A Practical Guide to QI Data Analysis: Run and Statistical Process Control Charts

Data analysis utilizing run charts and statistical process control (SPC) charts is a mainstay of quality improvement (QI) work. These types of time series analyses allow QI teams to evaluate patterns in data that may not be apparent with pre- and postintervention analysis. A run chart is most useful at the onset of a project when data points may be limited; points can be added prospectively to monitor for changes. An SPC chart is needed to determine if the system is "out of control," indicating an instance of special cause variation, and is recommended for more robust data analysis. These charts are valuable tools in identifying patterns of change, but cannot indicate what caused the change. QI teams can further investigate significant patterns to identify the impact of interventions and promote continued change or sustainability. In this article, we will provide a practical guide to the basics of run and SPC charts, including how to create and interpret them. The reader can use the supplemental data tables to gain the skills needed to build their own charts with readily available software. Finally, we will review more specialized software options that can assist in creation of run and SPC charts.

Height-based formulas for predicting intravascular length of tunnelled neck central venous catheter in paediatric population

INTRODUCTION

Central venous catheter (CVC) placement is commonly performed in children. We aim to develop simple formulas to predict CVC intravascular length to minimise radiation exposure associated with the procedure.

METHODS

124 paediatric patients who received tunnelled neck CVCs and subsequent CT thorax at Hong Kong Children's Hospital from January 2020 to July 2022 were reviewed retrospectively. Formula development cohorts were subdivided by insertion sites-9 right external jugular vein (REJV), 41 right internal jugular vein (RIJV), 14 left external jugular vein (LEJV), 10 left internal jugular vein (LIJV). Using measurements from CT by two radiologists, formulas predicting the CVC intravascular length based on height and insertion sites were developed using a linear regression model. These formulas were tested with validation cohorts (10 randomly selected cases in REJV and RIJV groups respectively). Validation cohorts were not available for LEJV and LIJV groups due to small sample sizes.

RESULT

The goodness-of-fit (R^2) of all formulas are above 0.8. In the validation cohorts, the REJV formula was predictive of intravascular CVC length within 1 cm in 70% of CVC with mean absolute difference of 0.63 cm (SD 0.48 cm), and the RIJV formula was predictive of intravascular CVC length within 1 cm in 80% of CVC with mean absolute difference of 0.67 cm (SD 0.53 cm).

CONCLUSION

Intravascular CVC length can be estimated using simple formulas based on height and insertion sites. Further prospective validation of the LEJV and LIJV formulas is needed.

Twelve tips for creating an escape room activity for medical education

Communication, teamwork, and resilience all require active practice by healthcare teams. Games such as escape rooms can add variety, interactivity, and value to teaching sessions. Escape room activities typically include a variety of sequential puzzles that lead participants to break free of a room, or can be adapted into an 'escape box' challenge where participants work to successfully unlock a box. Escape room or escape box exercises can help healthcare teams develop and enhance team skills, as well as reinforce medical knowledge. We developed an escape box session to teach and reinforce organizational Safety II principles and the resilience potentials: monitor, respond, learn, and anticipate. We report 12 tips to effectively organize and develop an escape room or escape box activity for multidisciplinary healthcare teams.

Design, Usability, and Acceptability of a Needs-Based, Automated Dashboard to Provide Individualized Patient-Care Data to Pediatric Residents

BACKGROUND AND OBJECTIVES

Pediatric residency programs are required by the Accreditation Council for Graduate Medical Education to provide residents with patient-care and quality metrics to facilitate self-identification of knowledge gaps to prioritize improvement efforts. Trainees are interested in receiving this data, but this is a largely unmet need. Our objectives were to (1) design and implement an automated dashboard providing individualized data to residents, and (2) examine the usability and acceptability of the dashboard among pediatric residents.

METHODS

We developed a dashboard containing individualized patient-care data for pediatric residents with emphasis on needs identified by residents and residency leadership. To build the dashboard, we created a connection from a clinical data warehouse to data visualization software. We allocated patients to residents based on note authorship and created individualized reports with masked identities that preserved anonymity. After development, we conducted usability and acceptability testing with 11 resident users utilizing a mixed-methods approach. We conducted interviews and anonymous surveys which evaluated technical features of the application, ease of use, as well as users' attitudes toward using the dashboard. Categories and subcategories from usability interviews were identified using a content analysis approach.

RESULTS

Our dashboard provides individualized metrics including diagnosis exposure counts, procedure counts, efficiency metrics, and quality metrics. In content analysis of the usability testing interviews, the most frequently mentioned use of the dashboard was to aid a resident's self-directed learning. Residents had few concerns about the dashboard overall. Surveyed residents found the dashboard easy to use and expressed intention to use the dashboard in the future.

CONCLUSION

Automated dashboards may be a solution to the current challenge of providing trainees with individualized patient-care data. Our usability testing revealed that residents found our dashboard to be useful and that they intended to use this tool to facilitate development of self-directed learning plans.

COVID-19 Impact on Intern Exposure to Common Inpatient Diagnoses

OBJECTIVE

We sought to understand the impact of the coronavirus disease 2019 (COVID-19) pandemic on the clinical exposure of pediatric interns to common pediatric inpatient diagnoses.

METHODS

We analyzed electronic medical record data to compare intern clinical exposure during the COVID-19 pandemic from June 2020 through February 2021 with the same academic blocks from 2017 to 2020. We attributed patients to each pediatric intern on the basis of notes written during their pediatric hospital medicine rotation to compare intern exposures with common inpatient diagnoses before and during the pandemic. We compared the median number of notes written per intern per block overall, as well as for each common inpatient diagnosis.

RESULTS

Median counts of notes written per intern per block were significantly reduced in the COVID-19 group compared with the pre-COVID-19 group (96 [interquartile range (IQR): 81-119)] vs 129 [IQR: 110-160]; P < .001). Median intern notes per block was lower in the COVID-19 group for all months except February 2021. Although the median number of notes for many common inpatient diagnoses was significantly reduced, they were higher for mental health (4 [IQR: 2-9] vs 2 [IQR: 1-6]; P < .001) and suicidality (4.5 [IQR: 2-8] vs 0 [IQR: 0-2]; P < .001). Median shifts worked per intern per block was also reduced in the COVID-19 group (22 [IQR: 21-23] vs 23 [IQR: 22-24]; P < .001).

CONCLUSIONS

Our findings reveal a significant reduction in resident exposure to many common inpatient pediatric diagnoses during the COVID-19 pandemic. Residency programs and pediatric hospitalist educators should consider curricular interventions to ensure adequate clinical exposure for residents affected by the pandemic.

A Quality Improvement Initiative To Improve Postdischarge Antimicrobial Adherence

OBJECTIVES

Bedside delivery of discharge medications improves caregiver understanding and experience. Less is known about its impact on medication adherence. We aimed to improve antimicrobial adherence by increasing on-time first home doses for patients discharged from the pediatric hospital medicine service from 33% to 80% over 1 year via creation of a discharge medication delivery and counseling "Meds to Beds" (M2B) program.

METHODS

Using sequential plan-do-study-act cycles, an interprofessional workgroup implemented M2B on select pediatric hospital medicine units at our quaternary children's hospital from October 2017 through December 2018. Scripted telephone surveys were conducted with caregivers of patients prescribed antimicrobial agents at discharge. The primary outcome measure was on-time administration of the first home antimicrobial dose, defined as a dose given within the time of the inpatient dose equivalent plus 25%. Process measures primarily assessed caregiver report of barriers to adherence. Run charts, statistical process control charts, and inferential statistics were used for data analysis.

RESULTS

Caregiver survey response rate was 35% (207 of 585). Median on-time first home antimicrobial doses increased from 33% to 67% (P < .001). Forty percent of M2B prescriptions were adjusted before discharge because of financial or insurance barriers. M2B participants reported significantly less difficulty in obtaining medications compared with nonparticipants (1% vs 17%, P < .001).

CONCLUSIONS

The M2B program successfully increased parental report of timely administration of first home antimicrobial doses, a component of overall adherence. The program enabled providers to identify and resolve prescription problems before discharge. Importantly, caregivers reported reduced barriers to medication adherence.

240. Reduction of antibiotic use in children admitted with viral respiratory tract infections

Background

Viral respiratory tract infections (VRTI) accounts for a significant proportion of hospitalized children and contributes to a substantial use of health care resources and costs. American Academy of Pediatrics (AAP) recommends against using antibiotics in uncomplicated viral respiratory infections in children. Overuse of antibiotics ranges between 29–80%. The goal of an Antibiotic stewardship programs (ASP) is to decrease antibiotic misuse, lower costs, and prevent emergence of antibiotic resistance in the community.

Proportion of children with Viral respiratory tract infections on antibiotics

Methods

Our smart aim was to reduce antibiotic use by 25% in admitted children with VRTI between October 2019-March 2020. Our outcome measure was to reduce inappropriate antibiotic use during the 2019–20 season by 25%. Process measures included percentage of antibiotic used in viral RTI, antibiotic days of therapy and appropriate audit-feedback from the ASP team to facilitate discontinuation or de-escalation of antibiotics based on culture data. Our balance measure included readmission rates in patients in whom antibiotics were discontinued or de-escalated. Several PDSA cycles implemented with predominant emphasis on communication between ASP team and primary providers.

Results

No differences were noted in patient demographics including sex, age, ethnicity between the viral season in 2018–19 and 2019–2020. In our previous study in 2018–2019 RSV season, there was 40.7% antibiotic use in patients admitted with RSV bronchiolitis. In 2019–2020 season we included all patients admitted with viral RTI. Of the 213 patients evaluated between October 2019 through Dec 2020, 40% of the patients received antibiotics. 100% of the antibiotics were justified, based on independent review of antibiotic data by the team. Most common cause of antibiotics were community acquired pneumonia, rule out sepsis and otitis media. Antibiotic discontinuation and de-escalation were achieved in over 90% of the justified antibiotics.

Conclusion

Though antibiotic usage was still at 40% at our institution, 100% of antibiotic use was deemed appropriate and significant proportion were discontinued or deescalated by the ASP team.

The ASP team played a crucial role in communicating with the primary providers to advocate for appropriate antibiotic use in the children.

Disclosures

All Authors: No reported disclosures

Clinical Predictors for Abnormal Renal Bladder Ultrasound in Hospitalized Young Children With a First Febrile Urinary Tract Infection

BACKGROUND

Physicians often obtain a routine renal bladder ultrasound (RBUS) for young children with a first febrile urinary tract infection (UTI). However, few children are diagnosed with serious anatomic anomalies, and opportunity may exist to take a focused approach to ultrasonography. We aimed to identify characteristics of the child, prenatal ultrasound (PNUS), and illness that could be used to predict an abnormal RBUS and measure the impact of RBUS on management.

METHODS

We conducted a single-center prospective cohort study of hospitalized children 0 to 24 months of age with a first febrile UTI from October 1, 2016, to December 23, 2018. Independent variables included characteristics of the child, PNUS, and illness. The primary outcome, abnormal RBUS, was defined through consensus of a multidisciplinary team on the severity of ultrasound findings important to identify during a first UTI.

RESULTS

A total of 211 children were included; the median age was 1.0 month (interquartile range 0-2), and 55% were uncircumcised boys. All mothers had a PNUS with 10% being abnormal. Escherichia coli was the pathogen in 85% of UTIs, 20% (n = 39 of 197) had bacteremia, and 7% required intensive care. Abnormal RBUS was found in 36% (n = 76 of 211) of children; of these, 47% (n = 36 of 76) had moderately severe findings and 53% (n = 40 of 76) had severe findings. No significant difference in clinical characteristics was seen among children with and without an abnormal RBUS. One child had Foley catheter placement, and 33% received voiding cystourethrograms, 15% antibiotic prophylaxis, and 16% subspecialty referrals.

CONCLUSIONS

No clinical predictors were identified to support a focused approach to RBUS examinations. Future studies should investigate the optimal timing for RBUS.

Improving Influenza Vaccination in Hospitalized Children With Asthma

OBJECTIVES

Children with asthma are at increased risk of complications from influenza; hospitalization represents an important opportunity for vaccination. We aimed to increase the influenza vaccination rate among eligible hospitalized patients with asthma on the pediatric hospital medicine (PHM) service from 13% to 80% over a 4-year period.

METHODS

Serial Plan-Do-Study-Act cycles were implemented to improve influenza vaccination rates among children admitted with status asthmaticus and included modifications to the electronic health record (EHR) and provider and family education. Success of the initial PHM pilot led to the development of a hospital-wide vaccination tracking tool and an institutional, nurse-driven vaccine protocol by a multidisciplinary team. Our primary outcome metric was the inpatient influenza vaccination rate among PHM patients admitted with status asthmaticus. Process measures included documentation of influenza vaccination status and use of the EHR asthma order set and a history and physical template. The balance measure was adverse vaccine reaction within 24 hours. Data analysis was performed by using statistical process control charts.

RESULTS

The inpatient influenza vaccination rate increased from 13% to 57% over 4 years; special cause variation was achieved. Overall, 50% of eligible patients were vaccinated during asthma hospitalization in the postintervention period. Documentation of influenza vaccination status significantly increased from 51% to 96%, and asthma history and physical and order set use also improved. No adverse vaccine reactions were documented.

CONCLUSIONS

A bundle of interventions, including EHR modifications, provider and family education, hospital-wide tracking, and a nurse-driven vaccine protocol, increased influenza vaccination rates among eligible children hospitalized with status asthmaticus.

Discharging Asthma Patients on 3-Hour β-Agonist Treatments: A Quality Improvement Project

OBJECTIVES

Asthma exacerbations are a leading cause of hospitalization among children. Despite the existence of hospital protocols and national guidelines, little guidance is available regarding appropriate short-acting β-agonist (SABA) frequency discharge criteria. Our aim was to reduce the median length of stay (LOS) for children hospitalized with asthma exacerbations by 4 hours by changing the discharge requirement SABA frequency.

METHODS

Multiple plan-do-study-act cycles based on findings in our key driver diagram were used to decrease LOS. Our primary intervention was reducing the SABA administration frequency discharge requirement from every 4 hours to every 3 hours. After a feasibility pilot, this change was implemented throughout the hospital. Our intervention bundle included updating our evidence-based guidelines, electronic health record order sets and note templates, house-wide education, and a new process for respiratory therapists to notify physicians of discharge readiness. Our primary metric was LOS, with 3-, 7-, and 14-day same-cause emergency department (ED) revisits and hospital readmissions as balancing metrics. Statistical process control charts and nonparametric testing were performed for data analysis.

RESULTS

Median hospital LOS was significantly lower in the postintervention period compared with the preintervention period (30.18 vs 36.14 hours respectively; P < .001). Statistical process control charts indicated special cause variation was achieved. No significant differences were observed in rates of ED revisits or hospital readmissions.

CONCLUSIONS

Reducing the discharge requirement of SABA frequency from every 4 hours to every 3 hours resulted in a reduction in LOS, with no increase in ED recidivism or hospital readmission rates.

Bronchiolitis Care in the Hospital

BACKGROUND

Viral bronchiolitis is a common cause of hospitalization in young children, but despite a variety of therapeutic options, the mainstay of treatment remains supportive care.

OBJECTIVE

To examine the most recent evidence for supportive care measures and pharmacologic options in the treatment of bronchiolitis in the hospital setting.

METHOD

MEDLINE search with expert medical librarian for publications on management and therapies for bronchiolitis.

RESULTS

Evidence does not support the use of bronchodilators, racemic epinephrine, deep suctioning, systemic corticosteroids, or antibiotics in the absence of a concomitant bacterial infection, as these treatments do not change the course of illness or shorten length of stay (LOS). Nebulized hypertonic saline is not routinely recommended, though it may provide some benefit for patients with anticipated prolonged LOS. Continuous pulse oximetry should not be routinely used in stable patients as it may be associated with longer LOS. Supplemental oxygen should be used to maintain oxyhemoglobin concentrations &#8805;90%, a level lower than what many clinicians may have used previously. Current evidence suggests high-flow nasal cannula may reduce intubation rate, but its effect on LOS is unclear. Intravenous or nasogastric tube hydration should be used when oral hydration is not sufficient.

CONCLUSION

Overall, bronchiolitis remains a self-limited disease whose mainstay of therapy is supportive care.

A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings

Handoffs represent a critical transition point in patient care that play a key role in patient safety. Our quality improvement project was a descriptive observational study aimed at standardizing pediatric hospitalist handoffs via implementation of a handoff checklist, with the goal of improving handoff quality and physician satisfaction within six months. The handoff checklist was quickly adapted by hospitalists, with median compliance rate of 83% during the study. Handoff quality was assessed by trained observers using the validated Handoff Clinical Evaluation Exercise (CEX) tool at multiple time periods pre- and post-implementation (at 2, 6, 12, and 24 months). Handoff quality improved during our study, with a significant decrease in the percentage of "unsatisfactory" handoffs from 9% to 0% (p-value 0.004), an effect which was sustained after initial project completion. The cumulative time required for verbal handoffs for different attending physicians paralleled patient census. However, our project identified wasted down time between individual physician handoffs, and an intervention to change shift times led to a decrease in the average total handoff process time from 86 minutes to 60 minutes, p-value <0.001. An average of 7.4 patient care items was identified during handoffs. A physician perception survey revealed improved situational awareness, efficiency, patient safety, and physician satisfaction as a result of our handoff improvement project. In conclusion, implementation of a checklist and standardized handoff process for pediatric hospitalists improved handoff efficiency and quality, as well as physician satisfaction.

A Quality Improvement Initiative: Improving the Frequency of Inpatient Electronic Prescribing

OBJECTIVE

To improve the frequency of electronic prescribing (e-prescribing) of discharge prescriptions at a children's hospital via a bundle of quality improvement interventions.

METHODS

Surveys and focus groups were conducted with patient families and pediatric residents to identify barriers and propose solutions to e-prescribing. These data were used to generate a series of interventions, including the following: (1) provider education; (2) changes in patient registration workflow; and (3) electronic health record changes to improve the frequency of e-prescribing on the pediatric hospital medicine (PHM) service. The primary outcome measure was the e-prescribing frequency, with a balance measure of e-prescribing errors.

RESULTS

From July 2014 through June 2015, e-prescribing frequency on the PHM service improved from a median of 7.4% to 48.9% (P < .001) and was sustained for an additional 6 months (July 2015-December 2015), surpassing meaningful use targets with associated US News and World Report hospital ranking points. The frequency of PHM prescription errors remained unchanged, and in comparison, the resident outpatient clinic revealed no statistically significant change in e-prescribing frequency during this time period.

CONCLUSIONS

Engaging front-line providers in hospital-wide initiatives and quality improvement interventions can directly affect hospital metrics in programs such as meaningful use and US News and World Report, as shown through successful improvement in PHM e-prescribing frequency. Future studies are necessary to determine whether increased e-prescribing frequency affects patient outcomes and compliance.

Surgical complications in parenteral Subutex abusers

INTRODUCTION

There were anecdotal reports of an increase in the admissions of parenteral Subutex abusers to our hospital over the past five months. This case study aimed to analyse the surgical complications related to parenteral Subutex abuse and describe the demographics of this group of patients.

METHODS

We reviewed all admissions to our hospital between July and November 2005. Only parenteral Subutex abusers were included in this case study.

RESULTS

A total of 53 parenteral Subutex abusers were admitted during this period. 31 had surgical complications, while 22 presented with medical ones. Of the surgical patients, 12 had cellulitis and thrombophlebitis, six developed abscesses of the limbs, ten were patients with ischaemia and gangrene of the digits and limbs, one had septic arthritis, one had necrotising fasciitis, and one had a pseudoaneurysm of the femoral artery. There were no reported mortalities. Only nine patients needed surgical interventions. Most of the patients are young with a mean age of 34.2 years. There was a male predominance of 92.4 percent (49 out of 53). Malays are more frequently affected (72 percent, n=38), followed by Indians (15 percent, n=8), and Chinese (13 percent, n=7).

CONCLUSION

Parenteral Subutex abuse is a rising concern in Singapore. Many patients present to the surgical and orthopaedic departments for limb and vascular complications. Surgery has a limited role in their management, and most are treated conservatively and expectantly. The solution to this emerging trend requires inter-hospital and ministerial collaboration.

Selective functional deficit in dendritic cell--T cell interaction is a crucial mechanism in chronic hepatitis B virus infection

A defect in specific T cell immunity has long been assumed to be the central mechanism of persistent Hepatitis B virus (HBV) infection. Recent studies on HBV transgenic mice have suggested, however, that functional deficit of dendritic cells (DC) was an underlying cause for the T cell dysfunction. The functions of monocyte-derived DC were determined by studying 75 subjects that included chronic hepatitis B patients with low or high HBV load; antibody to hepatitis B surface antigen (anti-HBs) positive individuals who had recovered completely from previous acute HBV infection; healthy donors who had received hepatitis B vaccination and were anti-HBs positive; and immunologically naïve to HBV or the vaccine individual. Impaired interactions between monocyte-derived DC and T cells were shown in chronic HBV infection patients, especially in those with active virus replication. The dysfunctions included: (i) failure of DC to increase human leukocyte antigen (HLA-II), B7 expression and interleukin-12 secretion in responses to hepatitis B surface antigen (HBsAg), (ii) defective induction of T cell proliferative response to HBsAg, (iii) failure to activate T cells to produce cytokines and (iv) deficit in the induction of antigen specific cytotoxic T lymphocytes (CTLs). In vitro treatment of DC with tumour necrosis factor-alpha improved HLA-II and B7 expression, as well as Th cell and CTL responses. It is concluded that defective DC-T cell interactions may account for the specific T cell immune defects in chronic HBV infection. Immunotherapy that aims at restoring DC functions could offer a new opportunity for effectively managing persistent HBV infections.

Rare pulmonary complications after transarterial chemoembolisation for hepatocellular carcinoma: two case reports

We report two rare cases of acute pulmonary complication after transarterial chemoembolisation for inoperable hepatocellular carcinoma. Both cases involved a large tumour and hepatic vein invasion. The first patient, a 27-year-old man, died of pulmonary tumour embolism 4 days after transarterial chemoembolisation. Acute dyspnoea developed in the second patient, a 63-year-old man, following the procedure due to pulmonary oil embolisation and chemical pneumonitis. The chest condition of this patient improved, but he subsequently died of liver failure 3 weeks later. Our cases illustrate the point that if locoregional treatment is offered as a palliative treatment, patients with hepatic vein invasion should be warned of the possible complications of massive tumour embolism, pulmonary oil embolisation, and subsequent death.

Clinical significance of cell differentiation in hepatocellular carcinoma

BACKGROUND/AIMS

Hepatocellular carcinoma is commonly found in Asian countries and prognosis still remains unsatisfactory due to recurrence after surgical tumor resection.

METHODOLOGY

We try to demonstrate the recurrence and survival time in 99 surgical patients grading by tumor cellular differentiation from surgical specimen.

RESULTS

The rates of well, moderate, and poor differentiation were encountered in 21 cases (21.2%), 61 cases (61.6%) and 17 cases (17.7%), respectively. Small tumor (< 3 cm) was found in only one (5.9%) in the poor differentiation group and 38.1% and 37.7% in the well and moderate differentiation groups. Capsular invasion was found in 13 (61.9%), 39 (63.9%) and 7 (41.1%) in the well, moderate and poor differentiation group, respectively. We found 41.9% (18/43) and 22.4% (13/58) to be tumor free in capsule invasion (-) and (+) after a period of 18.1 and 29.9 months, respectively. However, the recurrent time was 10.6 and 11.3 months, respectively with no significant difference (p > 0.05). Vascular invasion was more frequent in the poor differentiation group (76.5%) than the well (23.8%) and moderate (60.7%) differentiation groups (P < 0.05). We found 23.5% (4/17) and 35% (21/60) to be tumor free but the recurrence time was 6.5 and 14.1 months for the vascular invasion (-) and (+), respectively. The residual median survival times were 6.5 and 14 months after recurrence, respectively. The tumor recurrence rates were 52.7% (11/21), 52.4% (32/61), and 35.5% (6/17) and recurrence times were 11.7, 11.9, and 4.5 months for the well, moderate and poor differentiation group respectively totally. The recurrence time of young age group (< 39 years old) was shorter than the others and there was no patient of well differentiation less than 40 years old. The recurrence time was shorter in the poor differentiation group but there was no significant difference according to age group. The median survival times were 22.2, 22.9, and 9.5 months for each group, respectively.

CONCLUSIONS

Differentiation of hepatocellular carcinoma cell had a clinical significance and was found to be positively correlated with the invasive proclivity. The median survival time was longer in both the well and moderate differentiation group, but not in the poor differentiation group. The clinical data revealed that the extended operations performed upon the patients with poor differentiation effected the recurrence time but not the survival time.

Asperger's disorder: a case report of repeated stealing and the collecting behaviours of an adolescent patient

OBJECTIVE

To discuss special behavioural problems shown by a patient with Asperger's disorder from adolescence onward.

METHOD

The case and treatment of a 21-year-old male patient is described.

RESULTS

A 21-year-old male developed obstinate stealing behaviours when he was 17 years old. He was regarded as a schizophrenic at first, and was suspected of kleptomania later. Asperger's disorder was diagnosed after we reconsidered the relationship between the schizoid psychopathy in childhood and the stealing behaviours which occurred in adolescence.

CONCLUSION

A wide variety of bizarre behaviours and so-called borderline behaviours occur in late adolescence and adult life of patients with Asperger's disorder. But classic schizophrenia is very rare. Psychiatrists unacquainted with the clinical diagnosis/context may find it difficult to evaluate 'concrete', 'childish', or 'bizarre' symptoms in patients with Asperger's disorder, and thus are prone to misdiagnose them as having schizophrenia disorders or other similar disorders.

Significance of local electrostatic interactions in staphylococcal nuclease studied by site-directed mutagenesis

In this paper, we show that amino acids Glu(73) and Asp(77) of staphylococcal nuclease cooperate unequally with Glu(75) to stabilize its structure located between the C-terminal helix and beta-barrel of the protein. Amino acid substitutions E73G and D77G cause losses of the catalytic efficiency of 24 and 16% and cause thermal stability losses of 22 and 26%, respectively, in comparison with the wild type (WT) protein. However, these changes do not significantly change global and local secondary structures, based on measurements of fluorescence and CD(222 nm). Furthermore, x-ray diffraction analysis of the E75G protein shows that the overall structure of mutant and WT proteins is similar. However, this mutation does cause a loss of essential hydrogen bonding and charge interactions between Glu(75) and Lys(9), Tyr(93), and His(121). In experiments using double point mutations, E73G/D77G, E73G/E75G, and E75G/D77G, significant changes are seen in all mutants in comparison with WT protein as measured by fluorescence and CD spectroscopy. The losses of thermal stability are 47, 59, and 58%, for E73G/D77G, E73G/E75G, and E75G/D77G, respectively. The triple mutant, E73G/E75G/D77G, results in fluorescence intensity and CD(222 nm) close to those of the denatured state and in a thermal stability loss of 65% relative to the WT protein. Based on these results, we propose a model in which significant electrostatic interactions result in the formation of a locally stable structure in staphylococcal nuclease.

Clinical and electroencephalographic findings in early and late onset benign childhood epilepsy with occipital paroxysms

Twenty-six patients were studied who had the clinical and electroencephalographic features of benign childhood epilepsy with occipital paroxysms (BCEOP) as defined by the Commission of the International League Against Epilepsy (ILAE). Twelve patients were characterized as having early-onset benign childhood occipital seizures (EBOS) susceptible syndrome, as described by Panayiotopoulos, and 14 patients had late onset childhood idiopathic occipital seizures (LOS). Patients with symptomatic epilepsy and whose EEGs exhibited occipital spikes were excluded. The age of onset of the EBOS group ranged from 2.6 to 9.4 years (mean: 4.9+/-1.7 years), which was significantly younger than the LOS group (range: 4-12 years, mean:8.4+/-2.5 years). Both sexes were equally affected. The patients in the EBOS group had less frequent and longer seizures, ictal vomiting, more frequent deviation of the eyes, adversive seizures and more frequent nocturnal and secondary generalized seizures (P<0.05). By comparison, patients in the LOS group had a higher incidence of seizures, shorter duration of seizures and more frequent diurnal onset (P<0.01); also, although not statistically significant, the LOS group had more frequent visual hallucinations and headaches. The EEG topography in both groups showed at either side of occipital area typical paroxysms that were unilateral or bilaterally synchronous. Neither group had dipoles according to scalp voltage mapping. The clinical prognoses were favorable for both groups. To distinguish EBOS from LOS, detailed description of the age of onset, motor symptoms, visual symptoms, presence of eye deviation and diurnal or nocturnal occurrence are essential.

Stereospecific anionically promoted transannular hydride shifts in medium-ring hydroxy ketones. Probe of their reversibility and the potential for regiocontrol

Examples are provided of stereospecific transannular oxidation-reduction processes involving the conjugate bases of delta-hydroxy ketones in a nine-membered ring setting. The ability to control the direction of these equilibria by proper modulation of the solvent environment and level of hydroxyl group protection is demonstrated. MM3-derived steric energies of the isomer pairs suggest that the equilibrium distributions are the outcome of the extent to which intramolecular hydrogen bonding forces are disrupted by polar solvent molecules when present.

Community study of depression in old age in Taiwan: prevalence, life events and socio-demographic correlates

BACKGROUND

Published studies of prevalence of depression in old age in Taiwan have yielded equivocal results.

AIMS

To study the prevalence of depressive disorders among community-dwelling elderly; further, to assess socio-demographic correlates and life events in relation to depression.

METHOD

A randomised sample of 1500 subjects aged 65 and over was selected from three communities. Research psychiatrists conducted all assessments using the Geriatric Mental State Schedule. The diagnosis of depression was made with the GMS-AGECAT (Automated Geriatric Examination for Computerised Assisted Taxonomy); data on life events were collected with the Taiwanese version of the Life Events and Difficulties Schedule.

RESULTS

One-month prevalence of psychiatric disorders was 37.7%, with 15.3% depressive neurosis and 5.9% major depression. A high risk of depressive disorders was found among widows with a low educational level living in the urban community, and among those with physical illnesses.

CONCLUSIONS

Contrary to most previous reports, we found that the prevalence of depressive disorders among the elderly in the community in Taiwan is high and comparable to rates reported in some studies of UK samples.

Leukemia inhibitory factor expression in different endometrial locations between fertile and infertile women throughout different menstrual phases

PURPOSE

The purpose was to demonstrate the leukemia inhibitory factor (LIF) expression in different endometrial locations between fertile and infertile women throughout different menstrual phases. The relationship between progesterone level and LIF expression were evaluated.

METHODS

Endometrial biopsies were performed on idiopathic infertile and normal fertile women accepted the in follicular, periovulatory, and luteal phases. The luteal progesterone level was measured. Endometrial LIF immunostaining of luminal epithelium, glandular epithelium, and stroma were detected. The relationship between luteal LIF expression and progesterone level was evaluated.

RESULTS

Significant LIF expression was noted in the endometrium of fertile women rather than that of infertile women. The LIF expression was highest in the luminal epithelium, moderate in the glandular epithelium, and lowest in the stroma. The luminal and glandular epithelial staining were lowest in follicular phase, moderate in periovulatory phase, and strongest in luteal phase. The stromal LIF presented with a noncyclical manner. The LIF expression is not related with the progesterone level.

CONCLUSIONS

Endometrial LIF expression is related to human fertility. Endometrial LIF expression is dependent on cellular localizations and menstrual stages. Stronger LIF expression presents in the endometrial epithelium during luteal phase.

Effect of different concentrations of recombinant leukemia inhibitory factor on different development stage of mouse embryo in vitro

PURPOSE

To assess the influence of different concentrations of recombinant human leukemia inhibitory factor (LIF) on the in vitro development of mouse embryos.

METHODS

The 2- to 4-cell embryos of CB6F1 mice were cultured in the human tubal fluid (HTF) media containing different concentrations of LIF. Mouse embryos were divided into seven groups: (1) HTF; (2) 1500 IU/ml LIF; (3) 1000 IU/ml LIF; (4) 750 IU/ml LIF; (5) 500 IU/ml LIF; (6) 250 IU/ml LIF; (7) 125 IU/ml LIF. The embryonic numbers of different stages including 5-8 cell, 9-16 cell, morula, blastocyst, and hatching blastocyst were recorded.

RESULTS

The percentage of early embryo stage (2-cell embryos to 6- to 16-cell stages) in all groups were nonsignificantly different. There were higher formation rates of preimplantation embryos (morula to hatching blastocyst) in groups 2, 3, 4, and 5 than in groups 1, 6 and 7.

CONCLUSIONS

LIF has positive effects on preimplantation embryo development and has nonsignificant influence on the early embryo development. The lowest concentration of LIF which could provide the optimal embryo development is 500 IU/ml.

A randomized clinical trial comparing autologous blood clot and gelfoam in transarterial chemoembolization for inoperable hepatocellular carcinoma

BACKGROUND/AIM

Inoperable hepatocellular carcinoma is common in Asia and is usually treated with repeated transarterial chemoembolization. Gunji et al. showed better survival and fewer complications with autologous blood clot as compared with gelfoam used for embolization. Our aim was to compare the effect of blood clot versus gelfoam.

METHODS

We conducted a prospective randomized trial in 100 patients with inoperable hepatocellular carcinoma, and compared the side effects and cumulative survival in the two groups. Cox's proportional hazard model was used to study the prognostic factors.

RESULTS

The diameter of the main tumor was 7.9+/-4.6 cm. Our study did not show additional beneficial effects of blood clot. The proportion of side effects was similar and the common ones included fever, pain and vomiting. Though the hepatic artery remained patent for a longer period with blood clot (p=0.061), there was no difference in survival (p=0.129 for Okuda I disease and p=0.388 for Okuda II disease). Subgroup analysis showed longer survival in patients with vascular occlusion (p=0.034 for Okuda I and p=0.029 for Okuda II disease). The independent factors of survival were sex, Child's class, Okuda stage, tumor type and presence of metastases.

CONCLUSION

This study showed no additional benefits of blood clot in patients with inoperable hepatocellular carcinoma, in Okuda I and II disease. The longer survival in patients with vascular occlusion suggested that the damage to normal liver tissue by planned periodic transarterial chemoembolization may outweigh its benefit in later sessions of repeated TACE in certain patients.

Sperm cryopreservation with empty human or mouse zona pellucidae. A comparison

OBJECTIVE

To compare empty zona pellucidae (ZP) and human of mouse oocytes for sperm cryopreservation.

STUDY DESIGN

ZP was prepared by evacuating the cytoplasm of human or mouse oocytes. The evacuated ZP were injected with spermatozoa from patients with severe oligoasthenozoospermia from normally fertile men. After a freezing-thawing procedure, the spermatozoa were aspirated outside the ZP. According to the different origins of ZP and sperm, the spermatozoa number per ZP, motile sperm number before freezing and after thawing, lost sperm number per ZP after freezing and sperm recovery rate were compared.

RESULTS

Spermatozoa number, motile sperm number before freezing and after thawing, lost sperm number per ZP and sperm recovery rate in all groups were comparable. The total mean motile sperm number before freezing and after thawing, mean lost sperm number after thawing and sperm recovery rate were 15.1%, 12%, 1.6% and 80%, respectively.

CONCLUSION

ZP is an ideal vehicle for cryopreservation of sperm collected from patients with severe oligoasthenozoospermia. There were no differences between human and mouse ZP for sperm storage.

The expression of DAZL1 in the ovary of the human female fetus

OBJECTIVE

To determine whether DAZL1 is expressed in human fetal ovarian tissue.

DESIGN

The presence of DAZL1 expression was determined by reverse transcriptase polymerase chain reaction (RT-PCR).

SETTING

Academic tertiary care medical center and research unit of university.

PATIENT(S)

Five female abortuses between the 19th and 22nd week of gestational age.

INTERVENTION(S)

Fetal ovarian tissues were collected immediately after the cessation of the heart beat.

MAIN OUTCOME MEASURE(S)

The product of RT-PCR.

RESULT(S)

DAZL1 expression was detected in all five samples.

CONCLUSION(S)

DAZL1 is not only expressed in human testes but also in ovaries. It may play a role in germ cell survival and gonad development in both sexes.

Prolonged culture of human cryopreserved embryos with recombinant human leukemia inhibitory factor

PURPOSE

To evaluate the efficiency of recombinant human leukemia inhibitory factor (LIF) in the prolonged culture of human cryopreserved-thawing embryos.

METHODS

After thawing, all embryos were divided into four groups: (1) Human tubal fluid (HTF), (2) HTF + LIF, (3) M3TH medium, and (4) M3TH medium plus LIF. Following prolonged culture, embryo development in each group was compared.

RESULTS

In embryo development from about the 2- to 4-cell to 9- to 16-cell stage, there were nonsignificant differences between each group. There was lower morula formation rate in group 1 (6.9%) than those in other groups (23.2%, 19.7%, 23.1%). The lower blastocyst formation in group 1 and 3 (0%, 0%) than those in group 2 and 4 (11.0%, 12.8%) were noted.

CONCLUSIONS

LIF is beneficial for preimplantation embryos. LIF does not influence the early embryo development. LIF-supplemented HTF provided a similar culture environment for thawing embryos as LIF-supplemented M3TH medium.

Artificial insemination. Role of endometrial thickness and pattern, of vascular impedance of the spiral and uterine arteries, and of the dominant follicle

OBJECTIVE

To assess the roles of endometrial thickness and pattern, as well as vascular impedance of the spiral and uterine arteries and dominant follicle in predicting the pregnancy rate in women receiving controlled ovarian hyperstimulation (COH) following by intrauterine insemination (IUI).

STUDY DESIGN

All idiopathically infertile couples who accepted COH + IUI for the first time were prospectively included. The COH agents included clomiphene citrate and human menopausal gonadotropins. Endometrial thickness and pattern (trilaminar, nontrilaminar) and vascular impedance (pulsatility index [PI], resistance index [RI]) of the spiral and uterine arteries and ovarian dominant follicle were measured on the day of IUI. Analyses were made of the influences on pregnancy outcomes by endometrial thickness and pattern as well as Doppler surveys of the spiral and uterine arteries and dominant follicle.

RESULTS

A total of 110 couples with 110 cycles were enrolled, and there were 16 resulting pregnancy cycles. Trilaminar endometrium appeared in 87.5% and 57.4% of pregnant and nonpregnant women (P = .022), respectively. The pregnancy rates in trilaminar and nontrilaminar groups were 17.9% and 6.3%, respectively (P = .022). Endometrial thickness and PI/RI values for the spiral artery and uterine arteries and dominant follicle in pregnant women (12.1 +/- 2.6; 1.28 +/- 0.33/0.68 +/- 0.12; 2.67 +/- 0.51/0.72 +/- 0.32; 0.71 +/- 0.19/0.54 +/- 0.06 mm, respectively) were not statistically different from those for nonpregnant women (11.0 +/- 2.9; 1.46 +/- 0.49/0.71 +/- 0.21; 2.81 +/- 0.65/0.88 +/- 0.34; 0.74 +/- 0.24/0.55 +/- 0.09, respectively).

CONCLUSION

A trilaminar endometrium on the day of IUI provides a favorable prediction of pregnancy. Endometrial thickness and Doppler surveys of the spiral and uterine arteries and dominant follicle do not have useful predictive value in COH + IUI.

Low-dose aspirin for infertile women with thin endometrium receiving intrauterine insemination: a prospective, randomized study

PURPOSE

The objective was to evaluate the effect of aspirin on infertile women with thin endometrium.

METHODS

Patients who had thin endometrium (< or = 8 mm) and intrauterine insemination were divided into the aspirin and nonaspirin groups. Endometrial pattern (trilaminar and nontrilaminar) and thickness, the pulsatility index (PI) and resistance index (RI) of the uterine artery, spiral artery, and ovarian dominant follicles, and pregnancy rates of both groups were measured.

RESULTS

A total of 114 and 122 women were included in the aspirin and nonaspirin groups, respectively. There were significantly higher percentages of trilaminar endometrium (46.5% vs. 26.2%) and pregnancy rate (18.4% vs. 9.0%) after aspirin therapy. There was nonsignificant difference in the endometrial thickness, and PI/RI values of the uterine artery, spiral artery, and ovarian dominant follicle between both groups.

CONCLUSIONS

Higher pregnancy rate and better endometrial pattern were achieved in patients with thin endometrium after aspirin administration. Aspirin therapy could not significantly increase the endometrial thickness and the resistance of uterine and ovarian flow.

Ultrarapid cryopreservation of human embryos: experience with 1,582 embryos

OBJECTIVES

To demonstrate the effectiveness of ultrarapid cryopreservation in human embryos.

DESIGN

Retrospective study.

SETTING

An IVF unit of a medical center.

PATIENT(S)

All cases received ultrarapid freezing (URF) of embryos and frozen embryo transfer.

INTERVENTION(S)

Embryos were placed in phosphate-buffered saline (PB1) + 20% maternal serum (MS) for 5 minutes. Embryos were loaded to the straws containing PB1 + MS + 0.25 M sucrose (SUC) + 3.5 M dimethyl sulfoxide for 3 minutes, and then were stored in a liquid nitrogen tank. Embryos were thawed in a 37 degrees C water for 6 seconds and then cultured in PB1 + MS + SUC for 10 minutes. Embryos were transferred into PB1 + MS for 5 minutes and were transferred into patients.

MAIN OUTCOME MEASURE(S)

The embryo grades before and after URF, the survival and transferred embryo numbers, and the pregnancy and abortion rates were analyzed.

RESULT(S)

A total of 1,582 embryos were thawed, of which 1,273 (80.5%) embryos were transferred and 1,032 (65.2%) embryos survived with > or = 50% intact blastomere. The embryo numbers with grade I or II before and after freezing and thawing were 1,110 (70.2%) and 790 (50.0%). The mean embryo numbers per transfer was 5.0. Twenty-eight pregnancies (11.4% per transfer) were established, which included 5 miscarriages, 1 ectopic pregnancy, 4 preterm and 18 term deliveries.

CONCLUSION(S)

Ultrarapid freezing is worthy of reconsideration for embryo cryopreservation.

Recombinant human leukemia inhibitory factor enhances the development of preimplantation mouse embryo in vitro

OBJECTIVE

To assess the effect of recombinant human leukemia inhibitory factor (rhLIF) on mouse embryos in vitro.

DESIGN

Controlled prospective study.

SETTING

Academic research environment.

ANIMAL(S)

Female CB6F1 mice between 6 and 8 weeks old.

INTERVENTION(S)

Mice were divided randomly into three groups, which included a control group in an in vivo study (group I) and two groups in an in vitro study (groups II and III). Mice were killed at 116-120 hours (group I) and 44-48 hours (groups II and III) after hCG injection. Two-cell embryos (groups II and III) and blastocysts (group I) were obtained. Embryos in group II were cocultured with human tubal fluid (HTF) + 0.5% human serum albumin and in group III with HTF + rhLIF (1,000 U/mL) under paraffin oil.

MAIN OUTCOME MEASURE(S)

The embryonic numbers in different stages were recorded and compared.

RESULT(S)

Similar early embryo development to the four- to eight-cell and morula stages was noted between groups II and III (87.3% versus 91.0% and 74.6% versus 87.1%, respectively). However, further embryo development to the blastocyst, expanded blastocyst, and hatching blastocyst in group II (48.1%, 31.7%, and 18.5%, respectively) was lower than that in group III (83.6%, 53.7%, and 37.8%).

CONCLUSION(S)

RhLIF does not provide obvious stimulation in the early mouse embryo. However, rhLIF has positive effects on preimplantation blastocyst growth, differentiation, and hatching.

Bilateral simultaneous tubal sextuplets: pregnancy after in-vitro fertilization--embryo transfer following salpingectomy

The presence of a damaged tube has been suggested in recent studies to have a negative effect on in-vitro fertilization (IVF) outcome. Performing bilateral salpingectomy prior to IVF to maximize pregnancy rates may also result in unnecessary surgery. This case is also an example of the occurrence of interstitial pregnancy after salpingectomy. This unusual type of ectopic pregnancy must be kept in mind when evaluating a patient suspected of a possible early abnormal gestation after assisted reproductive technolologies.

Intra-arterial carbon dioxide-enhanced ultrasonogram of hepatocellular carcinoma treated by transcatheter arterial embolization and percutaneous ethanol injection therapy

The purpose of this study was to investigate the value of carbon dioxide-enhanced ultrasonography (CO2-US) in the evaluation of viable hepatocellular carcinomas (HCC) which were treated by transcatheter arterial embolization (TAE), percutaneous ethanol injection (PEI), or a combination treatment (TAE and PEI). Forty-one patients with 66 HCC were included in the study. They underwent CO2-US and angiography were performed in all tumours after they were treated by TAE, PEI or a combination treatment. Forty-six tumours were positively enhanced by CO2-US and 40 of them were positive by angiography. These 46 tumours were proved to be viable tumours either by biopsy or by follow-up studies. The positive predictive value was 100% for CO2-US and 87.8% in angiography. Twenty tumours were negative by CO2-US and these were also negative by angiography. Carbon dioxide-enhanced ultrasonography is a more reliable method for detecting the viable portion of the treated HCC compared with conventional angiography.

Sclerotherapy--an adjuvant therapy to endometriosis

OBJECTIVE

Recurrent endometriomas after medical or surgical treatment is a difficult clinical problem for those patients who wish to perform ovulation induction. Therefore we tried to investigate the efficacy of sclerotherapy as an adjuvant management before ovulation induction to preserve more ovarian tissue for folliculogenesis in ART program.

METHODS

Thirty-two patients with persistent or recurrent endometrioma after surgical or medical treatment were included in this study. Transvaginal ultrasound needle guided aspiration of the cyst followed by tetracycline instillation was performed before ovulation induction.

RESULTS

There is an encouraging clinical pregnancy rate of 34.37%. Also, there is a disappointing recurrent rate of 46.87% in 12 months follow-up course.

CONCLUSION

The increased interest in cost-effective outpatient therapy and the expected difficulty in surgical treatment of recurrent endometriomas made aspiration and sclerotherapy of endometrioma an attractive option before ovulation induction.

E5 proteins of human papillomavirus types 11 and 16 transactivate the c-fos promoter through the NF1 binding element

Human papillomavirus type 11 (HPV-11) and HPV-16 contain an E5 gene that can induce c-fos gene expression in mouse fibroblasts. This study investigated the human c-fos promoter characteristics by mapping the c-fos promoter sequence with several deletion and point mutants that confer responsiveness to E5 of HPV-11 or HPV-16. The mutant studies show that NF1 binding sequences within the c-fos promoter were crucial for the induction of the c-fos gene by E5, and the gel shift assay study suggested that E5 of both HPV-11 and HPV-16 is associated, perhaps indirectly, with this NF1 element in the transactivation of the human c-fos promoter. Using an inducible system, we demonstrate that increased induction of the HPV-11 E5 gene in cells led to increased transactivation of the NF1 element. In addition, the transactivating activity of a series of HPV-11 E5 mutants on the NF1 element had a strong correlation with their respective transforming activities.

Pregnancies after transfer of ultrarapidly frozen human embryos

PURPOSE

We report our experience of freezing human embryos using an ultrarapid freezing method.

METHODS

The patients were superovulated. Oocytes were inseminated and cultured in HTF + 10% serum. A maximum of three embryos was transferred and the rest of the embryos were frozen ultrarapidly after a 3-min equilibration period in PB1 + 3.5 M DMSO + 0.25 M sucrose. Embryos were thawed in a 37 degrees C water bath for 6 sec, then cultured in PB1 + 20% serum for 10 min. The surviving embryos were transferred into patients on the same day of thawing.

RESULTS

Sixty-three embryos were thawed, of which 52 embryos (83%) survived with at least one intact blastomere. Nineteen frozen-thawed embryo transfers were made. The mean embryos per transfer was 2.7. Three pregnancies (16%/transfer) were established. One miscarriage occurred in the eighth week of pregnancy. Two pregnancies went to term and three healthy infants were born.

CONCLUSIONS

The present data demonstrate that ultrarapid freezing is a method worth consideration in the area of human embryo freezing.

Subcutaneous low dose leuprolide acetate depot versus leuprolide acetate for women undergoing ovarian stimulation for in-vitro fertilization

A total of 100 women undergoing ovarian stimulation with gonadotrophin-releasing hormone agonist (GnRHa) and a human menopausal gonadotrophin (HMG) for in-vitro fertilization (IVF) participated in this randomized comparative study. Leuprolide acetate at a dose of 0.5 mg/day s.c. (n = 52, group I), or low-dose leuprolide acetate depot at a dose of 1.88 mg s.c. (n = 48, group II), was started on days 21-23 of the cycle. Stimulation with 225 IU/day HMG was started after pituitary desensitization had been achieved. The luteal phase was supported by human chorionic gonadotrophin (HCG) i.m. injection. There were no statistical differences in baseline oestradiol (24.5 +/- 4.8 versus 21.9 +/- 4.5 pg/ml) and follicle stimulating hormone (FSH) concentrations (3.9 +/- 1.9 versus 3.2 +/- 1.8 mIU/ml), and concentrations on the day of HCG administration of oestradiol (1657 +/- 245 versus 1512 +/- 165 pg/ml), luteinizing hormone (LH; 6.2 +/- 4.8 versus 5.6 +/- 4.3 mIU/ml) and FSH (10.6 +/- 2.8 versus 10.8 +/- 3.6 mIU/ml). There were also no statistical differences in the HMG dosage (26.8 +/- 1.8 versus 28.5 +/- 1.5), the number of oocytes retrieved (7.6 +/- 3.0 versus 8.1 +/- 4.3), the number of oocytes fertilized (5.3 +/- 2.1 versus 5.6 +/- 3.0) and the number of embryos transferred (3.5 +/- 1.3 versus 3.4 +/- 1.6). There was no evidence of a premature LH surge in either group, but two patients appeared to have a poor response in the leuprolide acetate group (group I). There were 11 pregnancies (21.2%) after the use of leuprolide acetate and 12 pregnancies (25.0%) in those given leuprolide acetate depot; no statistical difference existed between these two groups. Thus, a s.c. low-dose leuprolide acetate depot injection may offer a useful alternative for pituitary suppression in ovarian stimulation for IVF.

[Correlation between development indices and later intelligence quotients--the follow-up study of chlorinated biphenyls affected children]

All intelligence tests are for children old than two and a half years; we still do not have an intelligence assessment tool for children younger than this age. If we knew the relationship between the intelligence quotient and developmental indices as measured by the Bayley Scale of Infant Development (BSID), it would allow us to assess the mental development of young children earlier and to start adequate management sooner. The present study was designed to meet this need. We collected our data from a six-year follow-up study of Yu-Cheng (oil disease) children born to mothers who had a history of ingesting rice cooking oil contaminated with polychlorinated biphenyls (PCBs) in 1978-1979 and their matched controls. We analyzed the correlations between the developmental indices of the BSID assessed on 44 pairs of Yu-Cheng children and their controls in 1985 and the Stanford-Binet Intelligence Quotients (S-B IQ) assessed on the same group of children in 1987 and 1988. For the matched controls, we found practically no significant correlation between the BSID developmental indices and the S-B IQ (r = .04-.20, p = .23-.82). In the Yu-Cheng children, that is at-risk group, there was a significant correlation between the Mental Developmental Index (MDI) of BSID and the S-B IQ (r = .33-.43, p = .01-.05) and between the Psychomotor Developmental Index (PDI) of BSID and the S-B IQ (r = .31-.47, p = .00-.07). We conclude that the development indices of BSID has a better predictive power on the intelligence among the at-risk group such as Yu-Cheng children.

[Effect of the overactivated central renin-angiotensin system on the concentration of brain norepinephrine and epinephrine in stroke-prone spontaneously hypertensive rats and its significances]

The content of norepinephrine (NE) and epinephrine (E) in the brain of spontaneously hypertensive rats has proved abnormal, but the cause remained unknown. It was shown in the recent work that NE content in pons, posterior hypothalamus, nucleus caudatus and E concentration in medulla oblongata, anterior and posterior hypothalamus of 12-week old stroke-prone spontaneously hypertensive rats (SHRSP) were much higher than those of age-matched Wister-Kyoto rats (WKY). SHRSP also showed higher levels of systolic blood pressure (SBP) and brain angiotensin II (A II) than WKY. Intracerebroventricular (icv) perfusion of angiotensin-converting enzyme inhibitor captopril (20 micrograms for each time and three times for each day for four weeks) inhibited the synthesis of brain A II and reduced SBP and NE, E contents in all examined brain areas in SHRSP and WKY. However, the effects of chronically perfused captopril on SBP and brain NE, E levels in SHRSP were much more significant than in WKY. The results indicate that the modulatory effects of central renin-angiotensin system (RAS) on central adrenergic and noradrenergic system might be overactivated in SHRSP, which might partially responsible for the abnormally high levels of NE, E in some of the brain areas of SHRSP.

[Preliminary studies on the relationship between the blood pressure and renin-angiotensin system in brain and blood vessels in SHRSP]

This work analyzed the relationship between A I concentration in aorta tissue and systolic blood pressure (SBP) in stroke-prone spontaneously hypertensive rats (SHRSP) at different ages. The SBP of SHRSP increased progressively with the age until the age of 20 weeks, when the SBP of SHRSP no longer elevated but sustained at a relatively high and stable level. The A I concentration in aorta of SHRSP was much higher than that of Wistar Kyoto rats at all of the three different ages. Perfusion of captopril into the lateral cerebroventricle of SHRSP for four weeks evoked a considerable decrease of A I concentration in brain as well as a significant reduction of SBP accompanied by a decrement of A I concentration in aorta and concentration of norepinephrine and epinephrine in aorta tissue and plasma. The results further confirm the close relationship between the changed activity of renin-angiotensin system localized in blood vessels during hypertension and the pathogenesis of hypertension, and indicate the possible regulative control of A I generated from central nervous system over the production of A I from blood vessels by means of facilitating the activity of peripheral sympathetic nerve system.

Comparison of the immunogenicity, efficacy and safety of 10 micrograms and 20 micrograms of a hepatitis B vaccine: a prospective randomized trial

Four thousand and one hospital staff were screened for hepatitis B virus (HBV) markers in a vaccination programme in Hong Kong. The seropositivity rate for HBsAg, anti-HBs and anti-HBc were significantly higher in the 3160 existing hospital staff than in 841 new recruits. Of the subjects negative for HBV markers, 605 were randomized to receive three doses of either 10 or 20 micrograms of the Merck Institute vaccine (HB-VAX). Compared with the 20 micrograms dose, vaccination with the 10 micrograms dose results in equal immunogenicity and efficacy at the completion of the three injections but induced a slower response rate and lower anti-HBs titres with the first two doses. The commonest side-effect of local soreness was less with the 10 micrograms dose. We conclude that (1) hospital staff working in high endemic areas should be vaccinated on recruitment and (2) the 10 micrograms dose of HB-VAX can replace the recommended 20 micrograms dose for adults, being cheaper and as efficacious.