What clinical characteristics of children with autism influence their inclusion in regular classrooms?

BACKGROUND

This study took place in the context of recent legislation enacted in several countries--including France--and aimed at promoting inclusion of children with intellectual disabilities. It focuses on young children with autism and examines the links between the children's characteristics and their weekly hours of regular-classroom inclusion and intervention in specialised setting.

METHOD

Standardised clinical and sociodemographic data were collected for 77 children with autism, along with data about their interventional programmes.

RESULTS

The study showed that the number of hours of inclusion at school was influenced by the children's behavioural and adaptive characteristics, as well as by the socioprofessional category of their parents, although these factors did not affect the number of hours spent in specialised setting. Moreover, the total amount of time per week spent in interventional services of any kind was very small for some of the children.

CONCLUSION

The time spent in special-intervention services and regular classrooms combined did not add up to an adequate number of weekly hours for these children, particularly those exhibiting at least one of the following characteristics: low adaptation level, major behavioural problems or low socioprofessional category of parents.

[Prevalence of pervasive developmental disorders. A review]

INTRODUCTION

Estimates of the prevalence of autism and pervasive developmental disorders (PDD) are discordant and are moving towards an apparent increase in rates.

LITERATURE REVIEW

The studies carried out since 1966 illustrate the variability of the protocols used and explanatory hypotheses put forward. These investigations are difficult, sparse, but still growing at the same time that a debate develops on the possible increase in actual prevalence. Indeed, the rate initially admitted for classic autism was 5/10,000, then 1/1000 with an expanded definition to the forms, but the current figures are very different (almost 0.7% for all PDD), and this increase raises questions. The arguments in favour of an apparent increase are primarily methodological. Several biases are encountered when one compares the recent publications with those of previous years. First, autism is better known and recognized than 30 or 40 years ago. Then, the diagnostic criteria used over time are changing variables, and comparisons difficult. Recent studies using the criteria of a broader definition of autism, polyhandicap with severe retardation and autism signs of lighter forms. The fact that children with autism are diagnosed more frequently in the younger age could also occasionally lead to an artificial increase in the number of cases identified in new surveys in populations of young children. Other factors are cited to explain the current increase. There could be higher rates of autism (and mental retardation) among children of migrants from distant countries, with the aetiological hypothesis of maternal infections, more frequent due to immune deficiency against infectious agents depending on the environment, metabolic decompensations also related to changes in surroundings, or more births from unions among migrant mothers and men with Asperger syndrome (with increased risk of paternity of a child with autism). Other theories relate to pollution, vaccinations, a growing number of premature babies; all assumptions that appear, for the time being, insufficiently explored and documented. The issue is also one of the motivations underlying these steps, and setting a parallel prevalence actually increased with this or that factor has presently been scientifically validated. Finally, if a careful reading of recent publications indicates that autism has become more frequent; assumptions that describe an increase in "artificial", based on methodological arguments, seem to be more consistent. EFFECTS OF EXTENSION OF DIAGNOSTIC CRITERIA AND NOSOGRAPHY FOR PDD: Today, the recruitment of individuals with autism in a population far exceeds the initial criteria of Kanner in the 1970's. It includes clinical forms with associated pathologies, or lighter and probably more frequent clinical forms. Other assumptions arouse interest, but also controversy regarding their relevance. The enumeration of cases of PDD in a population is actually at its beginning. In the 1970's, "childhood psychoses" (the term then used) seemed rare. The identification of cases was probably the main reason. Long available figures remain scarce, and their rate increases gradually from the 1990s, but is, in fact, a problem of inflation. What is the part played in this flight of changing diagnostic criteria and substitutions, or other methodological effects? Or even opportunistic effects, if we speak of an epidemic to undermine a variety of factors. The evidence provided so far is the improved identification of cases, enlargement of the concept, and better shared diagnostic criteria. However, the validity and limitations of clinical forms are still vague and unresolved.

DISCUSSION

How to study epidemiology in the future - to move forward, studies should be designed with partners' medical history and medicosocial studies, based on a better consensual methodology, epidemiology, statistics and diagnosis, with a definition of the thresholds for inclusion, and arbitration procedures. On this basis, a study must also be coordinated with those concerning mental retardation, learning disorders, etc, otherwise the same topics will be counted twice or even three times. As for the addition of syndromic forms of PDD (those with known aetiology), their number is still below a proportion sufficient to be an appeal. Moreover, another problem exists: the degree of membership of each of these syndromes, or individual cases, or autistic spectrum disorders (internal variability phenotypes). For the moment, we could design two studies included better: developmental disorders and associated pathologies. Regarding the "ethic" dimension, a more regular diagnosis of PDD (preferred to that of mental retardation or learning disorder) will lead to shared practices and set limits for greater recognition.

La pédopsychiatrie de consultation–liaison intrahospitalière : étude prospective sur 215 interventions

The activity of child consultation-liaison psychiatry within the hospital can be defined as: the clinical, therapeutic and preventive care given by the staff members of the children psychiatric department, and their studies on pedagogy and research, in the other departments of the children hospital.

MATERIAL AND METHODS

Our study focused on the consultation-liaison interventions (N = 215) carried out in the Children Hospital of Tours (France) for 1 year (November 1999-October 2000): it dealt with their characteristics and those of the examined population. It aimed at describing qualitatively and quantitatively this activity and its evolution, by means of a prospective collection of information, and a comparison of some of them with researches carried on previously in the same setting.

RESULTS

Child consultation-liaison psychiatry plays a major part in pediatric hospital today. This activity increased by 33% since 1994. The nature of needs for pediatrics care has evolved, and crisis situations are now most dominant. Child psychiatry diagnoses are very varied: the most frequent ones concern adaptation troubles. The agreement on the suggested medical follow-up amounts to more than 50%.

[Autism and associated pathologies. Clinical study of 295 cases involving development disorders]

OBJECTIVE

Known since the first descriptions in 1943, diseases related to autism and associated disorders have incited a growing body of work. Both theoretical interrogations (what is the pathogenic role of autism?) and practical measures (management, screening) are implied. Nevertheless the frequency of autism-related disease has varied from 10 to 37% depending on the series reported. We studied the frequency of these factors in a population of children with major development disorders cared for at the Tours university hospital over a 39-month period.

PATIENTS AND METHODS

We reviewed retrospectively the medial features of 295 children examined in our psychiatry and neurophysiology unit for children at the Tours center for major development disorders (based on the DSM IV diagnostic criteria) between September 1995 and December 1998. We divided these factors into 4 categories: hereditary diseases, serious medical conditions, minimal physical disorders and ante- or perinatal antecedents.

RESULTS

Among these 295 children, 26.5% had a proven or probable hereditary disease, 19% had a serious medical condition and 21.7% had minimal physical disorders. Among the children with a serious medical condition, 34.4% also had ante- or perinatal antecedents. Among the 33% without any medical factor, 77% also had ante- or perinatal antecedents.

CONCLUSION

Our data point out the quantitative importance of medical factors associated with major development disorders. They imply a close multidisciplinary collaboration between child psychiatrists, pediatricians and geneticists in order to identify these disorders and develop an integrated management scheme. On a more theoretical level, it appears possible to identify subgroups of children among such a population based on associated diseases and neuropsychological patterns. This dimension would be useful for research into the pathogenic mechanisms involved.

[Early signs of autism and family films: a new study by informed evaluators and those unaware of the diagnosis]

Since the initial individualization of infantile autism by Kanner, subsequent work has attempted to define the age at which disorders appear, their symptomatology and their specificity. Initially, retrospective studies based on questionnaires and interviews with parents were conducted in order to determine the age of at which the first signs appeared. Combined with interviews, clinical observations have provided incontestable aid for describing the early signs of autism. The study of home movies taken by parents before their infant's disorders were recognized has led to a new approach to the initials signs of autism. Our study is a continuation of work in our Child Psychiatry Unit under way since 1984. The aim of this work is the symptomatological and comparative analysis of home movies of 14 autistic and 10 normal infants, during the first two years of their life. Each film was scored for the 0-8, 9-17 and 18-24 month periods. Based on the use of the Infant Behavioral Summarized Evaluation (IBSE), this study confirms prior data and also shows the emergence of very early disorders, perceptible within the first few months even by blind evaluators: a docile baby, showing no overt manifestations, not seeking contact, with an absence of pre-language. Even so, the results require caution when interpreting for methodological reasons which are discussed.

[Further clinical evaluations elicited by functional biological investigations in childhood autism]

As childhood autism is usually considered as a developmental disorder, complete assessment of each patient requires non only clinical examination but various biological investigations: EEG and evoked potentials recordings, biochemical dosages and sometimes, cerebral blood flow measures, molecular biologic explorations.... These investigations help to understand neurophysiological dysfunctionings which underly different autistic syndromes. It therefore seems necessary to develop quantified clinical tools which could allow closer matching between clinical evaluations and biological numerical data. These complementary evaluations must be both simple and quick to perform in medical practice, as they are added to an already heavy clinical examination. The main tools used in our bioclinical Department are described here. For each child, psychiatric, pediatric and neurological examination was performed. Different scales were progressively elaborated and validated to complete and precise behavioral parameters. Attention and perception were evaluated by a Behavior Summarized Evaluation (BSE) scale, association and imitation by appropriate scales, language by the Pre-Verbal Behavior Summarized Evaluation (PV-BSE) scale, early symptoms by the Infant Behavior Summarized Evaluation (t-BSE) scale. The main neurophysiological dysfunctionings were grouped in a Behavioral Functional Inventory (BFI). Clinical genetic data were scored in a summarized assessment carrying both on the antecedents and on the somatic abnormalities. The completed clinical data were gathered in a Quantified Multidimensional Assessment (QMA), with four axes: socialization, communication, cognition and neurological observation. These clinical evaluations provide behavioral details that can be integrated into a bioclinical database and give an objective approach to the heterogeneity of autism. They invite both clinicians and biologists to deepen the description of individual profiles which allow better understanding of physiopathological mechanisms in autistic children.

[Bourneville's tuberous sclerosis and autism]

Tuberous sclerosis is often associated with developmental and behavioural disorders including typical or partial autistic syndrome. However, it may be difficult to recognize tuberous sclerosis behind an infantile autism during the early stages of the disease. Therefore, tuberous sclerosis must be regularly looked for on the basis of its major and minor criteria in any cases of infantile autism. The child psychiatrist is preferentially involved in the management of the various aspects of this association, ie, behavioural or character disorders, difficulties in social relationships and communication, mental retardation, feeding disorders, and psychological consequences for the families. The support provided may be complemented by that offered by the Association for Bourneville's tuberous sclerosis.

Autism and genetics: clinical approach and association study with two markers of HRAS gene

Twin studies and familial aggregation studies indicate that genetic factors could play a role in infantile autism. In an earlier study, we identified a possible positive association between autism and a c-Harvey-ras (HRAS) oncogene marker at the 3' end of the coding region. In an attempt to confirm this finding, we studied a larger population, well-characterized clinically and genetically. We report a positive association between autism and two HRAS markers, the 3' marker used in the initial study and an additional marker in exon 1.

Tuberculous peritonitis in an adolescent male

OBJECTIVE

To report the use of a new diagnostic approach in children with tuberculous peritonitis.

PATIENT

A 14-year-old boy with tuberculous peritonitis.

RESULTS

None of the new diagnostic techniques helped us to make our diagnosis.

CONCLUSION

More experience of using the new diagnostic techniques will be necessary before they supersede invasive procedures.

Synthesis, structure-activity relationships, and pharmacological evaluation of pyrrolo[3,2,1-ij]quinoline derivatives: potent histamine and platelet activating factor antagonism and 5-lipoxygenase inhibitory properties. Potential therapeutic application in asthma

A series of pyrrolo[3,2,1-ij]quinoline derivatives was synthesized and evaluated for their in vitro and in vivo activities against histamine, platelet activating factor (PAF), and leukotrienes which are recognized to be of importance in asthma. The structure-activity relationship studies have shown that the optimum moiety on the 1-position of the pyrroloquinoline nucleus is a 2-[4-(4-methyl-2-pyridinyl)-1-piperazinyl]ethyl chain in conjunction with a methyl group on the 2-position for potent antagonism of both histamine and PAF. The introduction of substituents on the 8- and 4-positions was also investigated in order to increase the potency of 5-lipoxygenase inhibition while retaining or improving the activities against histamine and PAF. This series is exemplified by 4-n-butyl-5,6-dihydro-8-hydroxy-2-methyl-1- [2-[4-(4-methyl-2-pyridinyl)-1-piperazinyl]ethyl]-4H-pyrrolo[3,2,1- ij]quinoline (24, KC 11404) which was found to be active against all three of the selected mediators. Compound 24 was found to be orally active in guinea pig models against the histaminic phase of antigen-induced bronchospasm and PAF-induced bronchoconstriction (ED50 = 1.9 and 2.1 mumol/kg, respectively). When tested against the leukotriene-dependent phase of the antigen-induced bronchoconstriction, compound 24 showed the same potency as zileuton.

[Childhood autism: a relating deficiency due to a developmental disorder of the central nervous system]

Childhood autism with its difficulties in relating to others has been for a long time imputed to conscious or unconscious educative errors of the mother. Clinical and biological data can be opposed to this conception. Familial movies analysis exhibits early disorders in attention, perception, intention, limitation and muscular tone. Later, recording of cerebral reactivity to auditory stimulations confirms deficiencies in attention, perception, association ... and shows a diminution of the responses in the left hemisphere. Abnormalities in the development of the cerebellum are also described. Modifications of main neurotransmitters as Dopamine and Serotonin and their derivatives are often present. A recent study of the genes which control enzymes regulating metabolism of these transmitters does not show evident modifications by polymorphism analysis. On the contrary a peculiarity in the Harvey-RAS gene allows to differentiate in a significant way an autistic and a normal group. This gene is involved in the regulation of growth factor and/or differentiation of neural cells. These observations support the hypothesis considering autism as a relating deficiency due to a developmental disorder of central nervous system.

[Technetium 99m labeled dimercaptosuccinic acid (99m Tc-DMSA) scintigraphy in the diagnosis and follow-up of urinary infections in children]

BACKGROUND

The site of a urinary tract infection (UTI) is located by clinical findings plus imaging techniques. Renal imaging with technetium 99mTc-dimercaptosuccinic acid (99mTc-DMSA) has shown promise but its efficacy for detecting acute pyelonephritis is still debated as is its ability to differentiate between acute, potentially curable disease and scarring, definitive changes.

PATIENTS AND METHODS

The files of all the 166 patients that underwent one or two (32 patients) 99mTc-DMSA imaging sessions for UTI in 1989 and 1990 in our department were analysed. The results of this technique were compared with the clinical and laboratory data and with those of other imaging techniques (ultrasonography and retrograde voiding cystourethrogram). The patients (92 girls and 74 boys, mean age: 5 years, range 15 days-17 years) were assigned to one of 3 categories: 1) acute pyelonephritis (27 patients), 2) low UTI (60 patients) and 3) uncertain UTI (79 patients), on the basis of the clinical and laboratory data.

RESULTS

The first 99mTc-DMSA imaging was normal in 110 children; changes were unilateral in 45 and bilateral in 11 children. Images suggesting either acute or chronic changes were observed respectively in 19 and 48 children. 4 of the 7 acute changes were normalized on the second radioisotope scanning while 2 became worse; 19 of the 23 chronic changes were unchanged at the second scanning. Radioisotope scanning changes were seen in 81% of the patients classified as acute pyelonephritis and in only 27% of those with lower UTI. Reflux was detected in 56% of abnormal kidneys and in 36% of normal kidneys. The results of radioisotope scanning and ultrasound scan findings were not correlated in 24 patients (19 only abnormal radioisotope imaging, 5 only abnormal ultrasound scan).

CONCLUSIONS

DMSA scans are useful for investigating and following UTI. They help to distinguish acute pyelonephritis and lower UTI. It is a reliable method of detecting structural abnormalities and identifying children at risk of progressive renal damage.

Blind ratings of early symptoms of autism based upon family home movies

Ratings of family home movies of 12 infants (0 to 2 years old) who were later diagnosed as autistic and 12 normal infants were performed by two diagnosis-blind psychiatrists with Infant Behavior Summarized Evaluation scale. The objective was to identify early symptoms of autism and their intensity and frequency before and after 1 year of age. Several pathological types of behavior related to socialization, communication, motility, and attention were noted during the first year of infant life and differentiated autistic and normal groups. These same differentiating behaviors, observed again in the second year, were more intense and associated with other pathological types of behavior, in particular, gaze avoidance, hypoactivity, and absence of emotional expressions. Analysis of the evolution of behavioral pathology in autistic children as a group during the 2 first years of life confirms the persistence of and the increase in some types of abnormality related to socialization, communication, motility, and attention functions. The limitations and values of this study concerning the early identification of autistic symptoms and functional impairments from home movies for diagnosis and establishing individualized treatment program are discussed.

Validity and reliability of the infant behavioral summarized evaluation (IBSE): a rating scale for the assessment of young children with autism and developmental disorders

The Infant Behavioral Summarized Evaluation (IBSE) is a rating scale adapted from the Behavioral Summarized Evaluation (BSE) and specifically related to the assessment of behaviors of young children having autistic disorders. Content validity and reliability studies described in the paper were made from behavior ratings of videotapes for 89 children aged from 6 to 48 months. Results show a significant group of 19 items including some characteristic early autistic behaviors (communicative and social abnormalities) and some that are less commonly described in the syndrome (attentional, perceptive, and adaptive disorders). The value of the use of this scale for clinicians and professionals involved in behavioral evaluations and treatment of young children with developmental disorders and the necessity for further psychometric investigations are discussed.

Changes in respiratory muscle activity in conscious cats during experimental dives at 101 ATA

The rationale for the present study was to test the hypothesis that increased work of breathing during experimental deep diving may lead to respiratory muscle fatigue. For this purpose, electromyograms (EMGs) of respiratory and skeletal muscles, plus electrocardiogram and electroencephalogram (EEG) derivatives, were continuously recorded in conscious cats. In each muscle group, the ratio of power in a high (H) to that in a low (L) band of EMG frequencies was computed. Direct diaphragmatic stimulation in selected animals produced a mass action potential to obtain the muscle fiber conduction velocity (MFCV). The maximal pressure was 101 ATA (1,000 msw) with a maximal duration of 72 h. Four cats breathed an He-O2 mixture and five others a ternary mixture (10% N2 in He-O2). Inspired O2 partial pressure was 350 Torr. With the He-O2 mixture, all the animals died within 2-54 h during the study at maximal depth. EEG signs of high-pressure nervous syndrome (HPNS) were present in all cats, and low-frequency (11-14 Hz) hyperbaric tremor discontinuously contaminated all EMG tracings. The H/L ratio computed from diaphragmatic and intercostal muscle EMGs increased after 12 h at 101 ATA. With the He-N2-O2 mixture, the cats survived until the end of the sojourn at 101 ATA, during which no hyperbaric tremor was detected from EMG tracings, and EEG signs of HPNS were weak or absent. From 31 ATA, the H/L ratio decreased significantly in respiratory but not in skeletal muscles; this was associated with decreased MFCV in the diaphragm after several hours at maximal depth.(ABSTRACT TRUNCATED AT 250 WORDS)

Diaphragmatic fatigue produced by constant or modulated electric currents

In anesthetized rabbits the efficiency of phrenic nerve stimulation with trains of electric current was studied either when ventilation was effected entirely by bilateral nerve stimulation (electrophrenic ventilation) or during unilateral nerve stimulation when animals were ventilated with a pump and open chest. Trains of rectangular electric pulses (RPT) with constant amplitude and frequency or sine waves, both the amplitude and frequency of which were modulated and controlled by a computer (MSWT), were used with each animal. MSWT closely reproduced the physiological shape of transdiaphragmatic pressure waves. Diaphragm fatigue, as determined from the decrease in the maximal relaxation rate of twitches, occurred after 20 minutes of bilateral or unilateral nerve stimulation with RPT, but only after 60 min (unilateral stimulation) or 98 min (bilateral stimulation) with MSWT. These data show the importance of the motor signal pattern in long-lasting nerve stimulation.

Retropharyngeal synovial sarcoma in an infant: report of a case and of its response to chemotherapy; review of the literature

Synovial sarcoma of the retropharynx is an extremely rare neoplasm. To date, only 10 cases have been reported in patients less than 15 years old. Our 15-month-old patient is, to our knowledge, the youngest ever reported with a retropharyngeal synovial sarcoma in the world literature. In the past, treatment usually consisted of surgery followed by radiotherapy or adjuvant chemotherapy, or both. In the case reported here, combination chemotherapy (ifosfamide, vincristine, and actinomycin D), used as the initial treatment modality, induced a dramatic decrease of the synovial sarcoma.

Unusual Tc-99m MDP and I-123 MIBG images in focal pyelonephritis

A 6-year-old boy presented with an inflammatory syndrome. Because Tc-99m MDP bone scintigraphy revealed increased tracer uptake at the upper pole of the right kidney, further studies were oriented towards a diagnosis of renal or adrenal pathology. I-123 metaiodobenzylguanidine (MIBG) accumulated at the site of the abnormal MDP uptake. The diagnosis of neuroblastoma or allied disorder was excluded on the basis of other investigations and further evaluation, suggesting that the MIBG uptake was a false-positive. Findings on clinical imaging, laboratory findings, Tc-99m DMSA imaging, sonography, and CT scanning were highly suggestive of acute focal pyelonephritis.

Nonsurgical intervention in the resolution of acquired neonatal bronchial stenosis

A stricture of the right main bronchus developed in an 1100 gm premature (first delivered twin female) infant being mechanically ventilated for approximately 1 month. The stricture resolved with treatment consisting of three consecutive daily obturations with angiocatheters avoiding the use of a balloon inflation technique provoking a local dilation. The catheters were placed with a guide wire under fluoroscopic control. The clinical protocol advanced for the dilation of acquired bronchial stenosis was well tolerated by the patient. A 9-month clinical radiologic review confirmed normal pulmonary structures and functions. Catheter dilation is described as a new technique for treatment of bronchial stenosis in the very small infant.

Electromyographic study of respiratory muscles during human diving at 46 ATA

Electromyographic (EMG) recordings of the 6th to 7th intercostal space (thoracic EMG) and abdominal muscles, ventilatory pattern, and the work of breathing were studied in 4 human subjects exposed for 12 days to 46 ATA of helium-oxygen (density = 8.7 g.liter-1) then of nitrogen-helium-oxygen gas mixture (ternary mixture) (density = 11.1 g.liter-1). We found that the respiratory muscle work necessary for eupneic ventilation was multiplied by 4 at 46 ATA. During quiet breathing as well as during forced inspiratory maneuvers, the power spectrum of thoracic EMG shifted to the left in three individuals during the sojourn at maximal pressure, whichever gas mixture was inhaled. This was corroborated by the decreased ratio of EMG power in a high to that in a low band of frequencies. These alterations disappeared at the end of the decompression period, suggesting the existence of inspiratory muscle fatigue at high pressure. Hyperbaric tremor was recorded on the thoracic EMG and was maximal with He-O2 inhalation. It disappeared at the end of the period at 46 ATA (He-N2-O2).

Unexpected diagnosis of Candida albicans meningitis in a premature neonate

Candida albicans meningitis was found in an otherwise healthy 44-day-old premature infant whose birth weight was 1,860 gm. Almost no abnormal clinical or neurologic findings were present. The electroencephalogram, however, was abnormal. All previous body fluid cultures were negative. The combined use of amphotericin B and 5-fluorocytosine resulted in negative cerebrospinal fluid cultures after 3 weeks of therapy. Physical and psychomotor development remained normal on subsequent examination.

Bathing-induced seizures

Two unusual patients with sensory-induced seizures are presented. The clinical approach and evolution of seizures induced by bathing in patients with and without accompanying epilepsy are discussed.

[Teaching medical diagnosis by computer simulation]

A program of computer-assisted teaching, called AEDM, has been developed to simulate, with a conversational type terminal, the natural process of medical decision making. This system rests on two softwares, 'teaching' and 'inquiring', with 10 000 PASCAL instructions and the database of a computer-assisted diagnostic system (about 100 MO). The study describes the objectives and the characteristics of a system based on a simulation program; using natural procedures and non-specialized software is useful to develop computer-assisted teaching concerning different fields of pathology.

[Creation, development and maintenance of the data-base of a computer-assisted diagnostic system (ADM) (author's transl)]

The creation of the data-base for our ADM system begun in 1972, tests on a high productivity type of procedure which we consider should be explained. In organizing and creating our data-bank our routine procedures are: first, the capture of signs, symptoms and pathological data after the text editing of the description of diseases as prepared by medical students under the direction of the Medical Computing Service; second, the control and coding of the data by the personnel of the Medical Computing Service: third, the machine storage of the data and the automated logical controls by the Medical Computing Service; and fourth, the semantic control of the data as well as the availability of each new version. Other related procedures based on the individual theses and various studies are described as examples. From 1972 to 1980 an impressive data-bank was created holding descriptions of 2200 diseases with 22000 signs and symptoms and 3500 bibliographies. It is now foreseen that between 1980 and 1983, the prototype will be placed in service and adapted. The creation and maintenance of such a data-bank with all the problems that it entails, and developed under such economical conditions justifies our presentation.

[Use of a computer in a system to help teach medical diagnosis [AEDM] (author's transl)]

Computer-assisted instruction permits a student to work individually and at his own pace. His learning occurs by interactive dialogue with a conversational type terminal. The system comprises the following programs: tutorial, conversational and simulation. The study describes the objectives and the characteristics of a system based on a simulation program using the file of the data-base from the Rennes Hospital. Furthermore it describes in detail the steps that the student must take and discusses the programming of the system. The recording of the various lessons is subjected to statistical analyses to make the teaching exercises better and to adapt the conversation to the behaviour of the students facing the system.

[By-Products of the computer-assisted diagnostic system (ADM) (author's transl)]

The data-bank of signs and symptoms and classes of diseases developed for the computer-assisted medical diagnostic system (ADM) allows us to develop a series of interesting by-products. Some by-products are utilitarian: the inverted file and lexicon subset of signs, symptoms and diseases organized by medical discipline. Other by-products in the area of operational research serve to increase the quality and productivity of medical practice. Among the most interesting we note one by-product that helps teach physical diagnosis, one for therapeutics, one for the partial automation of observations, and one for assistance in decision-making in various specialized medical functions. The number and importance of these by-products demonstrates the powerful potential of the computer-assisted diagnostic system (ADM).

[Helping physicians arrive at medical diagnoses: how and why (author's transl)]

In the majority of the medical disciplines the diagnosis still constitutes the corner-stone of medicine. Every year this function becomes increasingly difficult and time-consuming and it is felt that the doctor should be able to benefit easily and rapidly from the most recent findings. A simple analysis of the natural process of decision-making, followed by a critical inventory of the various methods used to diagnose, has led us to develop our method for computer-assisted diagnosis (ADM). In our presentation of the methodology of diagnostic decision-making we examine the natural process, the analytical and synthetic methods as well as the difficulties and errors liable to occur. Four methods used in arriving at a diagnosis are analysed and criticized: those based on probability, those based on pattern recognition, those based on logic, and those based on classification methods. Finally a case is made for a computer-assisted diagnostic system based on a logical method of the documentation type.

[Computer-assisted diagnostic system: methods used (author's transl)]

Having chosen a computer-assisted diagnostic system (ADM) based on a logic method of the documentation type, a real example of a questionnaire is presented. The procedures actually utilized as well as those now being studied are presented and discussed in the light of the difficulties encountered. After giving various detailed examples, the fundamental procedures in developing the computer-assisted diagnostic system are described. These have been developed keeping in mind that the system must preserve utility, feasibility, transparency, simplicity, liberty of choice and scope but must also handle all difficulties and causes of error that are inherent in the process of arriving at a medical diagnosis.

[Effect of the computer-assisted diagnostic system [ADM] on the success and cost of diagnosis (author's transl)]

Taking into account the interest we have in helping physicians arrive at a diagnosis and in choosing the procedures utilized in the computer-assisted diagnostic system (ADM) already described, a study was devised to estimate the efficiency of the system in relation to costs. From 300 patient records, 80 presenting a true diagnostic problem within the framework of the diseases already in computer memory were selected. A comparison was made between the normal procedure, with and without computer help, keeping in mind the diagnoses themselves as well as the performance and the cost. Criteria and evaluation methods were evaluated. The results, even though preliminary, are encouraging and justify the continued development of the system.

[Purification and concentration of albumin solutions by diafiltration using a parallel membrane dialyzer]

The last two years, artificial Kidneys have been used for purification and concentration of human serum albumin solutions coming from plasma cracking in two Blood Transfusion Centers. Results are easily reproducible and the apparatus is reliable and of low cost. The properties of dialysis and ultrafiltration of the A.N. 69 membrane are useful for eliminating ethanol and water. The artificial Kidneys are effective at low pressure. It is then possible to use peristaltic pumps and to have a closed circuit. The whole apparatus must be sterilized with chemical reagents.

Sigma SR, a new method of measuring erythrocyte sedimentation rate. Its value in studying the action and interactions of non-steroidal anti-inflammatory agents

Sigma SR is a new method of measuring erythrocyte sedimentation rate (ESR) and is characterized by an unvarying haematocrit, routinely corrected to 35%, and the sum of 4 sedimentation levels at 20, 30, 40, and 50 minutes. Two studies were carried out in patients with inflammatory arthritic disorders; the first in 25 patients treated with 1800 mg ibuprofen daily for 7 days, and the second in 31 patients treated either with indomethacin alone (150 mg/day) or combined with aspirin (1500 mg/day) for 5 days. In addition to the assessment of clinical parameters, the ESR was measured using the classical Westergren and the sigma SR methods. The results showed that there were little or no changes from baseline values in the ESR using the Westergren method. With the sigma SR method, however, statistically significant changes were recorded after treatment and these correlated with the clinical findings which demonstrated the anti-inflammatory action of ibuprofen and the reduction in activity of indomethacin by aspirin.

Degradation of insulin by isolated rat liver cells

The degradation of insulin by isolated rat liver cells has been studied. The phenomenon is time- and temperature-dependent. After sixty minutes' exposure to 1.5 times 10-6 cells/ml, about 50 per cent, 15 per cent, and less than 5 per cent of insulin at 1.5 muM. are degraded at 37 degrees C., 20 degrees, and 0 degrees C., respectively. The methods used to measure the hormone degradation effect the apparent Vmax. Higher values of Vmax are found when radioimmunoassay rather than precipitation by trichloracetic acid and absorption to talc is used. However, the apparent Km. (0.27 muM) is virtually the same with any of methods used. N-ethyl-maleimide and Trasylol are potent inhibitors, whereas GSH increases the hormone degradation. Proinsulin acts as competitive inhibitor (apparent Ki equals 0.35 muM.). Gel filtration patterns of incubation supernates suggest that several enzymatic systems may be operative in the degradation of insulin by the liver cells. Glutathione-insulin-transhydrogenase is suggested by the appearance of a component that has the same elution volume as the A chain, but the inhibitory effects of trasylol on insulin degradation, as well as qualitative and quantitative similarities with insulin proteases, suggest that a proteolytic similiarities with insulin proteases, suggest that a proteolytic mechanism is involved. The insulin-degrading system in isolated liver cells closely resembles that observed in purified liver plasma membranes and in the isolated perfused liver. Such similarities stress the possible significance of the degradation process in the regulation of insulin action. These studies are also important for the quantitative analysis of insulin interaction with its specific receptors in isolated liver cells.