Reference percentiles for FEV(1) and BMI in European children and adults with cystic fibrosis

Background

The clinical course of Cystic Fibrosis (CF) is usually measured using the percent predicted FEV₁ and BMI Z-score referenced against a healthy population, since achieving normality is the ultimate goal of CF care. Referencing against age and sex matched CF peers may provide valuable information for patients and for comparison between CF centers or populations. Here, we used a large database of European CF patients to compute CF specific reference equations for FEV₁ and BMI, derived CF-specific percentile charts and compared these European data to their nearest international equivalents.

Methods

34859 FEV₁ and 40947 BMI observations were used to compute European CF specific percentiles. Quantile regression was applied to raw measurements as a function of sex, age and height. Results were compared with the North American equivalent for FEV₁ and with the WHO 2007 normative values for BMI.

Results

FEV₁ and BMI percentiles illustrated the large variability between CF patients receiving the best current care. The European CF specific percentiles for FEV₁ were significantly different from those in the USA from an earlier era, with higher lung function in Europe. The CF specific percentiles for BMI declined relative to the WHO standard in older children. Lung function and BMI were similar in the two largest contributing European Countries (France and Germany).

Conclusion

The CF specific percentile approach applied to FEV₁ and BMI allows referencing patients with respect to their peers. These data allow peer to peer and population comparisons in CF patients.

A national internet-linked based database for pediatric interstitial lung diseases: the French network

BACKGROUND

Interstitial lung diseases (ILDs) in children represent a heterogeneous group of rare respiratory disorders that affect the lung parenchyma. After the launch of the French Reference Centre for Rare Lung Diseases (RespiRare®), we created a national network and a web-linked database to collect data on pediatric ILD.

METHODS

Since 2008, the database has been set up in all RespiRare® centres. After patient's parents' oral consent is obtained, physicians enter the data of children with ILD: identity, social data and environmental data; specific aetiological diagnosis of the ILD if known, genetics, patient visits to the centre, and all medical examinations and tests done for the diagnosis and/or during follow up. Each participating centre has a free access to his own patients' data only, and cross-centre studies require mutual agreement. Physicians may use the system as a daily aid for patient care through a web-linked medical file, backed on this database.

RESULTS

Data was collected for 205 cases of ILD. The M/F sex ratio was 0.9. Median age at diagnosis was 1.5 years old [0-16.9]. A specific aetiology was identified in 149 (72.7%) patients while 56 (27.3%) cases remain undiagnosed. Surfactant deficiencies and alveolar proteinosis, haemosiderosis, and sarcoidosis represent almost half of the diagnoses. Median length of follow-up is 2.9 years [0-17.2].

CONCLUSIONS

We introduce here the French network and the largest national database in pediatric ILDs. The diagnosis spectrum and the estimated incidence are consistent with other European databases. An important challenge will be to reduce the proportion of unclassified ILDs by a standardized diagnosis work-up. This database is a great opportunity to improve patient care and disease pathogenesis knowledge. A European network including physicians and European foundations is now emerging with the initial aim of devising a simplified European database/register as a first step to larger European studies.

Comparison of routine and on-demand prescription of chest radiographs in mechanically ventilated adults: a multicentre, cluster-randomised, two-period crossover study

BACKGROUND

Present guidelines recommend routine daily chest radiographs for mechanically ventilated patients in intensive care units. However, some units use an on-demand strategy, in which chest radiographs are done only if warranted by the patient's clinical status. By comparison between routine and on-demand strategies, we aimed to establish which strategy was more efficient and effective for optimum patient care.

METHODS

In a cluster-randomised, open-label crossover study, we randomly assigned 21 intensive care units at 18 hospitals in France to use a routine or an on-demand strategy for prescription of chest radiographs during the first of two treatment periods. Units used the alternative strategy in the second period. Each treatment period lasted for the time taken for enrolment and study of 20 consecutive patients per intensive care unit; patients were monitored until discharge from the unit or for up to 30 days' mechanical ventilation, whichever was first. Units enrolled 967 patients, but 118 were excluded because they had been receiving mechanical ventilation for less than 2 days. The primary outcome measure was the mean number of chest radiographs per patient-day of mechanical ventilation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00893672.

FINDINGS

11 intensive care units were randomly allocated to use a routine strategy to order chest radiographs in the first treatment period, and 10 units to use an on-demand strategy. Overall, 424 patients had 4607 routine chest radiographs (mean per patient-day of mechanical ventilation 1.09, 95% CI 1.05-1.14), and 425 had 3148 on-demand chest radiographs (mean 0.75, 0.67-0.83), which corresponded to a reduction of 32% (95% CI 25-38) with the on-demand strategy (p<0.0001).

INTERPRETATION

Our results strongly support adoption of an on-demand strategy in preference to a routine strategy to decrease use of chest radiographs in mechanically ventilated patients without a reduction in patients' quality of care or safety.

FUNDING

Assistance Publique-Hôpitaux de Paris (Direction Régionale de la Recherche Clinique Ile de France).

Virtual surveillance of communicable diseases: a 20-year experience in France

Inserm has developed, since 1984, an information system based on a computer network of physicians in France. It allows for constitution of large databases on diseases, with individual description of cases, and to explore some aspects of the mathematical theory of communicable diseases. We developed user-friendly interfaces for remote data entry and GIS tools providing real-time atlas of the epidemiologic situation in any location. The continuous and ongoing surveillance network is constituted of about 1200 sentinel voluntary and unpaid investigators. We studied their motivation, reasons for either withdrawal or compliance using survival analyses. We implemented early warning systems for outbreak detection and for time-space forecasting. We conducted epidemiological surveys for investigating outbreaks. Large available time and space series allowed us to calibrate and explore synchronism of influenza epidemics, to test the assumption of panmixing in susceptibles-infectious-removed type models and to study the role of closing school in influenza morbidity and mortality in elderly. More than 250 000 cases of influenza, 150 000 cases of acute diarrheas, 35,000 patients for whom HIV tests have been prescribed by general practitioners and 25,000 cases of chickenpox have been collected. Detection of regional influenza or acute diarrhea outbreaks and forecasting of epidemic trends three weeks ahead are currently broadcasted to the French media and published on Sentiweb on a weekly basis. Age-cohort-period models assessed field effectiveness of mass immunization strategies against measles and influenza in the country. Case-control studies with more than 1200 sets of cases of acute diarrheas and their matched controls showed the role of calicivirus and rotavirus as probable major causes of gastroenteritis during recurrent widespread outbreaks in winter in France. An age-specific model for chickenpox showed the probable role of children in disease transmission to their susceptible parents or grandparents. High level of synchronism between influenza epidemics has been demonstrated, either at a regional level (in France) or between France and the USA. The designation of our lab as a WHO collaborating center for electronic disease surveillance stimulates the development of global monitoring of diseases. We developed operational systems that are now available for the global monitoring of influenza (FluNet), and human and animal rabies (RABNET). Extension of electronic syndromic surveillance is needed in the world for improving surveillance capacities and real-time response against emerging diseases.

ICPCview: visualizing the International Classification of Primary Care

This paper proposes a method to visualize the semantic content of data bases where the medical information is coded with the International Classification of Primary Care. The main idea is the identification of a pixel with a code and the conversion of all the data associated with these into an image the ICPCview. The method proceeds in two step, defining the reference frame and using this reference frame to visualize data. The reference frame is built by using a sign/diagnosis binary criterion, a seventeen category nosological criterion and an age ordinal criterion. The results are visualization of the signs and diagnosis of the ICPC according to gender, age and time period of the year. A limitation of the method lies in the fact that the result depends on the chosen reference frame. Further work has to be done with various reference frames and data. However the main point is that, when both the reference set of the image and of the mind of the user are built, the method is powerful at extracting the hidden content of a very large amount of data.

Respiratory-Like Rhythmic Activity Can Be Produced by an Excitatory Network of Non-Pacemaker Neuron Models

It is still unclear whether the respiratory-like rhythm observed in slice preparations containing the pre-Bötzinger complex is of pacemaker or network origin. The rhythm persists in the absence of inhibition, but blocking pacemaker activity did not always result in rhythm abolition. We developed a computational model of the slice to show that respiratory-like rhythm can emerge as a network property without pacemakers or synaptic inhibition. The key currents of our model cell are the low- and high-threshold calcium currents and the calcium-dependent potassium current. Depolarization of a single unit by current steps or by raising the external potassium concentration can induce periodic bursting activity. Gaussian stimulation increased the excitability of the model without evoking oscillatory activity, as indicated by autocorrelation analysis. In response to hyperpolarizing pulses, the model produces prolonged relative refractory periods. At the network level, an increase of external potassium concentration triggers rhythmic activity that can be attributed to cellular periodic bursting, network properties, or both, depending on different parameters. Gaussian stimulation also induces rhythmic activity that depends solely on network properties. In all cases, the calcium-dependent potassium current has a central role in burst termination and interburst duration. However, when periodic inhibition is considered, the activation of this current is responsible for the characteristic amplification ramp of the emerged rhythm. Our results may explain controversial results from studies blocking pacemakers in vitro and show a shift in the role of the calcium-dependent potassium current in the presence of network inhibition.

Automatic detection of microcalcifications in mammography using a neuromimetic system based on retina

The incidence of breast cancer in France is roughly 26,000 and the annual number of deaths is 11,000. The mammography is the choice examination for the early identification of the tumours in an asymptomatic population. This is a simple, reliable, inexpensive examination, allowing to identify a grave and frequent pathology, but that can be the object of an effective treatment if early detected. The recognition of the microcalcifications in the mammographies is the key for early detection of cancers. Automatic detection methods were already proposed, but they have a very weak specificity and a relatively low sensibility. Currently, the eye of the expert still remains the better judge. We propose a neuromimetic method to localize automatically the microcalcifications. In this method, we devise a network of formal neurones inspired from the mammal retina architecture. This model mimics one characteristic of the retina which is is a sensor that automatically adapts to the image characteristics to analyse and realize the outlines extraction and adaptative filtering of the pictures, based on its network properties. The results were tested using a public standardized data set (DDSM), which was designed to test the automatic detection methods. We show that our "retina" can extracts most of the microcalcifications that can be grouped together in clusters. While we achieve a 95% sensitivity, we must acknowledge a low specificity (22%). Current efforts will focus to enhance this latter parameter.

Epidemic spread and bifurcation effects in two-dimensional network models with viral dynamics

We extend a previous network model of viral dynamics to include host populations distributed in two space dimensions. The basic dynamical equations for the individual viral and immune effector densities within a host are bilinear with a natural threshold condition. In the general model, transmission between individuals is governed by three factors: a saturating function g( small middle dot) describing emission as a function of originating host virion level; a four-dimensional array B that determines transmission from each individual to every other individual; and a nonlinear function F, which describes the absorption of virions by a host for a given net arrival rate. A summary of the properties of the viral-effector dynamical system in a single host is given. In the numerical network studies, individuals are placed at the mesh points of a uniform rectangular grid and are connected with an m(2)xn(2) four-dimensional array with terms that decay exponentially with distance between hosts; g is linear and F has a simple step threshold. In a population of N=mn individuals, N0 are chosen randomly to be initially infected with the virus. We examine the dependence of maximal population viral load on the population dynamical parameters and find threshold effects that can be related to a transcritical bifurcation in the system of equations for individual virus and host effector populations. The effects of varying demographic parameters are also examined. Changes in alpha, which is related to mobility, and contact rate beta also show threshold effects. We also vary the density of (randomly chosen) initially infected individuals. The distribution of final size of the epidemic depends strongly on N0 but is invariably bimodal with mass concentrated mainly near either or both ends of the interval [1,N]. Thus large outbreaks may occur, with small probability, even with only very few initially infected hosts. The effects of immunization of various fractions of the population on the final size of the epidemic are also explored. The distribution of the final percentage infected is estimated by simulation. The mean of this quantity is obtained as a function of immunization rate and shows an almost linear decline for immunization rates up to about 0.2. When the immunization rate is increased past 0.2, the extra benefit accrues more slowly. We include a discussion of some approximations that illuminate threshold effects in demographic parameters and indicate how a mean-field approximation and more detailed studies of various geometries and rates of immunization could be a useful direction for future analysis.

Enhancement of epidemic spread by noise and stochastic resonance in spatial network models with viral dynamics

We extend a previous dynamical viral network model to include stochastic effects. The dynamical equations for the viral and immune effector densities within a host population of size n are bilinear, and the noise is white, additive, and Gaussian. The individuals are connected with an n x n transmission matrix, with terms which decay exponentially with distance. In a single individual, for the range of noise parameters considered, it is found that increasing the amplitude of the noise tends to decrease the maximum mean virion level, and slightly accelerate its attainment. Two different spatial dynamical models are employed to ascertain the effects of environmental stochasticity on viral spread. In the first model transmission is unrestricted and there is no threshold within individuals. This model has the advantage that it can be analyzed using a Fokker-Planck approach. The noise is found both to synchronize and uniformize the trajectories of the viral levels across the population of infected individuals, and thus to promote the epidemic spread of the virus. Quantitative measures of the speed of spread and overall amplitude of the epidemic are obtained as functions of the noise and virulence parameters. The mean amplitude increases steadily without threshold effects for a fixed value of the virulence as the noise amplitude sigma is increased, and there is no evidence of a stochastic resonance. However, the speed of transmission, both with respect to its mean and variance, undergoes rapid increases as sigma changes by relatively small amounts. In the second, more realistic, model, there is a threshold for infection and an upper limit to the transmission rate. There may be no spread of infection at all in the absence of noise. With increasing noise level and a low threshold, the mean maximum virion level grows quickly and shows a broad-based stochastic resonance effect. When the threshold within individuals is increased, the mean population virion level increases only slowly as sigma increases, until a critical value is reached at which the mean infection level suddenly increases. Similar results are obtained when the parameters of the model are also randomized across the population. We conclude with a discussion and a description of a diffusion approximation for a model in which stochasticity arises through random contacts rather than fluctuation in ambient virion levels.

Small intestine protection from radiation by means of a removable adapted prosthesis

BACKGROUND

A prosthesis has been designed to protect intestinal loops from radiation when postsurgical radiotherapy is necessary in cancer treatment. It is a silicone balloon that allows the small bowel to be pushed back away from the radiation field, and it is easily removed at the conclusion of radiotherapy.

METHODS

The device was used in 22 patients: 5 retroperitoneal tumors and 17 pelvic cancers. After surgical resection of the tumor, the device is placed either in the retroperitoneal area or in the pelvic cavity. A polyglactine 910 mesh is placed between the spacer and the bowel to prevent incarceration of the loops. The prosthesis can be filled or emptied between each radiation course and finally removed by means of a short incision under local or locoregional anesthesia.

RESULTS

The tolerance of the small intestine to radiation therapy has been satisfactory in each case, with a mean follow-up of 24.5 months (range 10 to 73). No modification of biological parameters was observed during the pelvic radiation therapy at 30, 45, and 65 Gy.

CONCLUSION

This device should appears to efficient for prevention of bowel injury during postsurgical radiation in successful treatment of abdominal, pelvic, or retroperitoneal tumors when indicated.

Modelling health care processes with SHARE

This paper describes the "SHARE" workframe, designed to provide a comprehensive environment for modeling and simulating health care processes. The objects defined within SHARE are Actors, subdivided in Clients and Resources, and Elementary Operations. Graphical tools allow to build processes from these objects, and to specify their relationships. Various strategies based on either clinical or managerial changes may be investigated. Summary information on the utilization of all actors, on waiting times and goodness of execution may be displayed after a simulation. Better description of processes, and their study a priori will improve reliability, quality of care and satisfaction of patients.

Periodically-modulated inhibition of living pacemaker neurons--III. The heterogeneity of the postsynaptic spike trains, and how control parameters affect it

Codings involving spike trains at synapses with inhibitory postsynaptic potentials on pacemakers were examined in crayfish stretch receptor organs by modulating presynaptic instantaneous rates periodically (triangles or sines; frequencies, slopes and depths under, respectively, 5.0 Hz, 40.0/s/s and 25.0/s). Timings were described by interspike and cross-intervals ("phases"); patterns (dispersions, sequences) and forms (timing classes) were identified using pooled graphs (instant along the cycle when a spike occurs vs preceding interval) and return maps (plots of successive intervals). A remarkable heterogeneity of postsynaptic intervals and phases characterizes each modulation. All cycles separate into the same portions: each contains a particular form and switches abruptly to the next. Forms differ in irregularity and predictability: they are (see text) "p:q alternations", "intermittent", "phase walk-throughs", "messy erratic" and "messy stammering". Postsynaptic cycles are asymmetric (hysteresis). This contrasts with the presynaptic homogeneity, smoothness and symmetry. All control parameters are, individually and jointly, strongly influential. Presynaptic slopes, say, act through a postsynaptic sensitivity to their magnitude and sign; when increasing, hysteresis augments and forms change or disappear. Appropriate noise attenuates between-train contrasts, providing modulations are under 0.5 Hz. Postsynaptic natural intervals impose critical time bases, separating presynaptic intervals (around, above or below them) with dissimilar consequences. Coding rules are numerous and have restricted domains; generalizations are misleading. Modulation-driven forms are trendy pacemaker-driven forms. However, dissimilarities, slight when patterns are almost pacemaker, increase as inhibition departs from pacemaker and incorporate unpredictable features. Physiological significance-(1) Pacemaker-driven forms, simple and ubiquitous, appear to be elementary building blocks of synaptic codings, present always but in each case distorted typically. (2) Synapses are prototype: similar behaviours should be widespread, and networks simulations benefit by nonlinear units generating all forms. (3) Relevant to periodic functions are that few variables need be involved in form selection, that distortions are susceptible to noise levels and, if periods are heterogeneous, that simple input cycles impose heterogeneous outputs. (4) Slow Na inactivations are necessary for obtaining complex forms and hysteresis. Formal significance--(1) Pacemaker-driven forms and presumably their modulation-driven counterparts, pertain to universal periodic, intermittent, quasiperiodic and chaotic categories whose formal properties carry physiological connotations. (2) Only relatively elaborate, nonlinear geometric models show all forms; simpler ones, show only alternations and walk-throughs. (3) Bifurcations resemble those of simple maps that can provide useful guidelines. (4) Heterogeneity poses the unanswered question of whether or not the entire cycle and all portions have the same behaviours: therefore, whether trajectories are continuous or have discontinuities and/or singular points.

A discrete map for the dynamics of recurrent excitatory neural networks in the presence of noise

We investigate the effect of the neuron characteristics on the behavior of a recurrent excitatory neural network model. First, we present the different types of dynamics obtained with simulations of a network of coupled excitatory spike-response neuron models placed under the influence of noise. Then, we derive a discrete map describing the dynamics of large fully connected networks. By studying the bifurcation structure of this map, we can determine for which ranges of the neuron model parameters the network will display collective oscillations or other types of dynamics.

Effects of transmission delays and noise in recurrent excitatory neural networks

Random perturbations, referred to as noise, are omnipresent in the nervous system. We investigate how noise modifies the dynamics of the neural networks according to the delay. In this report, we examine the effect of transmission delay on both the dynamics of a single neuron receiving a recurrent excitation and the dynamics of fully interconnected excitatory networks. In the case of the single neuron with a recurrent connection, depending on the value of the delay, the discharge pattern changes from regular to multiplets. More complicated patterns appears when noise is added, and depends on both the delay and the noise intensity, but classification can be described. In certain conditions, noise reduces the synchronization, whereas in others it increases the regularity of the network activity. Finally, the same network codes the input amplitude either using mean activity amplitude coding when short delays exist, and using frequency modulation when long delays exist.

SHARE: a tool to analyze and assess strategies in health care organization management

In health care organizations, management of both human and material resources implies decision making. When seemingly equivalent strategies are possible, simulation can help to make a decision on better grounds. The SHARE workframe was designed to address the specificities of health care and to provide a comprehensive environment for modelling and simulating health care processes. The typology of objects is defined as Actors, subdivided in Clients and Resources and Elementary Operations. Graphical tools allow us to build processes from these objects and to create their relationships. Various strategies based on either clinical or managerial changes may be investigated. After a simulation, graphical tools allow us to display summary information on the utilization of all actors, waiting times, and goodness of execution. The use of SHARE is exemplified with the analysis and simulation of changes in the Pulmonary Function Testing Laboratory of the Saint-Antoine Hospital, Paris.

Effect of delay on the boundary of the basin of attraction in a self-excited single graded-response neuron

Little attention has been paid in the past to the effects of interunit transmission delays (representing axonal and synaptic delays) on the boundary of the basin of attraction of stable equilibrium points in neural networks. As a first step toward a better understanding of the influence of delay, we study the dynamics of a single graded-response neuron with a delayed excitatory self-connection. The behavior of this system is representative of that of a family of networks composed of graded-response neurons in which most trajectories converge to stable equilibrium points for any delay value. It is shown that changing the delay modifies the "location" of the boundary of the basin of attraction of the stable equilibrium points without affecting the stability of the equilibria. The dynamics of trajectories on the boundary are also delay dependent and influence the transient regime of trajectories within the adjacent basins. Our results suggest that when dealing with networks with delay, it is important to study not only the effect of the delay on the asymptotic convergence of the system but also on the boundary of the basins of attraction of the equilibria.

Complex responses of living neurons to pacemaker inhibition: a comparison of dynamical models

A neuron can respond to periodic inhibitory input with a variety of complex behaviors, periodic and aperiodic. We present a succession of models to test hypotheses for mechanisms underlying complex behavior generation. Model comparison using non-linear dynamics techniques indicates that long-duration IPSP aftereffects and spiking behavior are necessary for most of the basic response properties, though not sufficient for some of their more subtle aspects.

XNBC: a simulation tool. Application to the study of neural coding using hybrid networks

XNBC is a software package for simulating biological neural networks. Two neuron models are available, a leaky integrator model and an ion-conductance model. Inputs to the simulated neurons can be provided by experimental data stored in files, allowing the creation of 'hybrid' networks. Graphic tools are used to describe the modeled neurons as well as the network. Neuron and network parameters can be modified during the simulation, to mimic electrical stimulations and drugs action. The temporal evolution of the network and of selected neurons can be visualized. A point process, frequency or dynamic analysis of the simulator output can be performed. The successive stages of the creation of a hybrid network are explained.

Single neuron model with recurrent excitation: response to slow periodic modulation

The influence of a recurrent excitatory connection on the response of three neuron models to slow periodic modulation is analyzed. The models are the graded response model and the threshold model with and without adaptation. Lissajous displays of the system's output (discharge rate) as a function of the instantaneous input value show hysteresis in all three models. Hence, the outputs are different depending on whether the input is increasing or decreasing. Recurrent excitation increases the width of the hysteresis with (i) the frequency of the periodic modulation, (ii) the transmission delay of the recurrent connection, and (iii) the connection strength.

A model for temporal and intensity coding in insect olfaction by a network of inhibitory neurons

Female insects release sex-pheromones which attract their conspecific males. These pheromones are detected through a distinct male-specific olfactory subsystem which resides at the first stage of olfactory processing, and consists of receptor, local and projection (relay) neurons. When male insects were stimulated by female sexpheromones, some projection neurons could distinguish between different pheromones, following input and code stimulus intensity. Presented here, is a simple biophysical model that described characteristic bursting responses observed for projection neurons. The bursting behavior of the model resulted from a particular cellular mechanism and specific network architecture. At the neuron level, a rapidly activating and slowly inactivating low-threshold calcium channel provided depolarizing current for bursting, while at the network level, inhibitory neurons implementing dis-inhibition which triggered this calcium channel. Also, the network architecture provided a mechanism by which certain projection neurons coded temporal input and stimulus intensity.

Periodically modulated inhibition and its postsynaptic consequences--II. Influence of modulation slope, depth, range, noise and of postsynaptic natural discharges

This paper examines the relation, or "synaptic coding", between the discharges of inhibitory fibres whose instantaneous firing rate is modulated periodically and pacemaker postsynaptic neurons using crayfish synapses and point process statistics. Several control parameters were varied individually, and the other maintained constant as far as possible: it extends the preceding publication that described the general features and varied only the modulation frequency [Segundo et al. (1995) Neuroscience 68, 657-692]. Statistics were mainly cycle histograms and Lissajous diagrams (with presynaptic and post-synaptic histograms on the abscissae and ordinate, respectively), complemented occasionally by displays of intervals along time and of interval differences along order ("basic graphs" and "recurrence plots", respectively). The postsynaptic influence of modulated inhibitory discharges is characteristically sensitive to all control parameters examined. (1) The frequency was reported in the companion paper [Segundo et al. (1995) Neuroscience 68, 657-692]. (2) The average slope per half-cycle, controlled via either frequency or depth, acts by way of its magnitude and sign in ways revealed by hysteretic loops. Hysteresis increases and varies as the modulation's steepness increases: it is minor and with a single clockwise loop at small slopes, but major and multi-looped at the larger ones. Slopes, because of their different postsynaptic consequences, were separated into the categories of "steep", "gentle" and "abrupt" if around, respectively, 1.0, 30.0 and 150.0 s-2. The influence of slopes in restricted portions of the cycle depends on their position on the inhibitory rate scale. (3) The modulation's range acts by way of its depth and of its position on the inhibitory rate scale. Deeper ranges, when compared with the shallower ones they contain, induce effects similar to those of shallower modulations with their central portion, plus effects peculiar to them at extreme rates. Changes in range position from the centre to the extremes of the inhibitory rate scale are influential (e.g., saturations appear). Changes within the centre can be highly influential, particularly when ranges are narrow and close to the postsynaptic natural rate, and modulation frequencies are low: relations between corresponding rates can be linear increasing, linear decreasing or piecewise linear. Changes around extreme rates are negligible, however, and saturations are present. (4) The usual modulations whose individual cycles did not differ from the cycle histogram were compared to others with the same cycle histograms but whose individual cycles had an unpredictable fast variability referred to as "noise".(ABSTRACT TRUNCATED AT 400 WORDS)

Periodically modulated inhibition and its postsynaptic consequences--I. General features. Influence of modulation frequency

Our aim was to examine the relation, or "synaptic coding", between spike trains across a synapse with inhibitory postsynaptic potentials when the presynaptic rate is modulated periodically and the postsynaptic cell is a pacemaker. Experiments were on the synapse in crayfish stretch receptor organs. Spike trains were considered point processes along time; the time series of corresponding pre- and postsynaptic intervals were extracted. Analyses used displays of intervals along time and order ("basic graphs", and "rasters", respectively), displays of differences between intervals along order ("recurrence plots"), cycle histograms (as such and as Lissajous diagrams with presynaptic and postsynaptic on the abscissae and ordinate, respectively), and correlation histograms. Cycle histograms and correlation histograms demonstrated that all presynaptic modulation frequencies (1/60-10 Hz) are reflected postsynaptically; novel frequencies may arise, not always relating simply to the pre- or postsynaptic ones. The transferred frequency domain is broad and physiologically meaningful. Indeed, vitally important functions have strong periodicities in all portions of the explored domain, and so do the discharges of participating neurons. Overall, pre- and postsynaptic discharges change oppositely, one accelerating while the other slows. Locally, however, pre- and postsynaptic discharges contrast clearly in other ways. The presynaptic evolution is everywhere smooth and orderly, half-cycles usually are symmetric, and there is a single kind of discharge, as expected because the presynaptic axon follows well the controlling stimuli. The postsynaptic cycle shows marked local distortions. These involve presynaptic domains called "congruent portions" where changes are in the same sense (e.g., joint accelerations), "saturated" domains where postsynaptic discharges are arrested, and asymmetric sensitivities to presynaptic change with hysteretic loops in the Lissajous diagrams; the postsynaptic discharge is heterogeneous showing dissimilar forms in succession. Congruent portions are either "positive segments" with pre- to postsynaptic rate ratios practically 1:1, 2:1, 1:1, or parts of Lissajous loops. Different modulation frequencies have different postsynaptic consequences. Differences involve the width and number of positive segments, the proportion of the cycle with saturation, the sense, magnitude and lead-lag characteristics of the hysteretic loops, etc. Because their consequences are separable, frequencies are classified within categories labelled "low" (under 0.5 Hz), "high" (between 0.5 and 5.0 Hz) and "very high" (over 5.0 Hz). Categories arise widely but each prevails in different biological functions (e.g., low or high in, respectively, respiration or vibratory sensitivity). The refactoriness of the inhibitory fibre affects how it can be modulated: consequently, the very high category resembles pacemaker discharges and was not analysed.(ABSTRACT TRUNCATED AT 250 WORDS)

SITIE: a health care workstation integration architecture for epidemiologists

SITIE is a workstation devoted to epidemiological data selection, analysis, and representation. Epidemiological data are collected using the French Communicable Diseases computer Network and stored in an Oracle database. Disease selection and spatial and temporal representations can be done using a user friendly graphic interface. SITIE automatically generates SQL requests to the Oracle database, extracts the data, processes it according to the user's choice, and represents the data. SITIE is built upon the AVS graphic package and allows the creation of new applications using previously developed modules linked together to form a network. SITIE can be viewed as a tool box for epidemiological data representations. Three example applications are detailed in order to make clear the way a new application can be built using SITIE. The reusability of modules is exemplified by a compound application.

An expert system for the analysis and interpretation of evoked potentials based on fuzzy classification: application to brainstem auditory evoked potentials

EPEXS is an expert system for evoked potential analysis and interpretation (a medical examination performed in clinical neurophysiology laboratories), working from available clinical records and numerical data extracted from evoked potential traces. EPEXS integrates two formalisms of knowledge representation: rules and structured objects. The rules represent the elementary concepts (shallow knowledge) and include a model of possibility based on the Dubois and Prade default reasoning and possibility theory. The structured objects (prototypes) are organized as hierarchical taxonomies (underlying knowledge). These allow the description of both the objects and their relationships. The heuristics used to interpret knowledge are based on two hypotheses: the unicity of the pathological process leading to several given symptoms and the progression from the general to the specific, leading to the adoption or rejection of a class of diagnoses. This avoids the problem of the differential diagnosis. These sources of knowledge are used in a dynamical way that could be described as a four-step process: acquisition of clinical data in order to define the nosological frame of the pathology, production of hypotheses about the nature and topography of lesions, interpretation of data in accordance with these hypotheses, and finally evaluation of their likelihood. The validation shows that EPEXS topographic diagnoses were correct in 100% of cases and 92% of it nosologic diagnoses were correct, and no pathological record was interpreted as normal. When examined on a given pathology basis EPEXS was not significantly different from human experts as regards to performance, specificity, and sensitivity.

Transients in the inhibitory driving of neurons and their postsynaptic consequences

The presynaptic fiber at an inhibitory synapse on a pacemaker neuron was forced to generate transients, defined here as spike trains with a trend, unceasingly accelerating or slowing. Experiments were on isolated crayfish stretch receptor organs. Spike train analyses used tools and notions from conventional point processes and from non-linear dynamics. Pre- and postsynaptic discharges contrasted clearly in terms of rates and interspike intervals. The inhibitory train evolved monotonically and smoothly, following tightly the simple prescribed curves; it was uniform, exhibiting throughout a single and simple discharge form (i.e. interval patterning). The inhibited postsynaptic train alternately accelerated and slowed, not following tightly any simple curve; it was heterogeneous, exhibiting in succession several different and often complex discharge forms, and switching abruptly from one to another. The inhibited trains depended on the inhibitory transient's span, range and average slope. Accordingly, transients separated (not cuttingly) into categories with prolonged spans (over 1 s) and slow slopes (around 1/s2) and those with short spans (under 1 s) and fast slopes (around 30/s2). Special transients elicited postsynaptic discharges that reproduced it faithfully, e.g. accelerated with the transient and proportionately; no transient elicited postsynaptic discharges faithful to its mirror image. Crayfish synapses are prototypes, so these findings should be expected in any other junction, as working hypotheses at least. Implications involve the operation of neural networks, including the role of distortions and their compensation, and the underlying mechanisms. Transients have received little attention, most work on synaptic coding concentrating on stationary discharges. Transients are inherent to the changing situations that pervade everyday life, however, and their biological importance is self-evident. The different discharges encountered during a transient had strong similarities to the stationary forms reported for different pacemaker drivings that are called locking, intermittency, erratic and stammering; they were, in fact, trendy versions of these. Such forms appear with several synaptic drivings in the same order along the presynaptic rate scale; they may constitute basic building blocks for synaptic operation. In terms of non-linear science, it is as if the attractors postulated for stationary drivings remained strongly influential during the transients, though affected by the rate of change.

[Elective cholecystectomy by celioscopy versus subcostal approach cholecystectomy. Comparative study of postoperative pain and discomfort]

The aim of this prospective study was to evaluate postoperative pain and discomfort in 70 patients undergoing cholecystectomy. The choice of surgical approach was left to the surgeon. Accordingly, these patients were then divided in two groups: laparoscopic cholecystectomy (group I; n = 37); classic cholecystectomy (subcostal incision) (group II; n = 33). There was no significant difference between these groups concerning weight/height ratio, size and number of stones. Patients in group II were older (55 +/- 16 years) than those in group I (46 +/- 11 years) (P < 0.01). The mean duration of surgery was shorter in group II (96 +/- 31 min) than in group I (119 +/- 49 min) (P < 0.01). Postoperative discomfort was evaluated by (group I versus group II respectively): a) the mean length of hospital stay after surgery (3.7 +/- 1.5 versus 6.7 +/- 1.1 days, P < 0.02); b) the mean delay to return of intestinal motility (1.5 +/- 0.6 versus 2.0 +/- 0.6 days, P < 0.001); c) the mean perfusion time (1.4 +/- 0.6 versus 2.6 +/- 0.8 days, P < 0.001); d) intensity of postoperative pain which was evaluated daily. There was no significant difference between these two groups concerning the use of analgesics; however, a statistically significant difference was found in the visual and verbal scales, starting on the second postoperative day and in autonomy as early as the first postoperative day.(ABSTRACT TRUNCATED AT 250 WORDS)

Maturation of regenerating nerve assessed by evoked potential in the rat: hyperbolic time course

Recovery of sensory fiber excitability after sciatic nerve lesion induced by freezing was assessed by the somesthesic evoked potential (SEP) in response to plantar pad electrical stimulation. SEP was recorded from the S1 area through chronically implanted cortical electrodes. The P1 wave reappeared on Day 22 or 23 postinjury, indicating that the axonal elongation rate ranged between 3.9 and 4.1 mm/day. P1 onset (P1o) latency decreased from 61.9 +/- 6.4 ms (SD) on Postoperative Day 22 to 18.8 +/- 1.13 ms on Day 50. Computation of standardized residuals showed that the best values for the regression equation as a function of time were obtained after hyperbolic transformation. Covariance analysis showed significant differences between untreated animals and after treatment with thyroxin (T4) and metformin p-chlorophenoxyacetate (MP) or after conditioning lesion (CL). This indicates that these treatments acted selectively on the components of the maturation process.

Respiratory rhythm multistability during sleep-wake states

Respiratory period (RP) changes occurring during sleep-waking states were studied during 5- to 8-h recording sessions in chronic cats. RP distribution was clearly trimodal, the shortest mode occurring essentially during alert wakefulness, the largest mode during slow wave sleep and the intermediate mode during drowsy wakefulness. Immediate shifts were observed at instant awakening, whereas after an EEG arousal lasting a few seconds, the RP could remain short for several minutes. Results suggest that the respiratory pattern generator depends upon several attractors.

Gallamine and vagotomy enhance respiratory modulation of reticular units

Respiration related units ( RRU ) were recorded in the brainstem of cats with spinal transection at the C7-Th 1 level and breathing N2O. The proportion of RRU in several structures was compared in control and in 3 experimental groups: (1) paralyzed with gallamine triethiodide; (2) vagotomized; and (3) both vagotomized and paralyzed. After gallamine, RRU percentage was multiplied by 3 in the bulbo-pontine reticular formation (RF) and as much as 20 in the mesencephalic RF. Vagotomy multiplied RRU proportions by 2 in the bulbo-pontine RF, by 12 in the mesencephalic RF and by 3 in the pneumotaxic complex (nucleus parabrachialis medialis ( NPBM ) and K olliker -Fuse (KF) nucleus). The effects of gallamine and vagotomy were not additive. Gallamine still increased proportion of RRU in the RF after vagotomy showing that the gallamine effect is not vagally mediated; this was in contrast to the previously reported suppression by vagotomy of phrenic discharge facilitation induced by gallamine. The total number of firing units in the RF was not modified by gallamine or vagotomy. It is concluded that the respiratory modulation of reticular neurons is selectively enhanced by gallamine and vagotomy through two independent mechanisms.

Apneusis and apnea after parabrachial or Kölliker-Fuse N. lesion; influence of wakefulness

Comparisons were made between the effects of bilateral lesions of either the nucleus parabrachialis medialis (NPBM) or the Kölliker-Fuse (KF) nuclei in bivagotomized, spinalized and immobilized cats. In a first group animals were electrolytically decerebrated; in a second group animals were locally anaesthetized and atraumatically restrained (semi-chronic encéphale isolé preparation). Lesions resulted in: (1) a marked increase in TI (apneusis); (2) 50--80% decrease in amplitude of the integrated phrenic discharge (IPD); (3) variable lengthening, of TE. Following KF lesion, effects were significantly larger on TE in the decerebrate group, and on TI in the encéphale isolé group. In the encéphale isolé group awakening reduced TE and TI and brought them close to their prelesion values following both NPBM and KF lesion; on the other hand light sleep induced by pentobarbital led to expiratory apnea after KF lesion and reduced IPD amplitude to zero after NPBM lesion. It is proposed that the onset, tonic drive and cut off of the I discharge are normally controlled by three differently weighted influences originating from NPBM, KF and reticular formation respectively.

A statistical analysis and comparison of soma diameter spectra for classical neurones from different regions of the cat retinal ganglion cell layer

Multimodal soma diameter spectra for neurones of the cat retinal ganglion cell layer have been represented by three subpopulations of independent, normal diameter distribution. Recurrent computation according to the technique of Vibert and Caille (1978) has extracted best fit populations for samples from various regions of central and peripheral retina. The model subpopulations from all these regions did not differ significantly in their relative proportions or variance. Significant progressive variation between subpopulations representing different regions of retina were observed only in the mean diameter of the alpha and beta mode cells. The parameters of the gamma mode population were statistically uniform across the retina. The cat retina thus appears to be more homogeneously organized than has been suggested elsewhere.