[Sensory modulation disorders and impairments in adaptative skills in autism spectrum disorders]

INTRODUCTION

People suffering from autism spectrum disorders (ASD) provide atypical responses to sensorial stimulations, indicating specific sensory processing. These responses vary from one another and within the same individual with ASD, resulting in maladaptive functional capacities in everyday life. Factors explaining those specificities are poorly defined and need to be better identified.

OBJECTIVES

To examine the relationship between sensory modulation symptoms (SMSs) and maladaptive behaviors in a group of children with ASD. To study how the sensory processing patterns in ASD are related to chronological age, intensity of autistic symptoms, and associated intellectual disability.

METHOD

A transversal observational study of a group of children with ASD was conducted for 1 year in an Autism Resource Centre in Marseille, France. The SMSs were assessed using the Dunn short sensory profile. The adaptive behaviors and social quotient were assessed using the Vineland adaptive behavior scale.

RESULTS

Forty-five children with ASD completed both scales. Significant correlations were found between SMS intensity and the children's adaptive behaviors. Furthermore, chronological age and intellectual disability showed a significant relationship with SMS intensity; chronological age and intellectual disability were also found to be significantly related. However, the severity of autistic symptoms was not associated with the intensity of SMSs.

CONCLUSION

These outcomes give a better understanding of sensory processing in ASD. The analysis of sensory processing is valuable during the diagnostic phase and for the development of individualized/custom-tailored interventions.

[Prospective assessment of children with pervasive developmental disorder after 2 years of day-hospital treatment]

The treatment of children with pervasive developmental disorders (PDD) has not been systematically assessed in French day-care units. In this prospective study, 11 children with a diagnosis of PDD were followed up for 2years in a day-care unit in the Marseille university hospital. The treatment they received is based on an initial assessment by the "Centre Ressources Autisme" (CRA PACA) and further included a continued observation of the child and an assessment of the child's abilities and needs. This treatment used various therapeutic approaches 10h weekly and also included parental counseling and coordinated work with schools. Treatment in our day-care unit can be categorized as eclectic, non-intensive therapy. It is based on methods such as TEACCH (Treatment and Education of Autistic and related Communication handicapped Children), Floor Time Play, speech and language therapy, developmental therapy, and psychotherapy. International studies on intensive behavioral therapies suggest that this treatment is superior to non-behavioral and/or non-intensive treatment. They suggest its efficiency is due both to the nature of the treatment (behavioral) and to its intensity (more than 25h a week). In this study, the CRA diagnosed children using the ADI and ADOS. The 11 children (mean age, 3years 5months) were tested twice, with the Vineland and CARS scales. The first assessment was on admission to the day hospital and the second was 2years later. The results showed developmental progress with a mean increase of 13.5 months at the Vineland Scale, and a decrease of the autism severity score on the CARS. The treatment presented here proves to be efficient; if compared to similar results in international studies, we obtained better results than their eclectic intensive or non-intensive treatment comparison group.

Two-year assessment by exercise thallium scintigraphy of myocardial revascularization using bilateral internal mammary and gastroepiploic arteries

OBJECTIVE

To assess the blood flow supply offered to the myocardium by surgical revascularization using bilateral internal mammary (IMAs) and gastroepiploic (GEA) arteries.

METHODS

Two-year assessment by exercise thallium myocardial scintigraphy without medical treatment was performed in 122 patients (mean age 61 +/- 9 years) who underwent coronary artery bypass grafting (CABG) with exclusive use of IMAs and GEA. Usually, the right IMA was used to bypass the left anterior descending coronary artery, and the left IMA to bypass the diagonal and the marginal arteries as a sequential graft if required. The GEA was used to bypass the right coronary artery (RCA) in 50 patients and its posterior branches in 72 patients.

RESULTS

During maximal or submaximal exercise stress testing, 119 patients (98%) were asymptomatic and 26 patients (21%) exhibited moderate ischemic ECG modifications which were correlated (P < 0.01) with incomplete revascularization and with the use of GEA to bypass the RCA. A third of patients had moderate ischemic thallium defects on exercise reversible after redistribution (anterior, 10; lateral, 2; inferior, 28). Silent residual myocardial ischemia detected by thallium scintigraphy was correlated (P < 0.001) with ECG modifications and incomplete revascularization; and inferior thallium defects were more frequent when GEA bypassed the RCA (P < 0.05). However, 26% of patients had residual ischemia despite a complete revascularization, and in at least 18% of cases for GEA and 8% for right IMA, arterial graft blood flow was insufficient at maximum exercise level and caused silent residual myocardial ischemia detected by thallium scintigraphy.

CONCLUSIONS

Myocardial revascularization using bilateral IMAs and GEA offers a satisfactory myocardial perfusion in the majority of cases; however silent residual myocardial ischemia was detected in a third of patients and was related to incomplete revascularization and to insufficient blood flow supply probably due to small diameter of the arterial grafts.

Hidden chromosome abnormalities in a primary central nervous system lymphoma detected by multicolor spectral karyotyping

Cytogenetic analysis provides important information for diagnosis and prognosis in some tumors. But karyotype analysis can be difficult in some cases, because metaphase chromosomes are contracted. New techniques, such as fluorescence in situ hybridization and, more recently, spectral karyotyping, or SKY, based on the hybridization of 24 fluorescently labeled chromosome painting probes, allow the detection and identification of complex chromosomal rearrangements. We report here a case of primary central nervous system lymphoma in which chromosomal rearrangements and marker chromosomes not identified by a routine cytogenetic technique were clarified by SKY. This shows the value of the SKY technique in the cytogenetic diagnosis of tumors.

Does the extended use of arterial grafts compromise the myocardial recovery after coronary artery bypass grafting in left ventricular dysfunction?

OBJECTIVE

To assess the prognostic factors of myocardial recovery expected after coronary bypass surgery and the impact of surgical technique used, a prospective non-randomized study including a 1-year postoperative evaluation of left ventricular function was performed in patients with left ventricular dysfunction (left ventricular ejection fraction (LVEF) < 0.40).

METHODS

From 1993 to 1996, 110 patients (mean age 61+/-11 years) were included in the study. The mean LVEF was 31+/-6%. All patients had preoperative radionuclide investigations based on the combination of stress/reinjection thallium single photon emission computed tomography (SPECT) and planar evaluation of LVEF; 88% of patients had reversible ischemic thallium defects. Two surgical technique were used: 53 patients received the left internal mammary artery with associated sequential vein graft, and 57 patients received only arterial grafts, internal mammary and gastroepiploic arteries. The mean number of distal anastomoses was 3.2+/-0.8 and 54% of patients had complete revascularization. At 1 year, all survivors had clinical evaluation and the same radionuclide investigations.

RESULTS

The early mortality was 2.7%. At 1 year, 100 patients were surviving; on average, NYHA class decreased 1.9+/-0.8 to 1.4+/-0.6 (P < 0.01) and CCS class from 2.8+/-0.6 to 1+/-0.3 (P < 0.01). The mean LVEF increase from 31+/-9 to 34+/-10% (P < 0.01) and the mean LV end-diastolic volume decreased from 317+/-112 to 285+/-108 ml (n.s.). The postoperative improvement in LV function was higher in patients in NYHA class 3 or 4 before surgery (P < 0.05), when associated sequential vein graft had been used (P < 0.01), and in patients with low preoperative LVEF (P < 0.01). The postoperative LVEF improvement observed was significantly correlated with the improvement in left ventricular end-diastolic (LVED) volume and the improvement in redistribution/reinjection thallium uptake. Multivariate analysis showed that the surgical technique used and the preoperative LVEF were independent prognostic factors of the postoperative myocardial function recovery, with a significant positive impact of the vein use.

CONCLUSION

This study confirms the excellent clinical results of coronary artery bypass grafting (CABG) in patients with coronary artery disease and LV dysfunction; improvement in LV function can be documented objectively and is correlated with reperfusion of hibernating myocardium. However, the extended use of arterial grafts does not allow to achieve the significant myocardial recovery observed with the use of one internal mammary artery (IMA) and associated sequential vein graft; it seems to be related to the preoperative selection of patients, but a direct negative impact of arterial grafts was documented and leads to be cautious in patients with severe LV dysfunction.

[Long-term outcome of mitral valve repair of dystrophic mitral regurgitation]

Between January 1984 and December 1994, 130 patients underwent mitral valvuloplasty for pure dystrophic mitral regurgitation. There were 94 men and 36 women with a mean age of 61 +/- 9 years: 52 patients were in atrial fibrillation; 91% of patients were in NYHA Classes III or IV. At preoperative echocardiography, the regurgitation was assessed as Grade III or IV and classified using the Carpentier classification according to type I (dilatation of the annulus) or II (mitral valve prolapse); 95% of patients had isolated prolapse of the posterior leaflet, 3% had isolated prolapse of the anterior leaflet and 2% had prolapse of the two leaflets. After valvuloplasty, a prosthetic ring was implanted in 124 patients (95%). The early mortality was 3%; 5.3% of patients had early complications. All patients underwent control transthoracic echocardiography in the first postoperative week. They were reviewed with a second transthoracic echocardiography after a mean follow-up of 5 +/- 0.3 years and a cumulative follow-up of 657 years-patients. At the immediate postoperative echocardiography, 24 minimal residual regurgitations were observed; at long-term, 20 new mitral regurgitations developed, all mild without any clinical symptoms and 98% of patients were in the NYHA Classes I or II. At 10 years, the actuarial survival was 73 +/- 16%; absence of thromboembolic complications 95 +/- 3%, absence of reoperation 95 +/- 5%. This study confirms the efficacy of mitral valvuloplasty and the postoperative stability of repaired valvular lesions. These results suggest that the operative indications should be considered at an earlier stage.

Neonatal death in Marshall-Smith syndrome

Marshall-Smith syndrome is characterized by accelerated skeletal maturation, failure to thrive and dysmorphic features. Since 1971, twenty cases of MSS have been reported. We describe another patient with a very early death demonstrating the clinical variability of the syndrome and the importance of systematic X rays of the skeleton for determining the causes of fetal or neonatal death.

[Brain death: myocardial consequences, an experimental study on pigs]

It is well known that brain death is responsible for major problems encountered in the clinical setting that may alter heart graft viability before transplantation. To investigate these myocardial dysfunctions, a model of brain death was prepared in pigs. Anaesthetised pigs were ventilated with FiO2 of 50% through an endotracheal tube. Animals were monitored by measuring systemic arterial pressure, pulmonary artery pressure, cardiac output, left ventricular developed pressure and dP/dT (Millar probe), cardiac contractility (sonomicrometers crystals), ECG, myocardial tissue oedema (impedance spectroscopy) and heart rate. Blood samples were drawn to assess arterial blood gases, serum electrolytes, plasma catecholamine levels, LDH isoenzymes and ascorbil free radicals production. Myocardial high energy contents (adenosine triphosphate, creatine phosphate) were measured by spectroscopy MRI. After 30 minutes stabilisation, brain death was induced by ligation of the supra-aortic vessels. To assess myocardial impairment all the parameters mentioned were recorded at baseline, 1', 30', 60', 120' and 180' following the brain death. Results showed initial tachycardia and a significant increase (p < 0.05) in cardiac function at 1' and 30', related to the cathecolamine level variations, followed by a significant depression (p < 0.05) of cardiac contractility by the end of the third hour; there was no modification whatsoever of myocardial high energy contents and of ascorbil free radical and LDH isoenzymes productions. In this pig model of brain death the observed myocardial dysfunction was directly related to the induced catecholamine secretion without any myocardial high energy substrate depletion up until 180'. Such results could be taken into account when evaluating a donor heart, allowing to use organs judged nowadays not feasible, and could be of some help in lowering the number of the "défaillances" of the transplanted hearts.

A new interface chamber for the study of mammalian nervous tissue slices

We describe a new interface-type chamber for electrophysiological studies in mammalian brain slices. Thermoregulation of the inner recording chamber is achieved using the Peltier effect and a feedback control unit. Between 15 and 40 degrees C, and for perfusion rates from 1 to 5 ml/min, the temperature can be maintained within +/- 0.1 degrees C of the command value; it can also be rapidly and reliably changed. An external bath, heated by a coiled resistor, generates a humidified, oxygenated atmosphere diffusing above the slices. Survival of neuronal tissue is excellent and stable intracellular recordings can be obtained using either sharp or patch-clamp micropipettes. Perfusion solutions can be readily exchanged, rendering this chamber suitable for the study of bath-applied neuroactive compounds.

The role of intraoperative transcranial Doppler monitoring in carotid artery surgery

Of 135 carotid artery reconstructions performed under general anesthesia in 127 patients (mean age 68 years), 119 were performed with continuous intraoperative Doppler recording of the middle cerebral artery. This investigation was impossible in nine (6.7%) cases because of the absence of a visible temporal window, and results were deemed uninterpretable in six (4.5%) additional cases. The goals of this study were to test the feasibility and reliability of transcranial Doppler monitoring in the evaluation of intracranial perfusion and to determine the risk of cerebral ischemia during carotid artery clamping. The two outcome parameters measured were mean velocity and percentage of decreased flow in the middle cerebral artery during clamping. Patients were divided into four groups based on variations in these parameters. Groups I and IIA (low risk) represented 69.7% of cases, group IIB (significant risk) represented 21.9%, and group III (major risk) represented 8.4%. Transcranial Doppler monitoring appears to be a reliable means of observing middle cerebral artery flow during carotid surgery and in our opinion provides objective criteria for determining the need for an indwelling shunt. Accordingly, in this study no neurologic complications imputable to clamping were observed. Transcranial Doppler monitoring can also be used to ensure correct functioning of the shunt and to detect intraoperative embolic complications.