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The causes of extremely elevated IgA, whether isolated or associated with an increase in other classes of immunoglobulin, are poorly defined in paediatrics. We reviewed the diagnostic significance of very high IgA levels (greater than 3 SD above the mean for age) in a cohort of patients referred to a tertiary care children's hospital. Hyper-IgA was found in 91 of 6364 subjects (1.4%) and in 68 cases was not associated with an increased IgG and/or IgM level. Most subjects with hyper-IgA (73.5%) had a severe immune defect, a chronic rheumatic disease or inflammatory bowel disease, while these conditions were very rare in a control group with normal IgA values (8%). Although our results may in part reflect the experience of a tertiary care centre, we suggest that hyper-IgA in children should always arouse suspicion of a serious disease., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

The aim of this paper is to suggest an original approach to the decision-making process in a computer-oriented medical record, now in use on an experimental basis, at a major District Hospital in Sesto S. Giovanni, near Milano, in a general medicine department. Two types of algorithms are introduced in order to 'capture' more effectively the different steps of the decisional process on the basis of a differential diagnosis approach. The first refers to the field of symbolic reasoning, close to the area of Artificial Intelligence and uses score variables, while the other can handle qualitative expressions since it follows the fuzzy-set approach. A comparison among the performances offered by such algorithms, the physician's decision and the Bayes Rule is then carried on. Further developments should clarify the problems of parameter sensitivity as regards the successive steps to the final diagnosis. The present implementation is suitable for individual hospital departments and educational purposes.