Effects of transglutaminase on sorption, mechanical and moisture-related properties of gelatin films

Biodegradable and edible protein films have received considerable research interest due to the increase in environment protection consciousness. However, protein films always have poor mechanical properties and water-resistant ability compared with synthetic films. Thus, the effects of transglutaminase on sorption characteristics including adsorption kinetics and sorption isotherm, mechanical properties, moisture content, total soluble matter and surface hydrophobicity (S0) of gelatin films were analyzed in this article. Relative humidity and plasticizer content significantly affected the moisture equilibration time. The lower the relative humidity and plasticizer content, the shorter the moisture equilibration time. Transglutaminase treatment significantly decreased moisture adsorption rate and balance moisture content of gelatin films. The sorption isotherm data were mathematically fitted to the GAB model. Transglutaminase treatment increased the tensile strength value and the mean contact angle by 8.4–25.6% and 2.1–2.3°, respectively; while decreasing the moisture content value by 2.6–9%. These results show that transglutaminase treatment could be an effective and practical method to modify moisture sorption characteristics, moisture content and surface hydrophobicity of gelatin films, which suggests that the water-barrier ability of gelatin films can be improved by transglutaminase treatment.

Medical costs and vasculometabolic comorbidities among patients with bipolar disorder in Taiwan - a population-based and matched-control study

BACKGROUND

Bipolar disorder (BD) is a costly disease with a high rate of vasculometabolic comorbidities. The aims of this study were to explore the 1-year treatment cost, including total medical and non-psychiatric services, and the prevalence of vasculometabolic comorbidities in individuals with BD.

METHODS

A nationwide population-based dataset, covering the years 2006 and 2007, was obtained from the Taiwan National Health Insurance claims database. The study sample comprised patients discharged from hospitals between 1 January 2006 and 31 December 2007. Annual non-psychiatric and total medical costs and vasculometabolic comorbidities were examined. Generalized linear models were used to examine the medical costs, and conditional logistic regression analyses were carried out to test the prevalence of vasculometabolic comorbidities in people with BD and to compare this with that found in matched controls.

RESULTS

The total medical cost was 11-fold higher (New Taiwan [NT] $227,040 vs. NT$20,461), and the non-psychiatric medical cost was 1.7-fold higher (NT$33,173 vs. NT$19,406) with regard to the individuals with BD vs. the matched controls. The prevalence of vasculometabolic comorbidities was significantly higher in the individuals with BD than in the controls (ratio ranging from 1.86 to 4.06).

CONCLUSIONS

Both the non-psychiatric healthcare utilization and the prevalence of vasculometabolic comorbidities are higher with regard to individuals with BD vs. their matched controls. Therefore, treatment of BD should integrate medical and psychiatric care to decrease the impact of medical comorbidities, which may also decrease the overall medical cost.

Cluster headache is associated with an increased risk of depression: A nationwide population-based cohort study

Objective

To investigate whether cluster headache (CH) was a risk factor for depression in a nationwide population-based follow-up study.

Background

There are few studies about the relationship between CH and depression, and prior research has been limited by cross-sectional studies or small sample sizes.

Methods

We identified 673 CH patients from the Taiwan National Health Insurance database between 2005 and 2009. The two comparison cohorts included age-, sex- and Charlson’s score-matched migraine patients ( n = 2692) and controls (patients free from migraine or CH, n = 2692). The cumulative incidence of depression was compared among these three cohorts until the end of 2009. We also calculated predictors of depression in the CH cohort.

Results

After the median 2.5-year follow-up duration, the CH cohort had a greater risk for developing depression compared to the control cohort (adjusted hazard ratio; aHR = 5.6, 95% CI 3.0–10.6, p < 0.001) but not the migraine cohort (aHR = 1.1, 95% CI 0.7–1.7, p = 0.77). Of the CH patients, the number of cluster bout periods per year was a risk factor for depression (aHR = 3.8, 95% CI 2.6–5.4, p < 0.001).

Conclusion

Our results showed that CH is associated with an increased risk for depression. The strength of this association is similar to that of migraine.

Cost-effectiveness analysis of the bivalent compared with the quadrivalent human papillomavirus vaccines in Taiwan

OBJECTIVE

To compare the epidemiological and economic impact of additional cross-protection against oncogenic human papillomavirus (HPV) types beyond 16/18 of the bivalent vaccine (BV) versus protection against nononcogenic HPV types 6/11 of the quadrivalent vaccine (QV) in Taiwan.

METHODS

A lifetime Markov model calibrated to the Taiwanese setting simulated the natural history of low-risk (engendering cervical intraepithelial neoplasia [CIN] 1 and genital warts) and high-risk HPV (engendering CIN1, CIN2/3, and cervical cancer [CC]) infections, screening, and vaccination (100% coverage) for a cohort of 12-year-old girls (N = 153,000). Transition probabilities, costs, and utilities were estimated from published data and expert opinion. Vaccine efficacy was obtained from each vaccine's respective clinical trials. Price-parity and lifelong protection was assumed for both vaccines. The number of CIN lesions, CC cases, CC deaths and genital wart (GW) cases, and quality-adjusted life-years were estimated. Costs and outcomes (discounted at 3% and 1.5%, respectively) were compared from a payer's perspective.

RESULTS

The model estimated that the BV led to an additional, undiscounted, 11,484 CIN1, 1,779 (+34.3% vs. QV) CIN2/3, 188 (+29.0% vs. QV) CC, and 69 (+29.0% vs. QV) CC deaths prevented compared with the QV, while the QV prevented 4,150 GW (+71%). This resulted in an additional 768 quality-adjusted life-years (QALY) and 11.6 million new Taiwan dollars costs saved for the BV versus the QV after discounting.

CONCLUSION

Both vaccines have a different epidemiological impact with an increased number of CC-related lesions potentially prevented for the BV because of additional cross-protection. In the Taiwanese setting, HPV mass vaccination using the BV was estimated to dominate vaccination using the QV.

A cost-consequence analysis of long-acting injectable risperidone in schizophrenia: a one-year mirror-image study with national claim-based database in Taiwan

OBJECTIVE

The development of long-acting atypical antipsychotics has provided a new paradigm for schizophrenia treatment. The economic effectiveness of risperidone long-acting injection (RLAI) on service costs has, however, never been studied in the real world with national claim-based database.

METHOD

To assess the change of service utilization and costs for schizophrenia before and after RLAI treatment, we conducted this 1-year mirror-image study with Taiwanese national claimed-data. Comparison was made for service sectors (the number of visits, acute admissions and relapse events) and cost components (outpatient, inpatient, emergency, medication and non-medication costs).

RESULTS

Service uses reduced in the post-RLAI period, along with a reduction of 34% and 32% on total inpatient services costs and inpatient non-medication costs, respectively (p < 0.005). However, overall psychiatric service costs went up by 26%, with an increase of 190% on total outpatient service costs and 177% on overall medication costs (p < 0.0001).

CONCLUSIONS

This 1-year mirror-image analysis showed that RLAI treatment was associated with reductions of service uses; however, overall psychiatric service costs were compromised by costs incurred from increased utilization of outpatient service and RLAI medication costs under the context of healthcare in Taiwan.

Nephrotoxicity of vancomycin in patients with methicillin-resistant Staphylococcus aureus bacteraemia

AIM

Vancomycin and teicoplanin are the two most used glycopeptides for the treatment of methicillin-resistant Staphylococcus aureus (MRSA). Vancomycin is suspected to have more nephrotoxicity but this has not been clearly established. The aim of this study was to assess its nephrotoxicity by a consensus definition of acute kidney injury (AKI): the risk (R), injury (I), failure (F), loss and end-stage renal disease (RIFLE) classification.

METHODS

Patients with MRSA bacteraemia who were prescribed either vancomycin or teicoplanin between 2003 and 2008 were classified. Patients who developed AKI were classified by RIFLE criteria. Variables such as comorbidities, laboratory data and medical cost information were also obtained from the database. Outcomes determined were: (i) the rate of nephrotoxicity and mortality; and (ii) the association of nephrotoxicity with the length of hospital stay and costs.

RESULTS

The study included 190 patients (vancomycin 33, teicoplanin 157). Fifteen patients on vancomycin and 27 patients on teicoplanin developed AKI (P = 0.0004). In the vancomycin group, four, eight and three patients were classified to RIFLE criteria R, I and F, respectively. In the teicoplanin group, 17, nine and one patient were classified to RIFLE criteria R, I and F, respectively. Kaplan-Meier analysis showed significant difference in time to nephrotoxicity for the vancomycin group compared to the teicoplanin group. No significant differences were found between the groups in terms of total mortality, length of hospital stay and costs.

CONCLUSION

The study data suggest that vancomycin is associated with a higher likelihood of nephrotoxicity using the RIFLE classification.

Epidemiology and comorbidities of psoriasis patients in a national database in Taiwan

BACKGROUND

Recent findings in psoriasis research have shown that psoriasis is frequently associated with systemic comorbidities.

OBJECTIVES

This study aims to describe the epidemiology of psoriasis and the prevalence of comorbidities in patients with psoriasis in Taiwan.

METHODS

Patients who had at least one outpatient visit or admission with ICD-9-CM diagnosis code 696.0-1 in the Taiwan National Health Insurance (NHI) claims database during 2006 were identified as psoriasis cases. The cases were further classified into moderate to severe psoriasis (sPsO) for those who had previously received systemic therapy during the study period and mild psoriasis (mPsO) for those who had not. The cases were matched in a 1:4 ratio with controls from a sample cohort of 997,771 enrolees representative of the Taiwan population. Matching variables included age, gender and residential area. Prevalence of comorbidities was assessed using prevalence relative risk (RR) based upon a Cox proportional regression model.

RESULTS

51,800 psoriasis cases were identified (prevalence=0.235%; mean age=46.4±18.6; male:female=1.6:1) and 17.5% of cases were sPsO type. Psoriasis was associated with a significantly increased prevalence ratio (RR; [95% confidence interval]) for hypertension (1.51; [1.47, 1.56]), diabetes (1.64; [1.58, 1.70]), hyperglyceridaemia (1.61; [1.54, 1.68]), heart disease (1.32; [1.26, 1.37]), hepatitis B viral infection (1.73; [1.47, 2.04]), hepatitis C viral infection (2.02; [1.67, 2.44]), rheumatoid arthritis (3.02; [2.68, 3.41]), systemic lupus erythematosus (6.16; [4.70, 8.09]), vitiligo (5.94; [3.79, 9.31]), pemphigoid (14.75; [5.00, 43.50]), pemphigus (41.81; [12.41, 140.90]), alopecia areata (4.71; [2.98, 7.45]), lip, oral cavity and pharynx cancer (1.49; [1.22, 1.80]), digestive organs and peritoneum cancer (1.57; [1.41, 1.74]), depression (1.50; [1.39, 1.61]), fatty liver (2.27; [1.90, 2.71]), chronic airways obstruction (1.47; [1.34, 1.61]), sleep disorder (3.89; [2.26, 6.71]), asthma (1.29; [1.18, 1.40]), and allergic rhinitis (1.25; [1.18, 1.33]). Conversely, psoriasis was not associated with an increased risk of Crohn's disease.

CONCLUSIONS

Psoriasis was associated with a significantly increased risk of comorbidities, especially for those patients with moderate to severe disease. These health associations should be taken into consideration when evaluating the burdens of psoriasis and designing effective treatment plans.

Effect of pre-eclampsia-eclampsia on major cardiovascular events among peripartum women in Taiwan

There is no large-scale population-based study to clarify the association between major adverse cardiovascular events (MACEs) and pre-eclampsia/eclampsia. A population-based Taiwanese cohort study was performed in 1,132,064 parturients from 1999 to 2003 using a dataset linking birth certificates and National Health Insurance hospital discharge data. Sociodemographic factors and obstetric complications were used in multivariate logistic regression models to determine adjusted hazard ratios of pre-eclampsia/eclampsia on risks of MACEs and mortality during pregnancy to at least the third year postpartum. Incidence rates of MACEs and all maternal mortality in women with pre-eclampsia/eclampsia were 16.21 and 40.38 per 100,000 patients per year, respectively. Women with pre-eclampsia/eclampsia had a 13.0-fold higher incidence of myocardial infarction, a 8.3-fold higher incidence of heart failure, a 14.5-fold higher incidence of stroke, a 12.6-fold higher incidence of MACEs, a 7.3-fold higher incidence of MACEs without stroke, a 2.3-fold higher incidence of MACE-related deaths, and a 6.4-fold higher incidence of overall death than women without pre-eclampsia/eclampsia. Kaplan-Meier survival curve discriminated in MACEs, nonstroke MACEs, MACE related death and overall death. In conclusion, women with pre-eclampsia/eclampsia have a significantly higher risk of MACEs, especially myocardial infarction and stroke, during pregnancy and their risk remains significant to ≥36 months postpartum. Our results suggest that women with pre-eclampsia/eclampsia should be closely monitored during pregnancy and for up to ≥3 years postpartum.

One-year post-hospital medical costs and relapse rates of bipolar disorder patients in Taiwan: a population-based study

OBJECTIVES

  We examined a nationwide population-based dataset of patients with bipolar disorder (BD) hospitalized in Taiwan, with our analyses focusing on one-year medical costs and relapse rates.

METHODS

  The data for this study, covering the years 2006 and 2007, were obtained from the Taiwan National Health Insurance (NHI) claims database. The study sample comprised BD patients who were discharged from hospitals between January 1 and December 31, 2006. Annual medical costs and relapse rates were described; the Kaplan-Meier method and the generalized linear models were carried out to examine the risk factors associated with cases of relapse.

RESULTS

  The annual medical costs associated with relapses among the study sample were found to be approximately 7.6 times the average per-capita NHI expenditure in Taiwan in 2006 (US$4,354 versus US$574), with a one-year relapse rate of 55%. Those patients between 20 and 60 years old with a medication possession ratio of <80 and with depressive episodes during the recruitment period were identified as being at risk of relapse.

CONCLUSION

  Bipolar disorder, which is a very costly disease, is associated with both poor medication adherence rates and frequent recurrences. Targeting drug adherence issues during maintenance treatment may well provide a valuable opportunity to reduce the risk of such recurrences.

Risk of death by unnatural causes during early childhood in offspring of parents with mental illness

OBJECTIVE

Limited evidence reveals an elevated mortality risk in offspring of psychiatric patients after infancy. This nationwide population-based study in Taiwan aimed to investigate mortality risk in preschool children up to age 5 whose parents have severe mental illness.

METHOD

Three nationwide population-based data sets were linked. A total of 3,166 children with one or both parents having schizophrenia or an affective disorder were identified, together with a comparison cohort of 25,328 children matched with the study group in terms of maternal age and year of delivery. Cox proportional hazard regressions were performed to compute hazard ratios, with adjustment for sociodemographic characteristics and maternal medical comorbidities.

RESULTS

During the preschool years, 54 (1.7%) deaths were documented among offspring of parents with severe mental illness and 155 (0.6%) in the comparison cohort. Parental mental illness was independently associated with a risk of death nearly 2.4 times higher (95% CI=1.72-3.28) than in the comparison cohort. The association was even more marked for unnatural causes of death, in which the mortality risk was 8.35 times greater (95% CI=4.04-17.24) in children of affected parents than in the comparison cohort. The proportional mortality rates were as high as 20.4% and 11.1% for accident and homicide, respectively, among offspring exposed to parental mental illness.

CONCLUSIONS

An elevated mortality risk, especially from unnatural causes of death, was identified for offspring of parents with severe mental illness during the preschool years in an Asian society. There is an urgent need for multidisciplinary team approaches and risk management strategies to support psychiatric patients who are having difficulty with the transition to parenthood.

Valuation of the economic benefits of human papillomavirus vaccine in Taiwan

OBJECTIVES

The study aims to apply the contingent valuation method to elicit the willingness-to-pay (WTP), and measure the value of a statistic life (VSL), for human papillomavirus (HPV) vaccine in Taiwan.

METHODS

A total of 512 questionnaires were completed on women aged 20 to 55 years with at least one daughter, during March through May 2007. The respondents' WTP for the vaccines was elicited by double-bounded binary-choice questions under two scenarios: one was to protect themselves from cervical cancer (CC) and the other was for their daughter(s). The WTP was modeled as a function of the respondents' knowledge score, attitudes toward CC and HPV vaccine, the vaccination outcome scenarios, and individual characteristics. A log-normal survival model was constructed and the maximum-likelihood method was used for estimation.

RESULTS

The median regression-adjusted WTP was estimated at US$1098 to US$1233 (US$913-1004) for vaccinating the daughter (mother); and the VSL was estimated at approximately US$0.65 to US$4.09 (US$0.56-3.16) million for vaccinating the daughter (mother).

CONCLUSIONS

The study results provided important evidences on the monetary value women placed on a HPV vaccine, and the differential benefits between vaccinating the women and their daughters.

Relapse and long-acting injectable risperidone: a 1-year mirror image study with a national claims database in Taiwan

OBJECTIVES

The development of long-acting, injectable atypical antipsychotics has provided a new paradigm for schizophrenia treatment. The study was designed to assess whether a risperidone long-acting injection (RLAI) is associated with reduced relapses and service utilization in the real world.

METHODS

The Psychiatric Inpatients Medical Claims dataset was used for the analysis. It is a longitudinal dataset that includes the National Health Insurance claims of service uses by a cohort of mentally ill patients. The inclusion criteria for this analysis were patients who: 1) had available information for at least 12 months after the first dose of RLAI; 2) had a primary diagnosis of schizophrenia; and 3) were regularly treated with RLAI for at least 1 year. Patients who accumulatively received at least 75-mg RLAI per 3-month period were considered to be undergoing regular treatment. Wilcoxon signed rank tests were performed to compare differences in numbers of acute admissions, hospital days, emergency room visits, and relapses between the pre- and post-RLAI periods in this 1-year mirror-image study.

RESULTS

In total, 108 patients were eligible for analysis. Significant reductions in the total annual numbers of acute hospital admissions by 55% (80 vs. 36, P = 0.0003), hospital days by 48% (4106 vs. 2126, P = 0.0021), and relapses by 54% (115 vs. 53, P = 0.0005) were observed. A reduction of emergency room visits was also observed, but did not reach statistical significance (55 vs. 25, P = 0.1255).

CONCLUSIONS

This 1-year mirror-image analysis with claims-based data demonstrated that RLAI treatment was associated with reductions in relapses and hospital service utilization.

Association between paternal schizophrenia and low birthweight: a nationwide population-based study

Using a nationwide population-based dataset, the aim of the present study was to investigate the association between paternal schizophrenia and the risk of low birthweight (LBW). This study linked the 2001 Taiwan National Health Insurance Research Dataset with Taiwan's birth and death certificate registries. In total, 220 465 singleton live births were included. The key dependent variable was whether or not an infant's father was diagnosed with schizophrenia, while the independent variable of interest was whether an infant had LBW. Multivariate logistic regression analysis was performed to explore the relationship between paternal schizophrenia and the risk of LBW, after adjusting for the infant and parents' characteristics. The results show that infants whose fathers had schizophrenia were more likely to have LBW than those whose fathers did not (12.6% vs 8.0%). Infants whose fathers had schizophrenia were found to be 1.58 (95% confidence interval = 1.10-2.52, P < .05) times more likely to have LBW than their counterparts whose fathers did not have schizophrenia, following adjustment for gestational week at birth, parity, paternal age and highest educational level, family monthly incomes, and marital status. We conclude that the offspring whose fathers had a diagnosis of schizophrenia had increased risk of LBW compared with those whose fathers had no schizophrenia. This finding paves the way for further studies and suggests that there may be potential benefit to early intervention to prevent LBW in pregnant women with husbands with schizophrenia.

Preeclampsia-eclampsia and the risk of stroke among peripartum in Taiwan

BACKGROUND AND PURPOSE

The occurrence of preeclampsia-eclampsia during pregnancy has been reported to increase the risk of stroke in mainly Western populations. However, few studies have evaluated stroke risk in Asian populations and followed women beyond the early postpartum period. Thus, the present study determined the risk of stroke in women in Taiwan during pregnancy and the first postpartum year.

METHODS

A population-based cohort study was performed on 1,132,019 parturients during 1999 to 2003 using a dataset linking birth certificates and National Health Insurance hospital discharge data. Stroke-free survival rates were estimated using the Kaplan-Meier method, and the log-rank test was used to examine the effect of preelampsia-eclampsia on the prevalence of stroke. Sociodemographic factors and obstetric complications were used in multivariate logistic regression models to determine the adjusted odds ratios of preeclampsia-eclampsia on the risk of hemorrhagic and ischemic stroke during pregnancy and within the first postpartum year.

RESULTS

The incidence of stroke was 21.47 cases per 100,000 deliveries. There were 139 cases of hemorrhagic stroke and 107 cases of ischemic stroke. The respective adjusted relative risk of preeclampsia-eclampsia for hemorrhagic and ischemic stroke were 10.68 (95% CI, 3.40 to 33.59) and 40.86 (95% CI, 12.14 to 137.47) within 3 months antepartum; 6.45 (95% CI, 1.42 to 29.29) and 34.71 (95% CI, 11.08 to 108.68) in the first 3 days postpartum; 5.61 (95% CI, 0.71 to 44.10) and 11.23 (95% CI, 2.45 to 51.59) from 3 days to 6 weeks postpartum; 11.76 (95% CI, 4.05 to 34.11) and 11.60 (95% CI, 3.30 to 40.82) from 6 weeks to 6 months pospartum; and 19.90 (95% CI, 7.75 to 51.11) and 4.35 (95% CI, 0.58 to 32.92) from 6 months to 12 months postpartum.

CONCLUSIONS

Women with preeclampsia-eclampsia have a significantly higher risk of stroke during pregnancy and in the first postpartum year. These results suggest that women with preeclampsia-eclampsia should be closely monitored even after pregnancy.

Reconstruction of the Thumb by Free Skin Flap of the Big Toe

Experience with 12 cases of thumb reconstruction is reported, utilizing a free skin flap from the big toe and remodelled iliac bone graft, to create metacarpal and phalangeal configuration. Results show that the reconstructed thumbs have good functional recovery, cosmetic appearance, and varying degrees of sensation. The procedure preserves the big toe of the donor foot and produces minimal impairment.

The effect of environmental salinity on the protein expression of Na+/K+-ATPase, Na+/K+/2Cl- cotransporter, cystic fibrosis transmembrane conductance regulator, anion exchanger 1, and chloride channel 3 in gills of a euryhaline teleost, Tetraodon nigroviridis

Chloride transport mechanisms in the gills of the estuarine spotted green pufferfish (Tetraodon nigroviridis) were investigated. Protein abundance of Na(+)/K(+)-ATPase (NKA) and the other four chloride transporters, i.e., Na(+)/K(+)/2Cl(-) cotransporter (NKCC), cystic fibrosis transmembrane conductance regulator (CFTR), Cl(-)/HCO(3)(-) anion exchanger 1 (AE1), and chloride channel 3 (CLC-3) in gills of the seawater- (SW; 35 per thousand) or freshwater (FW)-acclimatized fish were examined by immunoblot analysis. Appropriate negative controls were used to confirm the specificity of the antibodies to the target proteins. The relative protein abundance of NKA was higher (i.e., 2-fold) in gills of the SW group compared to the FW group. NKCC and CFTR were expressed in gills of the SW group but not in the FW group. In contrast, the levels of relative protein abundance of branchial AE1 and CLC-3 in the FW group were 23-fold and 2.7-fold higher, respectively, compared to those of the SW group. This study is first of its kind to provide direct in vivo evidence of the protein expression of CLC-3 in teleostean gills, as well as to examine the simultaneous protein expression of the Cl(-) transporters, especially AE1 and CLC-3 of FW- and SW-acclimatized teleosts. The differential protein expression of NKA, chloride transporters in gills of the FW- and SW-acclimatized T. nigroviridis observed in the present study shows their close relationship to the physiological homeostasis (stable blood osmolality), as well as explains the impressive ionoregulatory ability of this euryhaline species in response to salinity challenges.

The novel correlation of carbonic anhydrase II and anion exchanger 1 in gills of the spotted green pufferfish,Tetraodon nigrovirids

A novel relationship between branchial carbonic anhydrase II (CAII) and anion exchanger 1 (AE1) was investigated in the euryhaline spotted green pufferfish (Tetraodon nigroviridis). The immunoblots revealed that AE1 was only detected in the membrane fraction of gills while CAII can be probed both in the membrane and cytosol fractions of gills. CAII protein abundance in the membrane fraction is salinity dependent. Immunological detection of the membrane fraction CAII protein in gills showed 3.9-fold higher in the hyposmotic (freshwater) group than the hyperosmotic (seawater;35 per thousand) group. In contrast, there was no change in the protein level of cytosolic CAII between seawater and freshwater groups. The whole-mount immunocytochemical staining demonstrated that both AE1 and CAII were colocalized to the Na(+)/K(+)-ATPase-immunoreactive cells in gill epithelium of the pufferfish. The interaction between CAII and AE1 was further identified by co-immunoprecipitation because AE1 was detected in the immunoprecipitates of CAII and vice versa. Our results showed that in pufferfish gills CAII was not only expressed in the cytosol to produce the substrate for AE1 transport during Cl(-) influx but also associated with the plasma membrane via AE1. Obviously, it is essential for the physiological function of AE1 to interact with CAII in the membrane of gill Na(+)/K(+)-ATPase-immunoreactive cells. To our knowledge, this is the first study to demonstrate the interaction of branchial CAII and AE1 in fish. The novel correlation proposed a new model of Cl(-)/HCO(3) (-) transport in gills of the teleosts.

Willingness to pay for drug abuse treatment: results from a contingent valuation study in Taiwan

OBJECTIVE

In this study, we attempted to describe and justify the use of a contingent valuation (CV) method to elicit the willingness to pay (WTP) for a drug abuse treatment program by the general public in Taiwan.

METHOD

In total, 1817 CV survey questionnaires were conducted through telephone interviews from randomly dialed numbers. Subjects were members of the general public aged between 20 and 65 years, with full-time jobs, and residing in the three major Taiwanese cities of Taipei, Taichung, and Kaohsiung. Respondents' WTP for drug treatment programs was elicited for two different financing mechanisms: payment through 'compulsory' payroll tax/health insurance premiums, and through 'voluntary' donations. The WTP was modeled as a function of scenarios and policies of the treatment program, respondents' socio-demographic information, and their responses to knowledge and attitudes questions.

RESULTS

The general public in Taiwan was estimated to be willing to pay between NT$81.00 and NT$95.00 per month for a drug abuse treatment program, while the benefits of drug abuse treatment were estimated to range between NT$12.8 billion and NT$15.0 billion in 2004 (US$1=NT$31.9 in 2004), which was equal to around 0.15% of Taiwan's GDP for that year. The general public in Taiwan was more willing to pay for drug abuse treatment via increases in NHI premiums than via donations. Preferences for the drug abuse treatment program were also found to be sensitive to the target treated population as well as the sequence in which the WTP questions were asked.

CONCLUSIONS

Results of this study provide policymakers with important evidence on the monetary value of a substance abuse treatment program, allocation of healthcare resources, and a possible financing mechanism of the treatment program, which may be justified by knowledge of the WTP of the general public. This study has also advanced the knowledge of the methodological issues with regard to CV questionnaire design, and it provides a base case for further studies on drug abuse in Taiwan.

Risk-adjusted cesarean section rates for the assessment of physician performance in Taiwan: a population-based study

Background

Over the past decade, about one-third of all births nationwide in Taiwan were delivered by cesarean section (CS). Previous studies in the US and Europe have documented the need for risk adjustment for fairer comparisons among providers. In this study, we set out to determine the impact that adjustment for patient-specific risk factors has on CS among different physicians in Taiwan.

Methods

There were 172,511 live births which occurred in either hospitals or obstetrics/gynecology clinics between 1 January and 31 December 2003, and for whom birth certificate data could be linked with National Health Insurance (NHI) claims data, available as the sample for this study. Physicians were divided into four equivalent groups based upon the quartile distribution of their crude (actual) CS rates. Stepwise logistic regressions were conducted to develop a predictive model and to determine the expected (risk-adjusted) CS rate and 95% confidence interval (CI) for each physician. The actual rates were then compared with the expected CS rates to see the proportion of physicians whose actual rates were below, within, or above the predicted CI in each quartile.

Results

The proportion of physicians whose CS rates were above the predicted CI increased as the quartile moved to the higher level. However, more than half of the physicians whose actual rates were higher than the predicted CI were not in the highest quartile. Conversely, there were some physicians (40 of 258 physicians) in the highest quartile who were actually providing obstetric care that was appropriate to the risk. When a stricter standard was applied to the assessment of physician performance by excluding physicians in quartile 4 for predicting CS rates, as many as 60% of physicians were found to have higher CS rates than the predicted CI, and indeed, the CS rates of no physicians in either quartile 3 or quartile 4 were below the predicted CI.

Conclusion

Overall, our study found that the comparison of unadjusted CS rates might not provide a valid reflection of the quality of obstetric care delivered by physicians, and may ultimately lead to biased judgments by purchasers. Our study has also shown that when we changed the standard of quality assessment, the evaluation results also changed.

Risk adjustment for inter-hospital comparisons of caesarean section rates in Taipei municipal hospitals

BACKGROUND

This study sets out to determine whether adjustments for specific patient caesarean delivery risk factors have an affect on the assessment of performance rates among the municipal hospitals of Taipei City.

METHODS

Analysis of National Health Insurance (NHI) claims data, linked with birth certificate data, was undertaken on a cohort of 27,693 live births in the six general hospitals of the Taipei Medical Hospital System (TMHS) between 1999 and 2001. Using multivariable logistic regression modeling of the risk factors independently associated with caesarean deliveries, an expected caesarean delivery rate was constructed for each of the hospitals. By contrasting observed rates with expected rates to quantify the magnitude of the deviation from average practice, a measurement similar to relative risk (RR) was also constructed for each hospital.

RESULTS

The observed rates for two of the six hospitals examined fell within the expected 95% confidence interval (CI), two were above the expected upper limit, and two were below the expected lower limit. The RR ranking of Hospitals A (RR=1.08, CI=1.01-1.15) and C (RR=1.01, CI=1.00-1.03) improved from first to second, and third to fourth, whilst the RR of Hospitals B (RR=1.09, CI=1.05-1.14) and D (RR=1.02, CI=0.99-1.06) worsened from second to first, and fourth to third, respectively. The RR rankings of Hospitals E (RR=0.92, CI=0.88-0.96) and F (RR=0.80, CI=0.77-0.84) were the same as the observed rates.

CONCLUSIONS

Caesarean delivery rate profiles, or hospital comparisons without risk adjustment, may be methodologically biased and may lead to unfair judgments by healthcare purchasers.

Delayed parenthood and the risk of cesarean delivery--is paternal age an independent risk factor?

BACKGROUND

Between 1995 and 2001, the average cesarean section rates in Taiwan were as high as 33.34 percent. This study set out to determine the independent effects of paternal age on the likelihood of cesarean delivery among a sample of Taiwanese women.

METHODS

Logistic regressions were used to analyze 310,574 singleton deliveries by nulliparous women in Taiwan between 1999 and 2001, linking data abstracted from birth certificates and from the National Health Insurance claims database. After controlling for socioeconomic, pregnancy, and obstetric complications, as well as institutional factors, we investigated both maternal and paternal ages simultaneously, using the single category variable "parental age" to determine the differential age effects on the risk of cesarean delivery.

RESULTS

Taking 20- to 29-year-old couples as the reference group, we observed that the relative risks of cesarean delivery become progressively higher with advancing age of the mother. At the same time, within each maternal group, positive and significant variations in cesarean rates occurred for different paternal age groups. The respective increases in the relative risks of cesarean delivery for men aged 20-29, 30-34, 35-39, and 40 years or more, in conjunction with women aged 20-29, 30-34 and 35 or over, are 34 percent from 1.00 to 1.34, 18 percent from 1.51 to 1.69, and 16 percent from 2.03 to 2.19. Other confounding variables are also taken into account.

CONCLUSIONS

Irrespective of maternal age, advancing paternal age also appears to be an additional independent factor that has a strong association with the increase in cesarean section rates.

Association Between Surgeon and Hospital Volume in Coronary Artery Bypass Graft Surgery Outcomes: A Population-Based Study

BACKGROUND

We have found no study conducted outside of the United States on the association between physician volume and patient outcomes after coronary artery bypass graft surgery. The aim of this study is to examine the association between surgeon-hospital coronary artery bypass graft volume and patient outcomes using three-year population-based data on Taiwan.

METHODS

This study uses the Taiwan National Health Insurance Research Database covering the period 2000 to 2002, with the study sample comprising 9,895 first-time coronary artery bypass graft admissions, treated by 316 surgeons in 46 hospitals.

RESULTS

Of the sampled patients, 356 (3.6%) were discharged after death. Those patients treated by low-volume (1-50 cases) surgeons had significantly higher mortality rates than those treated by medium-volume (51-100 cases) surgeons (7.0% vs 3.8%), high-volume (101-150 cases) surgeons (7.0% vs 2.7%), or very-high-volume (> or = 151 cases) surgeons (7.0% vs 3.2%). However, hospital coronary artery bypass graft volume alone is an insufficient predictor of hospital in-patient deaths (p = 0.078). The adjusted odds ratio of hospital in-patient deaths declined with increasing surgeon volume, with the odds of in-patient death for those patients treated by low-volume surgeons being 1.52 times those of medium-volume surgeons, 1.89 times those of high-volume surgeons, and 2.04 times those of very-high-volume surgeons.

CONCLUSIONS

We conclude that for all coronary artery bypass graft surgeries taking place in Taiwan, the skill and experience of individual surgeons is a more critical factor for patient outcome than either hospital equipment or surgical teams.

Factors contributing to patient dumping in Taiwan

OBJECTIVE

Little research has been carried out to explore the issues surrounding patient dumping outside of the US. This study, therefore, uses a national research survey to examine the factors contributing to patient dumping within Taiwan.

METHODS

A self-administered postal survey was undertaken to assess the prevalence of patient dumping in Taiwan, with the study subjects being superintendents of general hospitals. Data from the Bureau of Medical Affairs at the Department of Health in Taiwan were used in conjunction with the Taiwan National Health Insurance Research Database (NHIRD) to obtain estimates of factors potentially contributing to patient dumping. A multiple logistic regression analysis was performed to determine the relationships between the perceived extent of patient dumping occurring within the respondents' healthcare networks, as well as other factors, including the total number of hospitals, total number of hospital beds, the percentages of beds in public, for-profit and teaching hospitals (vis-à-vis all hospital beds), discharges, discharges covered under the case payment system, transferred inpatients, and the perceived degree of competition within each healthcare market.

RESULTS

A total of 485 survey questionnaires were distributed, of which 251 were returned, giving a response rate of 51.75%. The responses from 29.9% of the sample group indicated that the perceived extent of patient dumping occurring in their service area was 'serious' or 'very serious'. The regression analysis showed that after controlling for other factors, the superintendents' perceived extent of the patient dumping occurring within their healthcare networks was positively related to the total number of patients covered under the case payment system, the total number of discharged patients, the extent of healthcare market competition and the number of respondent's hospital beds.

CONCLUSIONS

We conclude from our findings that, under the National Health Insurance system, patient dumping is a widespread problem within Taiwan's healthcare industry.

A survey of food hygiene knowledge and attitudes among Chinese food handlers in Fong Song Tong district

The purpose of this study was to find out the knowledge and attitudes concerning food hygiene among Chinese food handlers in Fong Song Tong district, and to analyze the impact of variables on the degree of knowledge and attitudes. Face-to-face interviews were conducted within Chinese food handlers in Fong Song Tong district using a self-designed questionnaire, which contained food hygiene knowledge and attitudes. Main knowledge outcome measures included food handling, personal hygiene and legislation issues. Questionnaires were completed by 580 (72.0%) Chinese food handlers from 91% premises of the district. 71.2% Chinese food handlers could respond correctly to eight or more out of 11 knowledge questions and 1.4% respondents only achieved full scores of knowledge. Fully correct response of personal hygiene knowledge was statistically and significantly higher than food handling knowledge (p<0.05). 79.0% of respondents showed their need of more food hygiene education. Male respondents, age less than 30, secondary education or above, five years or more of working experience, or who had previously attended a health training within the last two years, generally performed better on the knowledge of food hygiene. Chinese food handlers working in the kitchen and owners' beliefs on 'cleaning the kitchen before getting off duty' was reasonable. Those with secondary education at least, or who had prior participation in a health training within the last two years would need more food hygiene knowledge than the people aged over 30 or who were the owners. It would be more motivated by changing the traditional training model, community-based education in an optimum situation, additional authoritative information, attitudes and intentions of learning on food hygiene.

Association between maternal age and the likelihood of a cesarean section: a population-based multivariate logistic regression analysis

BACKGROUND

A majority of studies examining the relationship between advancing maternal age and the likelihood of cesarean section (CS) use data from regional samples or from a limited number of medical institutions. This study uses population-based data from Taiwan to explore the relationship between maternal age and the likelihood of a CS.

METHODS

The National Health Insurance Research Database (NHIRD) on registries of medical facilities and board-certified physicians and monthly claim summaries for inpatients were used. In total, 502 524 singleton deliveries were included in the study. Multivariate logistic regressions were performed with the presence of CS as the dependent variable and maternal age (<20, 20-29, 30-34 and >34 years) as the independent variable. The study controlled for maternal indications, institution characteristics, maternal requests and attending physician characteristics.

RESULTS

CS rates for the age groups <20, 20-29, 30-34 and >34 years were 17.7, 27.4, 37.4 and 47.5%, respectively. The regression analyses consistently showed that the likelihood of a CS significantly increased with advancing maternal age within each category of complication after adjusting for medical institution characteristics and characteristics of the attending physician.

CONCLUSIONS

This study found that, after adjusting for maternal indications, and healthcare institution and physician characteristics, there was a significant relationship between advancing maternal age and an increased likelihood of a CS. This finding, together with the high CS rate of 32.1% in Taiwan, one of the highest reported in the world today, highlights an imperative need to devise interventions to reduce the frequency of CSs.

Using a population-based database to explore the inter-specialty differences in physician practice incomes in Taiwan

Gaining an understanding of the distribution of physician incomes between different medical specialties could assist policymakers to predict the future medical manpower supply. The purpose of this study is to examine the differences in medical specialty-specific gross practice incomes between office-based physicians in Taiwan. The primary data source for the study, which includes 7444 office-based physicians, was provided by the Taiwan Department of Health, with the dependent variable of interest to this study being the annual gross income of physician practices, whilst the independent variable is physician specialty. The study controlled for physicians' age, gender, specialty-board status, type of practice, location of clinic and urbanization level of the community in which the practice was located. Multivariate regression analyses were carried out to explore the relationship between physician specialty and gross practice income. This study finds a significant relationship between the annual gross income of physician practices and the physician's medical specialty (P < 0.001). Of all physicians, those specializing in rehabilitation and orthopedics had the highest gross practice incomes; conversely, obstetricians and gynecologists had the lowest gross practice incomes. The regression analyses demonstrated that after adjusting for socio-demographic and professional characteristics, gross practice incomes of physicians were significantly related to their medical specialty. This study concludes that differences in the gross practice incomes of physicians were significantly related to medical specialties. Those physicians specializing in procedure-based specialties, such as rehabilitation and orthopedics, had higher practice incomes than their counterparts in other more diagnosis-oriented specialties such as family practice and pediatrics.

Costs per discharge and hospital ownership under prospective payment and cost-based reimbursement systems in Taiwan

This study in Taiwan examined the relationships between health care costs and hospital ownership under two financing systems with diametrically opposite incentives, case-payment (a form of prospective payment) and cost-based reimbursement. The universal sample of patients treated in 2000, for three standard care groups under each payment method, was included. The case payment diagnoses were uncomplicated cases of caesarean section, femoral/inguinal hernia operation and thyroidectomy, and the cost-based reimbursement diagnoses were uncomplicated cases of benign breast neoplasm, pneumococcal pneumonia and traumatic finger amputation. Costs per discharge were significantly lower in for-profit hospitals (by 2.8 to 5.7%) compared with public and not-for-profit hospitals for case payment diagnoses, which is consistent with the literature on US hospitals. For the cost-based reimbursement diagnoses, for-profits had 11.5 to 21.8% higher costs per discharge. The opposite direction of associations under the two payment systems validates the assumptions of the property rights theory in Taiwan's health care sector. Three plausible explanations for the study findings are suggested: (1). greater productive efficiency in private hospitals under case payment, (2). cost shifting from case payment diagnoses to cost-reimbursed diagnoses, and (3). patient dumping. Longitudinal studies using detailed hospital-level information with patient tracking facility are needed to clarify these issues.

Do consumers in Taiwan need physician information?

BACKGROUND

This article was written to determine the extent of consumers' needs for physician information and what information consumers use in decision making when selecting a physician.

METHODS

To collect data, a self-administered questionnaire was hand-delivered to 700 patients who visited the general surgery outpatient departments of seven hospitals during June 2003. A multiple logistic regression was conducted to identify the statistically significant factors related to patients' needs to use physician information.

RESULTS

Of the respondents (N = 687), 74.7% felt they "greatly needed" or "needed" physician information. About 90% of respondents would "certainly" or "possibly" change physicians if the performances of their physicians shown by physician profiling were not as good as others. Respondents ranked the three most needed physician information as specialties, malpractice history, and overall patient satisfaction level. The multiple logistic regression showed that respondent's age, hospital level, personal monthly income, and whether they had compared medical care quality provided by neighborhood physicians had significant relationships with the respondent's needs for physician information after adjusting for other factors.

CONCLUSIONS

This study found that 88.1% of respondents were in need of some amount of physician information. This is in light of calls for physician profiling from consumer-oriented organizations to assist consumers in selecting suitable physicians. It is recommended that the healthcare industry in Taiwan make a significant investment in a physician profiling system. The performance measures of this physician profiling system should be developed based on inputs from consumers, physicians, insurance companies, and researchers in this field.

Opinions of hospital administrators toward the prevalence of patient dumping in Taiwan

BACKGROUND

The purposes of this paper were to examine whether patient dumping has occurred under the National Health Insurance and to explore hospital administrators' attitudes toward the practice of patient dumping in Taiwan.

METHODS

The study subjects were administrators in general hospitals that were accredited by the Taiwan Joint Commission on Hospital Accreditation as medical centers, regional hospitals, or district teaching hospitals in the years 2000 and 2001. A self-administered postal survey was conducted using a structured questionnaire mailed to 128 administrators in general hospitals.

RESULTS

Of the respondents, 83 of 99 (83.8%) administrators perceived that patient dumping did occur in their service areas to a certain degree regardless of their hospital location, hospital level, or hospital ownership. A total of 67 of 74 (90.5%) administrators who attempted to answer the question on the prevalence of patient dumping perceived that different percentages (mean=13.27%) of hospitals transferred patients solely on economic considerations in their service areas. In addition, this study found that no statistically significant relationships existed between the administrators' perceived percentage of emergency patients received by their hospitals and hospital characteristics. However, there was a statistically significant relationship between the perceived percentage of inpatients received and hospital level (p = 0.007).

CONCLUSION

According to the results of this study, we concluded that patient dumping is a serious and widespread problem in the healthcare industry in Taiwan. Patient dumping can jeopardize patient health and impair the financial integrity of receiving hospitals. Implementation of a case payment system may worsened the situation in Taiwan.

XX-agonadism in a fetus with multiple congenital anomalies

We report on an 18-week gestation fetus with 46,XX karyotype, gonadal agenesis, meningo-encephalocele, spina bifida, omphalocele, webbing of right upper limb, deformed right clavicle and right sided ribs, absent interventricular septum, hypoplastic aorta, hypoplastic spleen, and single umbilical artery. This case is similar to the one previously described by Kennerknecht et al. in 1997 and may represent a unique syndrome.

Relationships between length of stay and hospital characteristics under the case-payment system in Taiwan: using data for vaginal delivery patients

BACKGROUND

Case payment has been implemented since the beginning of Taiwan's National Health Insurance Program in 1995. This study selected patients undergoing a vaginal delivery to explore the relationships between maternal length of stay (LOS) and hospital characteristics under the case-payment system in Taiwan.

METHODS

The National Health Insurance Research Database of 1999 from Taiwan's National Health Research Institutes was used in this study. In total, 5456 patients who underwent a vaginal delivery in 1999 meeting the selection criteria were drawn from the database. A multiple regression analysis was performed in which LOS was regressed against the variables of hospital level, hospital location, hospital ownership, and teaching status.

RESULTS

The regression model indicated that hospital level, hospital ownership, and hospital location were significantly related to LOS after adjustment for patient age, principal procedure, and the presence of a secondary diagnosis. The LOS for patients undergoing a vaginal delivery in private hospitals was shorter than those in public and non-profit proprietary hospitals. Patients admitted to medical centers or regional hospitals were more likely to have a longer mean LOS in comparison with their counterparts admitted to district hospitals. The LOS for patients hospitalized in northern Taiwan tended to be significantly longer on average than those in central and southern Taiwan.

CONCLUSIONS

This study demonstrates that wide variations in LOS exist among hospitals in Taiwan under the case-payment system. It is recommended that the Bureau of the National Health Insurance develop a national system to monitor certain hospitals that have an unusually short LOS.

Caspase activation in response to cytotoxic Rana catesbeiana ribonuclease in MCF-7 cells

Rana catesbeiana ribonuclease (RC-RNase) and onconase were proven to own anti-tumor activity. While molecular determinants of onconase-induced cell death have become more explicit, the RC-RNase-induced death pathway remains presently unknown. Here we demonstrated that RC-RNase-induced molecular cascades in caspase-3-deficient MCF-7 cells did not include activation of initiation caspase-8 and -9. Cleavage timing suggested that procaspase-2 and -6 might be processed by active caspase-7 in MCF-7 cells. Caspase-7 was also responsible for cleavage of the poly(ADP-ribose) polymerase. Furthermore, we reported that overexpression of Bcl-X(L) could raise the survival rates of MCF-7 cells treated with RC-RNase and onconase.

Demand for traditional medicine in Taiwan: a mixed Gaussian-Poisson model approach

Hurdle count models are used to examine the participation and consumption decisions in Chinese medicine use. Motivated by a household production model, a second censoring mechanism is introduced into existing single-hurdle models, and the resulting specification accommodates conscientious abstainers, as well as economic non-consumers, and admits excessive zeros in the sample. In contrast to previous studies that found few predictors, empirical results based on a Taiwanese national sample suggest that Western medicine is a gross substitute to Chinese medicine, and both time price and money price play more important roles than income. Insurance, lifestyle and demographics also determine the use of Chinese medicine.

Synergistic cytotoxicity of Rana catesbeiana ribonuclease and IFN-gamma on hepatoma cells

RC-RNase purified from Rana catesbeiana (bullfrog) oocytes is a pyrimidine-guanine sequence-specific ribonuclease. RC-RNase is derived from the RNase superfamily genes exerting distinct ribonucleolytic activity and possesses cytotoxicity to tumor cells, but rarely to primary cells. In this study, we utilized RC-RNase to function with antiproliferative cytokines. The combination with TNF-alpha or TNF-beta would not aggravate cell death. However, the combination with IFN-gamma could induce synergistic cytotoxicity verified by XTT assays toward three hepatoma cell lines bearing different differentiation stages. The distinct cytotoxicity from RC-RNase or RC-RNase/IFN-gamma on different hepatoma cells was correlated with the differentiation extent but not the proliferation rate of the cells. Despite the synergistic cytotoxicity and severe mitochondrial disruptions in the RC-RNase/IFN-gamma-treated cells, we scarcely detected any significant feature of apoptosis or necrosis by FACS analysis on annexin-V/propidium iodide staining. The mechanisms of cell death triggered by RC-RNase or RC-RNase/IFN-gamma require further investigation.

Characterization of human copine III as a phosphoprotein with associated kinase activity

The copines, first described by Creutz et al. [(1998) J. Biol. Chem. 273, 1393-1402], comprise a two C2 domain-containing protein family and are known to aggregate phosphatidylserine membranes in a calcium-dependent manner. No enzymatic function has been attributed to copines yet. Due to a cross-reacting activity of Mikbeta1, an antibody to the IL-2Rbeta chain, we were able to serendipitously purify, partially microsequence, and clone human copine III. The 5 kb copine III transcript is expressed ubiquitously as determined by a multitissue Northern blot analysis. Phosphoamino acid analysis revealed phosphorylation of copine III on serine and threonine residues. In vitro kinase assays were performed with immunoprecipitated endogenous copine III, chromatography-purified endogenous copine III, and recombinant copine III expressed in Saccharomyces cerevisiae. The exogenous substrate myelin basic protein was phosphorylated in all in vitro kinase assays containing copine III immunoprecipitate or purified copine III. A 60-kDa band was observed in corresponding in gel kinase assays with staurosporine-activated cells. Cell lines expressing high levels of copine III protein had correspondingly high kinase activity in copine III antiserum immunoprecipitate. However, the copine amino acid sequences lack the traditional kinase catalytic domain. Therefore, the data suggest copine III may possess an intrinsic kinase activity and represent a novel unconventional kinase family.

Poisoning due to an over-the-counter hypnotic, Sleep-Qik (hyoscine, cyproheptadine, valerian)

The clinical features and risk of hepatotoxicity of 'Sleep-Qik' (valerian dry extract 75 mg, hyoscine hydrobromide 0.25 mg, cyproheptadine hydrochloride 2 mg) were determined in 23 patients treated in our hospital between 1988 and 1991. The main clinical problems were central nervous system depression and anticholinergic poisoning. There was no clinical evidence of acute hepatitis in the 23 patients after taking an average of 2.5 g of valerian (range 0.5 to 12 g). There was no evidence of subclinical liver damage in 12 patients who had routine liver function tests performed approximately 6-12 hours after ingestion. Delayed onset of severe liver damage was excluded in 10 patients in whom a telephone follow-up was possible. However, subclinical liver dysfunction in the acute stage (onset after 12-24 hours) and in the intervening period after discharge from hospital could not be excluded. To establish the risk of hepatotoxicity in long-term users and in those taking an overdosage of valerian, a much larger study of longer duration with serial liver function tests is clearly needed.

[Relationship between illumination and growth of the stroma of Cordyceps sinensis (Berk.) Sacc]

The growth of the stroma of Cordyceps sinensis largely depends upon the illumination in its growth period. By increasing illumination time and light intensity, its growth height can be controlled, growth rate slowed down and the corrosion time of larva body of host insect prolonged. Ultraviolet light is able to affect the growth of stroma too. The stroma also shows the strong phototaxis in its growth period. The arrangement and formation of the perithecium vary with the illumination.

Reconstruction of the bones and joints of the upper extremity by vascularized free fibular graft: report of 46 cases

The vascularized free fibular graft was applied in reconstructing bone and joint structures of the upper extremity in 46 cases between August, 1977 and December, 1989. Among these, 30 were grafts of the fibular shaft and 16 were grafts of the fibular head. There were 19 bony defects after trauma or osteomyelitis, 18 bony or articular defects after resection of tumors, five congenital deformities or defects, and four replacements for fibrous dysplasia. The longest grafted fibula was 22 cm and the shortest, 5 cm. Thirty-one cases were followed for more than two years, and these were evaluated for functional ability in daily living, roentgenologic appearance, and 99mTc scan during follow-up. The results revealed quite sufficient functional restoration, solid bone healing, and adequate blood supply, in most cases. The vascularized free fibular head graft appears to be an ideal procedure for the reconstruction of defects of the lower end of the radius or the upper humerus, including the humeral head. The stability of the reconstructed wrist or shoulder joint was maintained by suturing the lateral collateral ligament, the palmar collateral ligament around the wrist, or by passing the long head of the biceps brachii through the grafted fibula at the shoulder. Methods for fixation of the fibular shaft to the recipient bone and the selection of vessels for anastomoses, both in the graft and at the recipient site, are discussed. The importance of postoperative functional exercise is emphasized.

Report on Shanghai norms for the Chinese translation of the Wechsler Intelligence Scale for Children-Revised

The Chinese translation of the Wechsler Intelligence Scale for Children--Revised (WISC-RC) was administered to 660 children (ages 6 through 16 yr.) in the city of Shanghai. The obtained norms represent children's intelligence levels in big cities where the economic and cultural development is advanced. The norms are reported as "Scaled Score Equivalents of Raw Scores" for each age group and as "IQ Equivalents of Sums of Scaled Scores." The reliability and validity of the norms indicate that the WISC-R is suitable for use with school-age children in China. The difference between the results for our Shanghai sample (WISC-RCs) and a USA sample (WISC-R) is also discussed.

Cross-bridge free skin flap transfer: case report

The authors present a procedure that can be used in cases of massive skin and soft tissue defect accompanied by extensive vascular injury. The technique involves the use of two donor components (a free skin flap and a vascular donor) which form a single unit postoperatively. The free flap is stretched over crossed limbs, with its major lateral portion serving to cover the defect, and the margin of its medial portion containing the flap pedicle sutured to a pedicled skin flap from the healthy contralateral limb. End-to-end anastomoses of vessels from both components are performed within the skin bridge that connects the crossed limbs. A temporary cross-over vascular supply to the free flap from vessels of the healthy limb is thus created. The procedure is offered as a satisfactory solution to the problem of transferring free flaps in cases where recipient site vessels are absent or unusable.