh(1)) and zygosity.The quantity of antibody bound to the red cells of unrelated Rh(0)(D) homozygous individuals of the same Rh phenotype (Rh(1)) showed an almost sixfold variation. A consequence of this observation was that the cells of Rh(0)(D) heterozygous children of high antibody uptake fathers took up more antibody than did the cells of low antibody uptake Rh(0)(D) homozygous fathers. The gene dosage effect for the Rh(0)(D) antigen demonstrable within a family does not appear to apply when unrelated individuals are tested, even though they may be of the same Rh phenotype.

[Primitive intracranial trigeminal nerve germinoma. Case report]. / Localisation trigéminale d'un germinome intracrânien primitif. A propos d'un cas.

A 22-year-old man presented headache, asthenia, body weight loss and trigeminal hypoesthesia worsening quickly. Radiological analysis showed an enhanced lesion that originated from the cavernous sinus and extended into the Meckel cave, owing to the fifth cranial nerve's course. The lesion was explored by a temporo-pterional approach and was partially removed. On the basis of histological analysis and negativity of tumor marker levels in serum and cerebrospinal fluid (alpha-fetoprotein alpha, human beta-chorionic gonadotropin), a primitive non-secreting intracranial germinoma was diagnosed. Under combined chemotherapy (carboplatine, ifosfamide, etoposide) followed by focal fractionated radiotherapy delivering 40 Gy to the initial tumor volume, the outcome was excellent. Five years later, the patient was in complete clinical and radiological remission. Primitive intracranial germinomas are rare malignant tumors involving mainly pineal and hypothalamic regions. We report a case of intracranial trigeminal nerve germinoma. To the best of our knowledge, no case of primitive germinoma was previously described in this location. Aspects of diagnosis and treatment are discussed in the light of previous publishing data.

Imaging the Addicted Brain: Alcohol.

Alcohol use disorder (AUD) represents a major public health issue due to its prevalence and severe health consequences. It may affect several aspects of an individual's life including work and relationships, and it also increases risk for additional problems such as brain injury. The causes and outcomes of AUD are varied; thus, attempting to understand this complex phenomenon requires investigation from multiple perspectives. Magnetic resonance imaging (MRI) is a powerful means to investigate brain anatomical and functional alterations related to AUD. Recent advances in MRI methods allow better investigation of the alterations to structural and functional brain networks in AUD. Here, we focus on findings from studies using multiple MRI techniques, which converge to support the considerable vulnerability of frontal systems. Indeed, MRI studies provide evidence for a "disconnection syndrome" which could be involved in the poor behavioral control observed in AUD.

Cryptosporidium parvum infection and associated risk factors in dairy calves in western France.

This study was conducted to determine the prevalence and risk factors for Cryptosporidium infection in calf neonates on dairy farms in Normandy. Fecal samples were randomly collected between July 2010 and September 2011 from 968 calves (7-21 days old) on 97 farms. Up to 10 calves were selected and sampled per farm, and feces examined for oocysts by microscopy. C. parvum oocyst shedding was scored semi-quantitatively (0-5). A questionnaire about calf-level care and management was completed, and mortality rates were obtained from the French national registration database (BDNI). Bivariable and multivariable analyses of potential risk factors for C. parvum oocyst shedding were conducted using generalized estimating equation (GEE) models (family=Binomial).Overall, 402 out of 968 calves (41.5%) were positive for oocysts, and 25.1% of animals had a shedding score >2. Seven of the 97 farms (7%) were negative for oocysts in all fecal samples. At the time of collection, 375 calves (39%) had diarrhea, and its prevalence strongly correlated with the score for C. parvum oocyst shedding (p<0.0001). The mortality rate at 90 days was significantly greater for calves with high combined scores of diarrhea and shedding. Factors associated with the shedding of C. parvum were the Normande breed (odds ratio=1.49; 95% confidence interval (CI): 0.93-2.37), dispensing of colostrum using a bucket (odds ratio=1.37; 95% CI: 1.00-1.89), treatment with halofuginone (odds ratio=0.46; 95% CI: 0.19-1.15) and feeding with fermented milk (odds ratio=0.32; 95% CI: 0.17-0.63). C. parvum is widespread among calves under 21 days old in dairy herds of western France. Shedding of C. parvum is associated with a high incidence of diarrhea and increased risk of mortality in young calves. This study identified some associated calf-level factors, although further investigations are necessary to determine appropriate measures that farmers and veterinary practitioners should take to reduce the prevalence of C. parvum.

Pituitary enlargement with suprasellar extension in functional hyperprolactinemia due to lactotroph hyperplasia: a pseudotumoral disease.

Beside the well characterized PRL-secreting adenomas, a wide spectrum of functional hyperprolactinemic states exists. We describe here five women, 21-38 yr old, all suspected of having a PRL-secreting adenoma because of a pseudotumoral appearance of the pituitary on computerized tomographic (CT) scan or magnetic resonance imaging (MRI). Four had oligomenorrhea with or without galactorrhea, one had amenorrhea with galactorrhea, and two complained of infertility. In the same patient, basal plasma PRL levels were variable on different days, sometimes normal (mean +/- SEM, 11.3 +/- 1.5 micrograms/L), sometimes elevated (49 +/- 7 micrograms/L), but in all cases, a PRL response of large amplitude to TRH (6- to 8-fold increase in the basal value) was observed. Basal plasma levels of estradiol were within luteal phase normal values (0.41 +/- 0.13 pmol/L), while progesterone levels were low (1.92 +/- 0.47 nmol/L). CT scan or MRI showed an intrasellar mass with suprasellar extension, suggesting a tumoral process. However, the signal intensity was homogeneous, and on coronal views, the suprasellar extension was pyramidal and symmetrical, and the pituitary stalk was always in the midline. The five patients were operated on by the transsphenoidal route, but no adenoma was found. Surgical biopsies were taken in four cases, and lactotroph hyperplasia, i.e. enlarged cell cords consisting mainly of PRL cells, was found in three of them. One case displayed a continuum between areas of lactotroph hyperplasia and adenomatous PRL cells. We conclude that functional hyperprolactinemia may mimic on CT scan or MRI a PRL-secreting adenoma.

Somatostatin receptors, adenylate cyclase activity, and growth hormone (GH) response to octreotide in GH-secreting adenomas.

To determine the cellular mechanism(s) of the variability in GH responsiveness to octreotide in acromegaly, somatostatin (SRIH) receptor status was studied in 37 GH-secreting adenomas. SRIH receptor binding was always present in all GH-secreting adenomas either in membrane preparations (Exp A; n = 17) or by quantitative autoradiography (Exp B; n = 20). In membranes, maximal binding capacities ranged from 83-2331 fmol/mg protein; affinity was in the nanomolar range (Kd, 1.3 +/- 0.2 nmol/L). By quantitative autoradiography, SRIH-14 and octreotide were equally active in displacing [125I]SRIH binding in tumors (Spearman correlation rho = 0.92). IC50 values ranged from 3-22 nmol/L (mean +/- SE, 8.0 +/- 1.3 nmol/L). In Exp A, basal adenylate cyclase (AC) activity was high in 7 tumors (841 +/- 306 pmol/L cAMP x 30 min/mg protein) compared to that in the other 10 (252 +/- 92 pmol/L cAMP x 30 min/mg protein). In these 7 tumors, GH-releasing hormone (0.1 mumol/L) stimulation of AC was lower (53 +/- 11% vs. 297 +/- 48%), whereas SRIH (1 mumol/L) inhibition was higher (52 +/- 5% vs. 34 +/- 5%). Similar results were obtained with Exp B tumors. In both experiments, no correlation was apparent between SRIH-binding capacity and inhibition of AC. In Exp B, a variable decrease in mean plasma GH levels was observed (> or = 80% in 5 patients, between 50-80% in 8 patients, and < or = 50% in 5 patients) after a single sc injection of octreotide (100 micrograms). A modest correlation was found between the GH response to octreotide and SRIH-binding capacity (rho = 0.48) or SRIH inhibition of AC (rho = 0.61). The IC50 values to displace SRIH binding were lower in poorly responsive patients than in highly responsive ones (IC50, 4.6 +/- 1.9 and 13.9 +/- 2.7 nmol/L, respectively). These data indicate that an absence of SRIH receptors cannot account for the weak response to SRIH therapy in 20-30% of acromegalic patients. Alternatively, the weak correlation between either SRIH binding or SRIH inhibition of AC with octreotide inhibition of plasma GH levels might reflect the heterogeneity of SRIH receptor subtypes in GH-secreting adenomas.

Intravenous lidocaine in central pain: a double-blind, placebo-controlled, psychophysical study.

OBJECTIVE: To investigate the effects of systemic administration of lidocaine on different components of neuropathic central pains by quantitative sensory testing. METHODS: The efficacy of systemic lidocaine (5 mg/kg IV over 30 minutes) was evaluated in a double-blind, placebo-controlled, and cross-over fashion, on both spontaneous ongoing pain and evoked pains (allodynia and hyperalgesia) in 16 patients with chronic poststroke (n = 6) or spinal cord injury (n = 10) related pain. RESULTS: Lidocaine was significantly superior to the placebo (saline) in reducing the intensity of spontaneous ongoing pain for up to 45 minutes after the injection: 10 of 16 patients (62.5%) receiving lidocaine showed a significant reduction in spontaneous pain, whereas only six patients showed this after the placebo. Lidocaine also significantly reduced the intensity of brush-induced allodynia and mechanical hyperalgesia, but was no better than the placebo against thermal allodynia and hyperalgesia. In general, the side effects were moderate and consisted mainly of lightheadedness (44%). CONCLUSIONS: Systemic lidocaine can induce a significant and selective reduction of several components of pain caused by CNS injuries. The observed preferential antihyperalgesic and antiallodynic effects of this drug suggest a selective central action on the mechanisms underlying these evoked pains.

Immunogenicity and safety of a trivalent tetanus, low dose diphtheria, inactivated poliomyelitis booster compared with a standard tetanus, low dose diphtheria booster at six to nine years of age. Munich Vaccine Study Group.

OBJECTIVE: To compare the immunogenicity and safety of a trivalent tetanus-diphtheria (low toxoid content)-inactivated poliomyelitis vaccine, Td-IPV (Revaxis; Pasteur Merièux), with a tetanus-diphtheria (low toxoid content) vaccine, Td (Td-Impfstoff Mérieux; Pasteur Merièux), when administered as a booster to children age 6 to 9 years. METHODS: A group of 301 children were randomized and vaccinated with Td-IPV (n = 150) or Td (n = 151) in this open, controlled, multicenter trial. Serum specimens were obtained before and 28 days after vaccination. Safety was assessed for up to 28 days postvaccination by parental diary cards. Solicited local and systemic reactions were recorded for 7 days after vaccination. RESULTS: Seroprotection (enzyme-linked immunosorbent assay titer, > or =0.10 IU/ml) against tetanus and diphtheria was induced by either Td-IPV or Td in all subjects. Tetanus and diphtheria geometric mean titer were higher after Td (34.0 and 5.74 IU/ml) than after Td-IPV (15.9 and 4.38 IU/ml). All subjects boosted with Td-IPV were seroprotected against each type of poliovirus (neutralizing antibody titer, > or =5/dilution). The most frequently reported solicited local and systemic symptoms were pain triggered by movement of the arm (54% vs. 39.1%) and headache (17.3% vs. 7.3%), after Td-IPV and Td, respectively. All other events were similar between the two groups. Reactions were generally mild and all were temporary. CONCLUSIONS: A booster dose of Td-IPV induced in all children seroprotection against tetanus, diphtheria and poliomyelitis. The overall safety profile of the two vaccines was acceptable.

Neural network analysis of serial cardiac enzyme data. A clinical application of artificial machine intelligence.

There has been a recent resurgence of interest in the study and application of computerized neural networks within the broad field of artificial intelligence. These "intelligent machines" are modeled after biological nervous systems and are fundamentally different from the many computerized expert systems that previously have been introduced as clinical decision-making aids. The authors describe a neural network designed and trained to predict the probability of acute myocardial infarction (AMI) based on the analysis of paired sets of cardiac enzymes. The neural network predicted 24 of 24 (100%) AMIs and 27 of 29 (93%) No-AMIs when compared with a pathologist's interpretation of the patient's laboratory data (P less than 0.000001). The authors attempted to validate the network's diagnoses by two independent methods. When compared with echocardiogram and EKG for diagnosis of AMI, the neural network agreed with the cardiologist's interpretation in 12 of 14 (86%) AMIs and 1 of 3 (33%) No-AMIs, but the correlation was not statistically significant. Using autopsy outcome for validation, the neural network agreed with the anatomic evidence in 24 of 26 (92%) AMIs and 4 of 6 (67%) No-AMIs (P = 0.001). The authors conclude that neural networks can be successfully applied to the analysis of cardiac enzyme data and suggest that broader applications exist within the domain of clinical decision support.

Coloration of breast fluid related to concentration of cholesterol, cholesterol epoxides, estrogen, and lipid peroxides.

The coloration of nipple aspirates of breast fluid from 2,343 women were compared with breast fluid concentrations of cholesterol. cholesterol epoxides, lipid peroxides, estrogens, and immunoglobulins. Darker-colored breast fluid had significantly higher mean concentrations of cholesterol, cholesterol epoxides, lipid peroxides, and estrogens than did lighter-colored fluids, whereas no relationship of coloration with immunoglobulin levels was found.

Effects of caffeine-free diet on benign breast disease: a randomized trial.

There is considerable interest in the potential effect on benign disease of a diet free of methylxanthines (caffeine, theophylline, and theobromine) found in coffee, tea, colas, and chocolate. We randomly assigned 158 women who presented with a breast concern either to a group encouraged to abstain from methylxanthine-containing foods and beverages or to a group who received no dietary recommendations (controls). At the initial visit each patient's sociomedical history and data on methylxanthine consumption were obtained by interview, and clinically palpable breast findings were graded on a scale of 0 to 4 (no nodularity to confluent hard "dysplasia") for each quadrant of both breasts. On the follow-up visit approximately 4 months later similar information was obtained. Mammograms were taken at both visits for a subset of women in each group. We found a statistically significant reduction in clinically palpable breast findings in the abstaining group as compared with controls, but the absolute change was minor and may be of little clinical significance. Comparison of before-after mammograms offered little support for the methylxanthine hypothesis. There was no relation between clinically palpable breast finding scores at initial examination and caffeine consumption levels reported at that time.

Stability and phase locking in human soccer juggling.

We explored a variant of juggling in which human adults were asked to rhythmically bounce a soccer ball with their dominant foot while standing on the other foot. Eight subjects performed the task at three prescribed heights and one free height condition. Kinematic analyses of foot movement at ball-foot impact showed that, for the smallest height, foot acceleration was positive or zero at impact, which indicates an active stabilization regime. Increasing juggling height resulted in foot acceleration becoming increasingly negative at impact, which is required for a passive dynamical stability regime. These results show that skilled soccer jugglers exploit the passive stability regime afforded by the task, but that similar stability can be achieved with an active stabilization strategy.

Combined neurosurgical and neuroradiological treatment of a complex superior sagittal sinus dural fistula: technical note.

OBJECTIVE AND IMPORTANCE: Dural arteriovenous fistulas of the superior sagittal sinus (SSS) account for 8% of intracranial dural fistulas. Their association with a thrombosis of the posterior part of the SSS is rare. In such cases, the usual neurosurgical and endovascular approaches cannot provide a good technical solution for treatment of the lesion, and a combined neurosurgical and neuroradiological approach is therefore needed. CLINICAL PRESENTATION: A 68-year-old man presented with rapidly evolving dementia. Cerebral angiography revealed a dural arteriovenous fistula of the SSS associated with thrombosis of the posterior part of the SSS. Various endovascular and neurosurgical approaches failed to cure the fistula. INTERVENTION: A burr hole was drilled in the frontal region, in the neurosurgical room. The patient was then transferred to the angiographic room, and the SSS was occluded using free spirals. CONCLUSION: This procedure led to a complete anatomic cure of the fistula, and a slow clinical improvement was observed.

[How to evaluate nursing practices?]. / Comment évaluer les pratiques de soins?

Assessment of clinical health care focuses on 'what is really done' in order to describe day-to-day practice. These data could be compared with standards or guidelines. The method used, the 'clinical audit', aims to improve the quality of care through specific actions. Finally, a second data collection could assess the efficacy of these actions. Many protocol designs could be used; they are illustrated by two examples in this article. The choice of protocols depends on the field and on the objectives of the work. Most of the time, assessment of clinical health care is included in a continuous quality improvement programme.

[Treatment of cerebrovascular accidents in an intensive care unit. 230 cases]. / Traitement des accidents vasculaires cérébraux dans une unité de soins intensifs. Deux cent trente observations.

Over a 20 months' period, 230 patients were treated in an intensive care unit for acute cerebral vascular accident. There were 157 ischaemic accidents and 73 haemorrhages. The mean age of the patients was 61.7 years. Mechanical ventilation was used in a quarter of the cases, and tracheotomy was performed in 7%. Surgery was considered necessary in only less than 5%. The overall mortality in the unit was 20% for patients with established ischaemia and 44% for those with cerebral haemorrhage. After 6 months, 64% of patients with ischaemia and 44% of patients with haemorrhage were still alive; 82% were independent, usually without sequelae, and 6% were bed-ridden; 15% of those who had mechanical ventilation survived. Prognostic factors are analyzed and the role of intensive care units in the management of cerebral vascular accidents is discussed.