Sodium Bicarbonate Prescription and Extracellular Volume Increase: Real-world Data Results from the AlcalUN Study

Oral alkalization with sodium bicarbonate (NaHCO₃ ) or citrate is prescribed for conditions ranging from metabolic acidosis to nephrolithiasis. Although most nephrologists/urologists use this method routinely, extracellular volume (ECV) increase is the main feared adverse event reported for NaHCO₃ . Thus far, no trial has specifically studied this issue in a real-world setting. AlcalUN (NCT03035812) is a multicentric, prospective, open-label cohort study with nationwide (France) enrollment in 18 (public and private) nephrology/urology units. Participants were adult outpatients requiring chronic (>1 month) oral alkalization by either NaHCO₃ -containing or no-NaHCO₃ -containing agents. The ECV increase (primary outcome) was judged based on body weight increase (ΔBW), blood pressure increase (ΔBP), and/or new-onset edema at the first follow-up visit (V1). From February 2017 to February 2020, 156 patients were enrolled. After a median 106 days of treatment, 91 (72%) patients reached the primary outcome. They had lower systolic (135 (125, 141) vs. 141 (130, 150), P = 0.02) and diastolic (77 (67, 85) vs. 85 (73, 90), P = 0.03) BP values, a higher plasma chloride (106.0 (105.0, 109.0) vs. 105.0 (102.0, 107.0), P = 0.02) at baseline, and a less frequent history of nephrolithiasis (32 vs. 56%, P = 0.02). Patients experienced mainly slight ΔBP (< 10 mmHg). The primary outcome was not associated (P = 0.79) with the study treatment (129 received NaHCO₃ and 27 received citrate). We subsequently developed three different models of propensity score matching; each confirmed our results. Chronic oral alkalization with NaHCO₃ is no longer associated with an ECV increase compared to citrate in real-life settings.

A large extended family with hyperparathyroidism-jaw tumor syndrome due to deletion of the third exon of CDC73: clinical and molecular features

PURPOSE

We described the phenotype of a large 4-generation family with Hyperparathyrodism-Jaw Tumor syndrome (HPT-JT) associated with a rare deletion of exon 3 of the CDC73 gene.

METHODS

We collected medical, genetic data on 24 family members descended from a common ancestor carrying a heterozygous deletion of exon 3.

RESULTS

Thirteen carried the deletion, the penetrance was estimated at 50% at 40 years. Seven patients (39 ± 14.5 years) presented with HPT which could start at 13. Median plasmatic calcium and PTH levels were 3.13 ± 0.7 mmol/L and 115 ± 406 pg/ml, respectively. Kidney disease related to hypercalcemia were present in 57.1% of patients. All seven patients underwent surgery to remove a single parathyroid adenoma. One recurrence occurred 7 years post-surgery. No parathyroid carcinoma has been found to date. We found two atypical parathyroid adenomas. We described an additional somatic variant in exon 1 of gene CDC73 in two tumors. Jaw tumors were not necessarily associated with hyperparathyroidism, as shown in one case. Two kidney cysts were also reported. Variable phenotype expressivity was emphasized by clinical presentations in 2 monozygotic twins: acute hypercalcemia, kidney failure and ossifying fibroma in one twin, versus normocalcemic parathyroid adenoma in the other one.

CONCLUSION

We report a family carrier of a deletion of exon 3 of the CDC73 gene. This is characterized by a high level of hypercalcemia, deleterious kidney effects and atypical parathyroid adenomas without carcinomas. Onset and intensity of HPT remain unpredictable. The additional somatic mutation found in the parathyroid tumor could lead to these phenotypical variations.

Skeletal Muscle Index as a Prognostic Marker for Kidney Transplantation in Older Patients

OBJECTIVE

Low skeletal muscle mass has emerged as a risk factor for mortality after liver transplantation. We evaluated the prognostic value of muscle mass on length of hospitalization and adverse outcomes after kidney transplantation in aging end-stage renal disease patients.

METHODS

One hundred twenty-two patients aged 60 years or older at the time of transplantation were retrospectively analyzed. Skeletal muscle index (SMI), evaluated by computed tomography scan, was calculated from total muscle surface area at L3 vertebral level divided by body height squared. Outcomes were compared according to SMI (namely, length of hospitalization, wound complications, combined endpoint comprising all-cause mortality, and graft failure within 1 year).

RESULTS

In male patients, by multivariate analysis, a low SMI (<42 cm²/m²) was associated with longer immediate post-transplantation hospitalization (β = 17.03 ± 4.3; P = .0002), longer total hospitalization during the first year (β = 34.3 ± 10.7; P = .002), higher rate of wound complications (odds ratio = 12.1 [1.9-77.0]; P = .008), and higher rate of the combined endpoint of graft loss or death (odds ratio = 3.4 [3.0-399.5]; P = .004). In female patients, low SMI was not associated with length of hospitalization or adverse outcomes after transplantation.

CONCLUSION

SMI is an independent marker of morbidity and mortality after kidney transplantation in older men and could help thereby nephrologists better select aging candidates for kidney transplantation with a view to improving post-transplant outcomes.

Risk factors for severity of COVID-19 in chronic dialysis patients from a multicentre French cohort

BACKGROUND

Coronavirus disease 2019 (COVID-19) is an emerging infectious disease, related to severe acute respiratory syndrome coronavirus 2 infection. Few data are available in patients with end-stage renal disease (ESRD).

METHODS

We conducted an observational cohort study of COVID-19 patients at 11 dialysis centres in two distinct districts of France to examine the epidemiological and clinical characteristics of COVID-19 in this population, and to determine risk factors of disease severity (defined as a composite outcome including intensive care unit admission or death) and mortality.

RESULTS

Among the 2336 patients enrolled, 5.5% had confirmed COVID-19 diagnosis. Of the 122 patients with a follow-up superior to 28 days, 37% reached the composite outcome and 28% died. Multivariate analysis showed that oxygen therapy on diagnosis and a decrease in lymphocyte count were independent risk factors associated with disease severity and with mortality. Chronic use of angiotensin II receptor blockers (ARBs) (18% of patients) was associated with a protective effect on mortality. Treatment with azithromycin and hydroxychloroquine (AZT/HCQ) (46% of patients) were not associated with the composite outcome and with death in univariate and multivariate analyses.

CONCLUSIONS

COVID-19 is a severe disease with poor prognosis in patients with ESRD. Usual treatment with ARBs seems to be protective of critical evolution and mortality. There is no evidence of clinical benefit with the combination of AZT/HCQ.

The impulsivity rating scale (IRS): preliminary results

Until now, the instruments for the clinical evaluation of impulsivity have relied essentially on either personality inventories or to a lesser extent on specific questionnaires. Therefore this paper presents the preliminary results of a new rating scale: the Impulsivity Rating Scale (IRS). This is a 7-item hetero-evaluation of impulsivity based on the behaviour of the patient in usual life situations. The administration of the scale is easy and short: 15 minutes. The IRS was tested in five different population samples: 31 impulsive inpatients, 36 adults with major depressive episode, 15 healthy control subjects, 56 smokers before and after one week of tobacco withdrawal, and 47 adolescent depressed inpatients before and four weeks after antidepressant treatment. The results show good construct validity, good concurrent validity, good inter-rater reliability and sensitivity to change. A threshold of 8 for the total score (range 0 to 21) gives good specificity and sensitivity. The principal component analysis shows the existence of a main factor composed of all items, with lower correlation for two items which may belong to a second factor needing further investigations.

Unilateral nephrectomy versus renal arterial embolization and technique survival in peritoneal dialysis patients with autosomal dominant polycystic kidney disease

BACKGROUND

Autosomal dominant polycystic kidney disease (ADPKD) is a common genetic disorder associated with progressive enlargement of the kidneys and liver. ADPKD patients may require renal volume reduction, especially before renal transplantation. The standard treatment is unilateral nephrectomy. However, surgery incurs a risk of blood transfusion and alloimmunization. Furthermore, when patients are treated with peritoneal dialysis (PD), surgery is associated with an increased risk of temporary or definitive switch to haemodialysis (HD). Unilateral renal arterial embolization can be used as an alternative approach to nephrectomy.

METHODS

We performed a multicentre retrospective study to compare the technique of survival of PD after transcatheter renal artery embolization with that of nephrectomy in an ADPKD population. We included ADPKD patients treated with PD submitted to renal volume reduction by either surgery or arterial embolization. Secondary objectives were to compare the frequency and duration of a temporary switch to HD in both groups and the impact of the procedure on PD adequacy parameters.

RESULTS

More than 700 patient files from 12 centres were screened. Only 37 patients met the inclusion criteria (i.e. treated with PD at the time of renal volume reduction) and were included in the study (21 embolized and 16 nephrectomized). Permanent switch to HD was observed in 6 embolized patients (28.6%) versus 11 nephrectomized patients (68.8%) (P = 0.0001). Renal artery embolization was associated with better technique survival: subdistribution hazard ratio (SHR) 0.29 [95% confidence interval (CI) 0.12-0.75; P = 0.01]. By multivariate analysis, renal volume reduction by embolization and male gender were associated with a decreased risk of switching to HD. After embolization, a decrease in PD adequacy parameters was observed but no embolized patients required temporary HD; the duration of hospitalization was significantly lower [5 days [interquartile range (IQR) 4.0-6.0] in the embolization group versus 8.5 days (IQR 6.0-11.0) in the surgery group.

CONCLUSIONS

Transcatheter renal artery embolization yields better technique survival of PD in ADPKD patients requiring renal volume reduction.

Home dialysis : what are the barriers . A French nephrologist survey

Home dialysis, which includes Peritoneal Dialysis and Home Hemodialysis, provides lots of profit to patients suffering of Chronic Kidney Disease, especially in terms of comfort, life quality and autonomy. However, its use is marginal in France, with an inhomogenous distributaion according to geographical regions. We conducted a French national survey of nephrologists to assess the barriers to the development of home dialysis. After analyzing the responses of the 230 participating nephrologists, the main obstacles to the development of the two techniques were identified and classified according to their reporting rate. The major obstacles that emerge from the survey are : the lack of information among the general public, a lack of acknowledgement of nurses specializing in these techniques, the limited number of structures that practice dialysis at home, and information difficulties among patient about dialysis techniques. The specific peritoneal dialysis-related difficulties reported are : difficulties in management of follow-up care and rehabilitation, the fear of insufficient purification and the difficulties related to the dialysis catheter. Concerning home hemodialysis, the barriers concern fear of autopunction and the need for a third party. This study helps to identify the representations of nephrologists on the major obstacles to the development of home dialysis to develop lines of thought for its promotion, both in terms of training, institutional acknowledgement, and the necessary regulatory evolution.

[Obstetrical follow-up and perinatal prognosis in drug addict pregnant women]

OBJECTIVE

To identify the factors associated with a good obstetric follow-up and a good perinatal prognosis, in order to adapt the management of pregnant women with addiction to opiates.

METHODS

A retrospective study was carried out in our maternity between January 2012 and December 2014, including 104 women who were addicted to opiates, whether or not they were substituted, with or without associated consumptions, regardless of the term of delivery beyond 22 weeks of amenorrhea.

RESULTS

A good obstetrical follow-up was observed by 32.7% of women. The father's presence (OR=3.9; P=0.0113) and investment in pregnancy (OR=4.4; P=0.0029), as well as the desired character of the pregnancy (OR=4.5; P=0.0008) appeared to be associated with the quality of the observed follow-up. Preterm deliveries (11.8 versus 35.8%; P=0.0103), and social measures taken at the discharge of the newborn from the maternity (2.9 versus 24.3%, P=0.0057) were less frequent. A good perinatal prognosis was found for 29.8% of the cases. Associated consumptions <3 (OR=2.6 [1.1-6.2]; P=0.0281) confirmed by negative urine drug screening (OR=2.9 [1.1-7.8]; P=0.0307) were more numerous.

CONCLUSION

Although the follow-up and the perinatal prognosis of these pregnancies have improved considerably in recent years, it seems necessary to further optimize their management.

Signaling of Serum Amyloid A Through Receptor for Advanced Glycation End Products as a Possible Mechanism for Uremia-Related Atherosclerosis

OBJECTIVE

Cardiovascular disease is the leading cause of death in patients with end-stage renal disease. Serum amyloid A (SAA) is an acute phase protein and a binding partner for the multiligand receptor for advanced glycation end products (RAGE). We investigated the role of the interaction between SAA and RAGE in uremia-related atherogenesis.

APPROACH AND RESULTS

We used a mouse model of uremic vasculopathy, induced by 5 of 6 nephrectomy in the Apoe(-/-) background. Sham-operated mice were used as controls. Primary cultures of Ager(+/+) and Ager(-/-) vascular smooth muscle cells (VSMCs) were stimulated with recombinant SAA, S100B, or vehicle alone. Relevance to human disease was assessed with human VSMCs. The surface area of atherosclerotic lesions at the aortic roots was larger in uremic Apoe(-/-) than in sham-operated Apoe(-/-) mice (P<0.001). Furthermore, atherosclerotic lesions displayed intense immunostaining for RAGE and SAA, with a pattern similar to that of α-SMA. Ager transcript levels in the aorta were 6× higher in uremic animals than in controls (P<0.0001). Serum SAA concentrations were higher in uremic mice, not only after 4 weeks of uremia but also at 8 and 12 weeks of uremia, than in sham-operated animals. We investigated the functional role of RAGE in uremia-induced atherosclerosis further, in animals lacking RAGE. We found that the induction of uremia in Apoe(-/-) Ager(-/-) mice did not accelerate atherosclerosis. In vitro, the stimulation of Ager(+/+) but not of Ager(-/-) VSMCs with SAA or S100B significantly induced the production of reactive oxygen species, the phosphorylation of AKT and mitogen-activated protein kinase-extracellular signal-regulated kinases and cell migration. Reactive oxygen species inhibition with N-acetyl cysteine significantly inhibited both the phosphorylation of AKT and the migration of VSMCs. Similar results were obtained for human VSMCs, except that the phosphorylation of mitogen-activated protein kinase-extracellular signal-regulated kinases, rather than of AKT, was subject to specific redox-regulation by SAA and S100B. Furthermore, human aortic atherosclerotic sections were positively stained for RAGE and SAA.

CONCLUSIONS

Uremia upregulates SAA and RAGE expression in the aortic wall and in atherosclerotic lesions in mice. Ager(-/-) animals are protected against the uremia-induced acceleration of atherosclerosis. SAA modulates the functions of murine and human VSMCs in vitro in a RAGE-dependent manner. This study, therefore, identifies SAA as a potential new uremic toxin involved in uremia-related atherosclerosis through interaction with RAGE.

[Hyponatremias: From pathophysiology to treatments. Review for clinicians]

Hyponatremia could be defined as a public health topic: too many patients are concerned in both hospitalized and general populations; hyponatremia induces lots of clinical outcomes and a great economic burden. Its pathophysiology involves thirst regulation (hypotonic water intakes) and losses regulation (through the kidney under vasopressin control). Diagnostic approach should insure that hyponatremia reflects hypo-osmolality and hypotonicity: first, a false hyponatremia should be ruled out, then a non-hypotonic one. Next step is clinic: extracellular status should be evaluated. When increased, any edematous status should be evoked: heart failure, liver cirrhosis or nephrotic syndrome. When decreased, any cause of extracellular dehydration should be evoked: natriuresis could help distinguishing between renal (adrenal insufficiency, diuretics use or salt-losing nephropathy) or extrarenal (digestive mostly) etiologies. When clinically normal, a secretion of inappropriate antidiuretic hormone (SIADH) should be evoked, once hypothyroidism or hypoadrenocorticism have been ruled out. Therapy depends on the severity of the clinical impact. From extracellular rehydration, through fluid restriction, the paraneoplastic and heart failure-induced SIADH benefit from a new class of drug, available among the therapeutic strategies: aquaretics act through antidiuretic hormone receptor antagonism (vaptans). Their long-term benefits still have to be proven but it is a significant step forward in the treatment of hyponatremias.

Recurrent IgA nephropathy is predicted by altered glycosylated IgA, autoantibodies and soluble CD89 complexes

IgA nephropathy (IgAN), the most common primary glomerulonephritis worldwide, frequently leads to end-stage renal disease and kidney transplantation. However, disease recurrence often occurs after transplantation. Here we evaluated the predictive value of three markers for IgAN recurrence: the presence of galactose-deficient IgA1, IgG anti-IgA autoantibodies, and IgA-soluble (s) CD89 complexes. This was analyzed in 38 kidney transplant recipients with IgAN recurrence and compared with 22 patients transplanted for IgAN but without recurrence and with 17 healthy controls. Pre-transplantation galactose-deficient IgA1 serum levels were significantly higher in the recurrence compared with the no recurrence or control groups. IgA-IgG complexes were significantly elevated in the recurrence group. Both the recurrence and no recurrence groups had increased values of IgA-sCD89 complexes compared with healthy controls, but values were significantly lower in patients with recurrence compared with no recurrence. Areas under the receiver operating curve of the markers in pre-transplantation sera were 0.86 for galactose-deficient-IgA, 0.82 for IgA-IgG, and 0.78 for sCD89-IgA; all significant. Disease recurrence was associated with decreased serum galactose-deficient IgA1 and appearance of mesangial-galactose-deficient IgA1 deposits, whereas increased serum IgA-sCD89 complexes were associated with mesangial sCD89 deposits. Thus, galactose-deficient-IgA1, IgG autoantibodies, and IgA-sCD89 complexes are valuable biomarkers to predict disease recurrence, highlighting major pathogenic mechanisms in IgAN.

Prevalence of Clostridium species and behaviour of Clostridium botulinum in gnocchi, a REPFED of italian origin

Sales and consumption of refrigerated processed foods of extended durability (REPFEDs) have increased many-fold in Europe over the last 10 years. The safety and quality of these convenient ready-to-eat foods relies on a combination of mild heat treatment and refrigerated storage, sometimes in combination with other hurdles such as mild preservative factors. The major hazard to the microbiological safety of these foods is Clostridium botulinum. This paper reports on the prevalence and behaviour of proteolytic C. botulinum and non-proteolytic C. botulinum in gnocchi, a potato-based REPFED of Italian origin. Attempts to isolate proteolytic C. botulinum and non-proteolytic C. botulinum from gnocchi and its ingredients were unsuccessful. Based on assessment of the adequacy of the methods used, it was estimated that for proteolytic C. botulinum there was < 25 spores/kg of gnocchi and < 70 spores/kg of ingredients. The total anaerobic microbial load of gnocchi and its ingredients was low, with an estimated 1 MPN/g in processed gnocchi. Most of the anaerobic flora was facultatively anaerobic. A few obligately anaerobic bacteria were isolated from gnocchi and its ingredients and belonged to different Clostridium species. The protection factor, number of decimal reductions in the probability of toxigenesis from a single spore, was determined for eight different gnocchi formulations by challenge test studies. For all gnocchi stored at 8 degrees C (as recommended by the manufacturer) or 12 degrees C (mild temperature abuse), growth and toxin production were not detected in 75 days. The protection factor was >4.2 for proteolytic C. botulinum, and >6.2 for non-proteolytic C. botulinum. When inoculated packs were stored at 20 degrees C (severe temperature abuse), toxin production in 75 days was prevented by the inclusion of 0.09% (w/w) sorbic acid (protection factors as above), however in the absence of sorbic acid the packs became toxic before the end of the intended shelf-life and the protection factors were lower. Providing sorbic acid (0.09% w/w) is included in the gnocchi, the safety margin would seem to be very large with respect to the foodborne botulism hazard.

[Risk-taking. Adolescent girls versus adolescent boys]

Epidemiologists as well as professionals working in the area of adolescent health generally agree that adolescence is a period characterized by a difference in frequency of risk-taking behaviour between girls and boys. An explanation of these data through ethno-psychological and psychodynamical approaches is hereby presented. Such approaches should be taken into account for general preventive strategies to take effect.

Personality dimensions in social phobics with or without depression

OBJECTIVE

This study investigated the personality traits of social phobics using the Temperament and Character Inventory (TCI).

METHOD

A sample of 178 social phobics was assessed with the TCI, and compared with controls. The patients were classified into two groups, according to the absence (SP group) or to the presence (SP+D group) of depression.

RESULTS

We found significant elevated scores for harm avoidance (HA) in social phobics when compared with controls (16.2 +/- 2.7), in both the SP (26.2 +/- 3.5), and the SP+D (28.9 +/- 4.7), groups. Lower self-directedness scores were found in the SP and in the SP+D groups when compared with the controls. Patients with the generalized type of social phobia had higher HA scores as compared with other social phobics.

CONCLUSION

The personality profile obtained in these social phobics, whatever their depressive symptomatology, reflects a dramatically anxious and avoidant temperament associated to an immature character.

Screening for clostridium botulinum type A, B, and E in cooked chilled foods containing vegetables and raw material using polymerase chain reaction and molecular probes

A molecular method was used for the detection of Clostridium botulinum spores of type A, B, and E in commercial cooked and pasteurized vegetable purées and in the raw materials (vegetables and other ingredients). The method allowed the detection of less than 8 spores/g of product for C. botulinum type A, less than 1 spore/g for proteolytic type B, less than 21 spores/g for nonproteolytic type B, and less than 0.1 spore/g for type E. Thirty-seven samples of raw vegetables and ingredients were tested for the presence of C. botulinum type A, B, and E; 88 and 90 samples of vegetable purées were tested, respectively, for the presence of C. botulinum type A and B and for the presence of C. botulinum type E. All samples were negative, suggesting that the prevalence of C. botulinum in these vegetable purées and the raw ingredients is probably low.

[Anxiety, aggression, agitation and depression: psychopathologic aspects]

While clinical experience has long since shown that there are different types of depression, in particular anxious and hostile depressions, the psychopathological analysis of the various forms remains of current interest. At least four psychopathological models are currently available. The first raises the question of the continuity between reactions to separation, particularly studied in children, and the clinical expression of certain forms of depression in adults. In many aspects, the latter suggest the sequence: protest-despair-detachment. The second model raises the question of the relationship between the depressive disorder and the organization of certain personalities. The considerable comorbidity between the borderline personality and affective disorders suggest that these two different disorders share a common dimension. The third-cultural-model hypothesizes a relationship between the sociocultural prohibition of aggressive responses and the incidence of depression. The fourth model is based on the existence of a specific biological constraint related to abnormalities of serotonin metabolism, to which dysregulation of anxious and aggressive-impulsive behavior patterns during depression are considered related. In conclusion, it may be considered that several models, in particular that of reaction to separation, may, at least in part, account for "positive-expression" depression, but that at least two questions have still to be answered: that regarding the relationships between depression and personality, and that concerning the relationships between the psychopathological constraints related to serotonin metabolism dysfunction and the "positive" expressions.

[Panic attack and panic disorder in the child and adolescent]

In the light of the current interest in the development of this disorder in adults, a number of recent studies have been devoted to the condition in children and adolescents. These papers include retrospective studies of adults suffering from the disorder, clinical reports on children or adolescents with the same problems, epidemiological studies of children and adolescents consulting psychiatrists, epidemiological studies of the general population, family studies, and studies of chemotherapeutic treatments. The conclusion from these papers is that many children and adolescents who present with physical symptoms are suffering from a panic disorder which has not been identified as such at the time. Other studies have analysed the age of onset of the first attack. All these studies are now in agreement in confirming that adolescence is the preferential age of onset of panic disorder. There even appears to be a correlation between the stages of puberty (Tanner) and the onset of panic attacks in young adolescents. At each successive stage of puberty, C. Hayward et al. (1992) found a progressively higher rate of panic attacks. "Panic disorder" thus preferentially develops in adolescence, more commonly in girls than boys, particularly in subjects who are prone to anxiety or show traits of the "avoiding personality", but who also have a depressive tendency. A number of studies also suggest that pathological separation anxiety developing in childhood represents a risk factor for the development of "panic disorder" and/or agoraphobia during adolescence or adult life. The natural history of Panic Disorder in adolescence is still little known. The greatest risk appears to be chronic anxiety, but the progressive establishment of panic disorder, its development in the direction of depressive disorder, and self-medication and/or abuse of psychotropic drugs, also give cause for concern. Finally, a number of psychopathological considerations have raised the possibility that the onset of a panic disorder may be a danger signal of an underlying depressive personality.

[Disorders of catecholamine metabolism in infantile autism. Comparative study of 22 autistic children]

In a group of 22 autistic children aged 5 to 16 y., and a group of normal controls matched for age and sex, catecholamines metabolism has been investigated in plasma, platelets and urine. This investigation was part of a research project in which several biological parameters (including serotonin) were simultaneously explored in the same children. In the autistic group, epinephrine and norepinephrine and dopamine were significantly lower in isolated platelets, and no significant difference was found between the two groups for the urinary excretion of epinephrine, norepinephrine, dopamine, DOPAC and MHPG. Other differences between the two groups in the statistical correlations of several biochemical parameters (plasma norepinephrine and dopamine with platelet MAO activity, platelet norepinephrine with platelet dopamine, platelet dopamine, platelet dopamine with platelet serotonin) also suggest abnormalities of bioamine metabolism in the platelets of autistic children.

[Metabolism of serotonin in autism in children]

In this controlled study of 22 autistic children and 22 normal controls matched for age and sex, the frequency of hyperserotonemia in infantile autism was confirmed. Platelet serotonin was elevated in patients. Comparative to controls, serotonin was also high in urine of autistic patients, while, on the contrary there was no difference for the urinary excretion of 5-HIAA. No difference was observed either for serotonin uptake and efflux or for MAO activity, in isolated platelets. The elevation of plasma free tryptophan - significant only with the Kolmogorov Smirnov test - suggests that 5-HT biosynthesis might be enhanced. In the group of patient reported in this study, disorders of serotonin metabolism are associated with disturbances of platelet catecholamines, and also with elevated immunoglobulins and enhanced cellular immunity reactions.

[Immune status in infantile autism. Correlation between the immune status, autistic symptoms and levels of serotonin]

In sixteen autistic children high values of IgG and a high level of lymphocyte stimulation with PHA were observed. Principal component analysis showed: 1) a significant correlation between basic lymphocyte mitogenic activity and the clinical symptoms opposition and hyperactivity, 2) a significant correlation between high Ig levels, high PHA stimulation responses and the main autistic symptoms (withdrawal, inaffectivity, hypoactivity, mannerism, stereotypy and negatively echolalia), 3) a significant correlation with serotonin uptake by platelets and high immunological responses. Such correlations are strongly in favor of an immunologic component in autistic disease.

Serotonin metabolism and other biochemical parameters in infantile autism. A controlled study of 22 autistic children

The serotonin metabolism was extensively studied in 22 couples of autistic children and age- and sex-matched controls. Histamine, calcium, and uric acid were also measured in urine and whole blood or plasma. Autistics and controls did not differ in histamine, and only minor changes were noticed in calcium content. According to previous reports, serotonin levels were often, but not always, elevated in the blood of autistic children. Based on data including urinary serotonin and 5-hydroxyindoleacetic acid, platelet serotonin uptake and efflux, platelet monoamine oxidase and glutathione peroxidase activities, and uric acid and plasma tryptophan, the origin(s) of such hyperserotonemia in autism appear(s) to be of metabolic origin, i.e., a decreased catabolism and/or an increased biosynthesis of serotonin.

Catecholamines metabolism in infantile autism: a controlled study of 22 autistic children

In a group of 22 autistic children aged 5 to 16 years and a group of normal controls matched for age and sex, catecholamines metabolism was investigated in plasma, platelets, and urine. This investigation was part of a research project in which several biological parameters (including serotonin) were explored simultaneously in the same children. In the autistic group, epinephrine and norepinephrine were significantly elevated in plasma, while epinephrin, norepinephrine, and dopamine were significantly lower in isolated platelets. No significant difference was found between the two groups for the urinary excretion of epinephrine, norepinephrine, dopamine, DOPAC, and MHPG. Other differences between the two groups in the statistical correlations of several biochemical parameters also suggest abnormalities of bioamine metabolism in the platelets of autistic children.

[Heterogeneity of the depressive mood. Construction of a polydimensional scale]

The evaluation of depressive mood implies several levels of the clinician's inferences: behaviour observation, subjective experience report, affective communication... The authors report the first stages in the construction of a specific depressive mood scale administered to a major depressive disorder population of 52 patients meeting DSM III criteria. The principal component analysis splits mood into three main factors: dysphoria, expressed sadness, emotional blunting. These various emotional dimensions should be taken into account for the analysis of drugs effects.

[A "condemned" child. Case of borderline personality disorder]

The import of this observation resides in the significance of the patient's destiny and in the poor organization of his personality, indicating that defense mechanisms may have been prevented from building up as a result of the bearing of real and phantasmic events on his mental working. We speculate that a mechanism as essential as interiorization could not develop, as a direct result of the continuous confrontation of conflicts with a disrupted reality and the recollection of this last. The limits constituted by death and incest could not be normally interiorized and integrated within the psychic organization of this young boy, "doomed" at the age of four, and perhaps even earlier.

[Psychoanalytic therapy in adolescence]

Psychoanalytic therapies in adolescence can be classified into four groups: the analytic cure or "standard cure", psychoanalytic psychotherapy (PP), psychoanalytic psychodrama and psychoanalytic relaxation psychotherapy. In other instances, the psychoanalyst works with the adolescent's family or with the staff working in an institution for adolescents, but this does not involve a direct relationship between the psychoanalyst and the adolescent. In adolescence, PP and psychodrama seem to be the most readily used psychoanalytical methods.

[Depression in adolescents]

After having believed that depression is a normal feature of adolescence, most practitioners discriminate between the moderate, transient, depressive feelings, which are indeed part of the normal process of adolescence, and the various forms of true depression that may occur at this age. The problem of "depressive equivalents" is probably the most studied. Our opinion, based on a clinical and psychodynamic viewpoint, is that four types of depression can be distinguished in adolescence: anxious-depressive reactions, inferiority depression, abandonment depression and melancholic depression. These four conditions share a basic depressive reaction typified by a psychomotor slowness and "freezing" of feelings, ideas and motions.

[Psychiatry of adolescence. Prevention of mental diseases in adults]

Several impediments to the recognition of psychological disorders in adolescents are analyzed. In spite of the difficulties, it is worthwhile to overcome these obstacles. Indeed, it must be pointed out that the therapy of psychological disturbances during adolescence has a preventive effect upon longstanding psychiatric disorders in adulthood. Psychological manifestations in adolescence can be classed into four groups: the normal process of transformation, transient psychopathological reactions to transformation, conflictual organizations and severe impediments to the process of transformation. To these four clinical groups answer different consultation settings.