BACKGROUND:This study provided insight into the molecular mechanisms by which exogenous basic fibroblast growth factor(bFGF)promotes wound healing. OBJECTIVE:To investigate the effect of exogenous bFGF on macrophage phenotype transition and granulation regeneration during wound repair in rats. METHODS:(1)In vitro experiment:Cells were divided into normal control group,low-dose bFGF group,high-dose bFGF group,and bFGF+valproic acid group.100 and 200 μg/L bFGF was added into the cell culture medium of low-dose bFGF group and high-dose bFGF group,respectively,while 200 μg/L bFGF and 20 mmol/L valproic acid were added into the cell culture medium of valproic acid group.EdU test,scratch test and tubule formation test were used to detect the effects of bFGF on proliferation,migration and angiogenesis of human umbilical vein endothelial cells.(2)In vivo experiment:Sprague-Dawley rats were randomly divided into model group,low-dose bFGF group,high-dose bFGF group and bFGF+valproic acid group.The open wound model of full-thickness skin defect was established in low-dose bFGF group,high-dose bFGF group and bFGF+valproic acid group.Rats in the low-and high-dose bFGF groups were given 100 and 200 μg/L bFGF through subcutaneous injection,while those in the bFGF+valproic acid group received subcutaneous injection of 200 μg/L bFGF and intraperitoneal injection of 10 mg/kg valproic acid.The wound healing rate of rats was detected at 7 and 14 days of administration.TUNEL was used to detect the apoptosis of cells in wound tissue.Enzyme linked immunosorbent assay was used to detect the serum levels of malondialdehyde,superoxide dismutase,tumor necrosis factor-α and interleukin-10.Immunofluorescence detection was conducted to detect the phenotypic transformation of macrophages in wound tissue.Immunohistochemistry was used to detect the expression of proliferating cell nuclear antigen,platelet endothelial cell adhesion molecule-1(CD31)and vascular endothelial growth factor in wound tissue.Western blot was used to detect the expression of Notch1 and Jagged1 in wound tissue. RESULTS AND CONCLUSION:(1)Compared with the normal control group,bFGF could significantly promote the proliferation,migration and angiogenesis of human umbilical vein endothelial cells in a dose-dependent manner.(2)Compared with the model group,bFGF could significantly promote wound healing,downregulate the rate of apoptosis in wound tissue,decrease the levels of malondialdehyde and tumor necrosis factor-α in serum,increase the levels of superoxide dismutase and interleukin-10,promote the conversion of macrophages to type M2 in wound tissue,upregulate the expression of proliferating cell nuclear antigen,CD31 and vascular endothelial growth factor in wound tissue,and inhibit the expression of Notch1 and Jagged1 in a dose-dependent manner.Valproic acid could partially reverse the promoting effect of bFGF on wound healing.To conclude,bFGF can significantly promote wound healing and granulation regeneration and induce the conversion of macrophages to M2,which may be related to the regulation of Notch1/Jagged1 signaling pathway.

Objective: To explore the effect of replacing rice bowls with trays on controlling the salt intake among school aged children, providing new evidence and insights for salt reduction intervention. Methods: From April to May 2024, 373 students from grades 4-9 at a boarding school in Guizhou Province were enrolled through stratified random cluster sampling, with one intervention class and one control class per grade. During the intervention period for one month, and the types of meals provided, pricing standards, and dining procedures shall remain consistent with daily operations, the intervention group ( n =181) compartmentalized trays for lunch and dinner, while the control group ( n =192) still used a rice bowl. Pre and post intervention assessments included 24 hour urine collection, questionnaire surveys, and physical measurements. The difference in differences analysis combined with multiple linear regression was used to analyze the changes in sodium intake and to evaluate the net effect of the intervention. Results: The post intervention 24 hour sodium intake in the intervention group was ( 2 222.6 ±1 013.6) mg, an increase of 94.6 mg from baseline, with no statistically significant difference ( t=1.10, P >0.05). In contrast, the post intervention 24 hour sodium intake in the control group was (2 080.5±895.7) mg, a decrease of 190.8 mg from baseline, showing a statistically significant difference ( t=-2.39, P <0.05). The difference in differences results indicated that after adjusting the model for factors such as gender, grade and dietary behaviors affecting sodium intake, the intervention group showed a net increase of 232.5 mg [ β(95%CI )=232.5(-40.3-505.2)] in 24 hour sodium intake compared to the control group, with no statistically significant net effect ( P >0.05). Conclusions Merely changing tableware is insufficient to control children s salt intake effectively. Based on continuous practical explorations and evidence based research grounded in the nudge theory, multi dimensional measures such as salt reduction education and the construction of a supportive environment should be integrated to form an intervention system that achieves synergistic and enhanced effects.

Objective To evaluate the effectiveness and safety of inferior oblique transposition combined with medial and lateral rectus surgery in the treatment of inferior oblique hyperfunction combined with V-type strabismus.Methods Thirty-nine patients with inferior oblique hyperfunction combined with V-type strabismus admitted to Jiaxing Hospital of Traditional Chinese Medicine Affiliated to Zhejiang Chinese Medical University from November 2020 to September 2021 were selected as study objects,and were divided into combined operation group(n=28)and multiple operation group(n=11)according to different surgical programs.The visual acuity,eye position,cure rate of V sign,correction rate of inferior oblique hyperfunction,oculocardiac reflex,oculogastric reflex and complications were compared between two groups.Results One month after surgery,patients of two groups recovered the first eye position,and there were no statistical significances in the number of V sign cured and the number of inferior oblique hyperfunction corrected(P>0.05).Visual acuity returned to preoperative level in both groups.There were no significant differences in oculocardiac reflex and oculogastric reflex between two groups(P>0.05).There were no inflammatory reaction,massive subconjunctival hemorrhage,subcutaneous hematoma of eyelid,retrobulbar hemorrhage and other complications in two groups.Conclusion The effect of inferior oblique transposition combined with medial and lateral rectus surgery in the treatment of inferior oblique hyperfunction combined with V-type strabismus is not inferior to that of conventional divided operation,but it can reduce the number of operations and avoid the pain caused by the second operation,which is worthy of clinical application.

Objective:To investigate the clinical characteristics and management status of children with Turner syndrome (TS) in China.Methods:As a cross-sectional study, 1 089 TS patients were included in the database of the National Collaborative Alliance for the Diagnosis and Treatment of Turner Syndrome from August 2019 to November 2023. Clinical characteristics (growth development, sexual development, organ anomalies, etc.), karyotypes, auxiliary examinations, and treatments were collected and analyzed.Results:Among the 1 089 TS cases, 809 were recorded karyotypes. The karyotype distribution was as follows: 45, X in 317 cases (39.2%), X chromosome structural variants (including partial deletions of p or q arm, ring chromosome, and marker chromosome) in 89 cases (11.0%), 45, X/46, XX mosaicism in 158 cases (19.5%), mosaicism with X chromosome structural variants in 209 cases (25.8%), and presence of Y chromosome material in 36 cases (4.4%). Among the 824 TS cases, the age of diagnosis was 9.7(6.4, 12.2) years, with a height standard deviation score (HtSDS) of -3.1±1.2. Five hundred and fifty three cases underwent growth hormone (GH) stimulation test, and 352 cases (63.7%) had GH peak values <10 μg/L and 75.9% (577/760) had low IGF1 levels, with IGF1 SDS ≤-2 accounting for 38.2% (290 cases). Among 471 cases aged ≥8 years, 132 cases (28.0%) showed spontaneous sexual development (mean bone age (11.0±1.7) years), 10 cases had spontaneous menarche (mean bone age (12.0±2.2) years), and 2 cases had regular menstrual cycles. Common physical features included cubitus valgus (311 cases (28.5%)), neck webbing (188 cases (17.2%)), low posterior hairline (185 cases (17.0%)), shield chest (153 cases (14.0%)), high arched palate (127 cases (11.6%)), short fourth metacarpal (43 cases (3.9%)), and spinal abnormalities (38 cases (3.5%)). Congenital cardiovascular and urogenital anomalies occurred in 91 cases (19.4%) and 66 cases (12.0%)respectively. Abdominal ultrasound in 33 cases (7.2%) indicated fatty liver, hepatomegaly, intrahepatic bile duct stones, and splenomegaly. Among 23 cases undergoing oral glucose tolerance test (OGTT) test, 2 were diagnosed with diabetes mellitus and 4 with impaired glucose tolerance. Following diagnosis, 669 cases (80.7%) received rhGH treatment at a chronological age of (9±4) years and bone age of (8.3±3.2) years. Additionally, 112 cases (19.4%) received sex hormone replacement therapy starting at the age of (14±4) years and bone age of (12.6±1.2) years.Conclusions:The karyotypes of 45, X and mosaicism were most common in Chinese children with TS. The clinical manifestations were mainly short stature and gonadal dysplasia. However, a few TS children could be in the normal range of height, and some cases among those aged of ≥8 years old had spontaneous sexual development. Some exhibited physical features, congenital cardiovascular and urogenital anomalies, and dysfunction of the hypothalamic-pituitary-IGF1 axis. Moreover, a few of them developed impaired glucose tolerance and diabetes mellitus. Following diagnosis, most of the patients received rhGH treatment, and a few of them received sex hormone replacement therapy.

Objective:To prepare the chitin/hyaluronic acid/collagen hydrogel loaded with mouse adipose-derived stem cells and to explore its effects on wound healing of full-thickness skin defects in rats.Methods:The research was an experimental research. Chitin nanofibers were prepared by acid hydrolysis and alkaline extraction method, and then mixed with hyaluronic acid and collagen to prepare chitin/hyaluronic acid/collagen hydrogels (hereinafter referred to as hydrogels). Besides, the hydrogels loaded with mouse adipose-derived stem cells were prepared. Thirty male 12-week-old guinea pigs were divided into negative control group, positive control group, and hydrogel group according to the random number table, with 10 guinea pigs in each group. Ethanol, 4-aminobenzoic acid ethyl ester, or the aforementioned prepared hydrogels without cells were topically applied on both sides of back of guinea pigs respectively for induced contact and stimulated contact, and skin edema and erythema formation were observed at 24 and 48 h after stimulated contact. Adipose-derived stem cells from mice were divided into normal control group cultured routinely and hydrogel group cultured with the aforementioned prepared hydrogels without cells. After 3 d of culture, protein expressions of platelet-derived growth factor-D (PDGF-D), insulin-like growth factor-Ⅰ (IGF-Ⅰ), and transforming growth factor β 1 (TGF-β 1) were detected by Western blotting ( n=3). Eight male 8-week-old Sprague-Dawley rats were taken and a circular full-thickness skin defect wound was created on each side of the back. The wounds were divided into blank control group without any treatment and hydrogel group with the aforementioned prepared hydrogels loaded with adipose-derived stem cells applied. Wound healing was observed at 0 (immediately), 2, 4, 8, and 10 d after injury, and the wound healing rate was calculated at 2, 4, 8, and 10 d after injury. Wound tissue samples at 10 d after injury were collected, the new tissue formation was observed by hematoxylin-eosin staining; the concentrations of interleukin-1α (IL-1α), IL-6, IL-4, and IL-10 were detected by enzyme-linked immunosorbent assay method; the expressions of CD16 and CD206 positive cells were observed by immunohistochemical staining and the percentages of positive cells were calculated. The sample numbers in animal experiment were all 8. Results:At 24 h after stimulated contact, no skin edema was observed in the three groups of guinea pigs, and only mild skin erythema was observed in 7 guinea pigs in positive control group. At 48 h after stimulated contact, skin erythema was observed in 8 guinea pigs and skin edema was observed in 4 guinea pigs in positive control group, while no obvious skin erythema or edema was observed in guinea pigs in the other two groups. After 3 d of culture, the protein expression levels of PDGF-D, IGF-I, and TGF-β 1 in adipose-derived stem cells in hydrogel group were significantly higher than those in normal control group (with t values of 12.91, 11.83, and 7.92, respectively, P<0.05). From 0 to 10 d after injury, the wound areas in both groups gradually decreased, and the wounds in hydrogel group were almost completely healed at 10 d after injury. At 4, 8, and 10 d after injury, the wound healing rates in hydrogel group were (38±4)%, (54±5)%, and (69±6)%, respectively, which were significantly higher than (21±6)%, (29±7)%, and (31±7)% in blank control group (with t values of 3.82, 3.97, and 4.05, respectively, Pvalues all <0.05). At 10 d after injury, compared with those in blank control group, the epidermis in wound in hydrogel group was more intact, and there were increases in hair follicles, blood vessels, and other skin appendages. At 10 d after injury, the concentrations of IL-1α and IL-6 in wound tissue in hydrogel group were significantly lower than those in blank control group (with tvalues of 8.21 and 7.99, respectively, P<0.05), while the concentrations of IL-4 and IL-10 were significantly higher than those in blank control group (with tvalues of 6.57 and 9.03, respectively, P<0.05). The percentage of CD16 positive cells in wound tissue in hydrogel group was significantly lower than that in blank control group ( t=8.02, P<0.05), while the percentage of CD206 positive cells was significantly higher than that in blank control group ( t=7.21, P<0.05). Conclusions:The hydrogel loaded with mouse adipose-derived stem cells is non-allergenic, can promote the secretion of growth factors in adipose-derived stem cells, promote the polarization of macrophages to M2 phenotype in wound tissue in rats with full-thickness skin defects, and alleviate inflammatory reaction, thereby promoting wound healing.

Objective To investigate the effect of fear-induced stress during pregnancy on the expression of glucose transporters(GLUT)in the placenta,providing evidence for the theory of fetal damage caused by fear-induced stress during pregnancy.Methods Twenty pregnant Wistar rats were randomly divided into a control group and a model group of 10 rats each.In the model group,a fear-induced stress model was established using the modified bystander electroshock method for 20 days.After the experiment,the number of offspring and the weights of the placenta and fetal rats were measured,and the placental efficiency was calculated.Transmission electron microscopy was used to observe the morphological changes of placental cells.Bioinformatics analysis was performed to screen for differential genes in placentas affected by pregnancy stress-phobia,and gene set enrichment analysis was performed.Protein immunoblotting(Western Blot),Real-time fluorescence quantitative polymerase chain reaction(Real-time PCR),and immunohistochemistry were used to detect the expression levels of GLUT1,GLUT3,GLUT6,and GLUT7 proteins and genes.Results The placental efficiency was significantly reduced in the model group compared with that in the control group.The result of transmission electron microscopy in the model group showed that the placental microvilli were sparse and short and that the mitochondria and endoplasmic reticulum were swollen.Gene set enrichment analysis revealed that placental genes were significantly enriched in cellular glucose homeostasis in the model group compared with those in the control group.The result of Western Blot,Real-time PCR,and immunohistochemistry indicated a decrease in both the protein and gene expression levels of GLUT1,GLUT6,and GLUT7 in the placenta of pregnant rats.Conclusions Prenatal exposure to fear-induced stress may lead to adverse pregnancy outcomes.These adverse outcomes are potentially associated with reduced levels of three key GLUTs in the placenta:GLUT1,GLUT6,and GLUT7.

Objective:To investigate the current status on fundamental construction of clinical laboratories in China.Methods:A web-based external quality assessment (EQA) system was used to collect basic information from the clinical laboratories that participated in EQA program of National Center for Clinical Laboratory in 2023. The indicators include the construction of laboratory information systems (LIS), laboratory building area, human resource, and the number of clinical testing item. The comparisons of the indicators between different types of laboratories were tested.Results:A total of 14 405 clinical laboratories submitted the required information in 2023. Guangdong province accounted for the highest proportion of the numver of laboratories, which is 10.6% (1 533/14 405). The building area and staff numbers in the independent clinical laboratory were higher than other institutions, which were 1 400 (850, 2 196) m 2 and 20 (12, 35), respectively. The building areas, the staff numbers and the number of clinical testing item of tertiary hospitals and general hospitals were significantly higher than other hospitals. The building areas of the tertiary hospitals and the general hospitals were respectively 1 050 (600, 1 800) m 2 and 1 000 (500, 1 600) m 2, and the staff numbers were respectively 30 (19, 45) and 26 (17, 39). Besides, the number of clinical testing item were 287 (189, 388) and 285 (198, 378), respectively. The proportion of staff in hospitals with master′s degrees or higher titles was 18.2% (52 138/286 855). Meanwhile, 17.4% (49 280/282 528) of the staff had higher academic title. It showed that 24.5% (3 528/14 405) of the clinical laboratories still have no LIS. Conclusion:The fundamental construction in different type of clinical laboratories varied significantly in China. The clinical laboratories should strengthen the construction of information systems and pay more attention to human resources.

ObjectiveTo observe the intervention effect of Chaihu and Longgu Mulitang （CLMT） on rat depression model prepared by chronic unpredictable mild stress （CUMS） based on cyclic adenosine monophosphate （cAMP）/protein kinase A （PKA）/cAMP-response element-binding protein （CREB）-brain-derived neurotrophic factor （BDNF） signaling pathway. MethodSixty SD rats were divided into normal group， model group， and CLMT low-， medium- and high-dose groups and fluoxetine group （positive control） according to random number table. They， except the normal group， were treated with CUMS for 49 days to prepare the rat depression model. The CLMT low-， medium- and high-dose groups were given 2.89， 5.78 11.56 g·kg^-1 of CHMD granules， respectively， and the fluoxetine group was given 2.06 mg·kg^-1 of fluoxetine hydrochloride on the 29^th day. The normal group and the model group received equal volume of normal saline for 21 days. The behavioral performance of rats were observed by open field test and forced swim test. The levels of 5-hydroxytryptamine （5-HT）， norepinephrine （NE） and cAMP in rat hippocampus were measured by enzyme-linked immunosorbent assay （ELISA）. The mRNA expressions of PKA， CREB， and BDNF in rat hippocampus were detected by real-time fluorescence quantitative polymerase chain reaction （Real-time PCR）， and the protein expressions of PKA and BDNF were detected by Western blot. Immunohistochemistry was used to determine the expression of CREB， and hematoxylin and eosin （HE） staining and Nissl staining were used to observe the morphological changes of hippocampus. ResultCompared with the conditions in the normal group， the immobility time of the model group in the forced swim test was increased （P<0.01） and the total movement distance， residence time in central area， number of entries in central area and movement distance in central area were decreased （P<0.01）. Additionally， the contents of 5-HT， NE and cAMP in hippocampus of the model group as well as the protein expressions of PKA， BDNF and CRE，the mRNA expressions of BDNF and CREB were lower than those in the normal group （P<0.01）. Compared with the model group， the CLMT groups had reduced immobility time （P<0.01）， elevated total movement distance， residence time in central area， number of entries in central area and movement distance in central area （P<0.05， P<0.01）， up-regulated contents of 5-HT， NE and cAMP in hippocampus （P<0.05， P<0.01）， and up-regulated protein expressions of PKA， BDNF and CREB and mRNA expressions of BDNF and CREB （P<0.01）. HE staining and Nissl staining showed that CLMT significantly improved the neuronal structure in rat hippocampus. ConclusionCLMT alleviates the anxiety and depression of rats. These effects may be mediated by regulating monoamine neurotransmitters 5-HT and NE in hippocampus of depressed rats， activating cAMP/PKA/CREB/BDNF signaling pathway， up-regulating the expression of BDNF and protecting hippocampal structure and function .

ObjectiveTo observe the effects of Cuscutae Semen on the learning and memory ability， N6-methyladenosine （m⁶A）-related modification enzymes and total m⁶A level in hippocampus of the offspring of fear-damaged pregnant rats. MethodForty-five pregnant rats were randomly divided into blank group， model group and Cuscutae Semen group. From the 1^st day to the 19^th day of pregnancy， rats in the model group and the Cuscutae Semen group were induced by observing electric shock of other rats. The Cuscutae Semen group was treated with 5 g·kg^-1·d^-1 Cuscutae Semen decoction （ig）， while the other two groups were treated with the same amount of purified water. The offspring were assigned following the grouping method of their maternal generation. The behavioral changes of the offspring were tested by Morris water maze on 21^st day after birth， and the development of hippocampal neurons was observed by transmission electron microscopy. The mRNA and protein expression levels of methyltransferase-like 3 （METTL3）， METTL14， Wilms tumor 1 associated protein （WTAP）， fat mass and obesity-associated protein （FTO） and Alk B homologue 5 （ALKBH5） were detected by Real-time polymerase chain reaction （Real-time PCR）， Western blot and immunohistochemistry （IHC）. The total content of m⁶A in hippocampus was determined by high performance liquid chromatography tandem mass spectrometry （LC-MS/MS）. ResultCompared with the conditions in the blank group， the average latency duration in the model group was prolonged， and the number of entries in the target quadrant， the target quadrant duration and the number of crossing the platform were decreased （P<0.01）. Additionally， the model group had seriously damaged structure of hippocampal CA1 and CA3 neurons， swollen mitochondria， expanded endoplasmic reticulum， and small number of synapses with some having blurred structure， and the expression levels of METTL3， METTL14， FTO， ALKBH5 as well as the total m⁶A level were lower than those in the blank group （P<0.05，P<0.01）. Compared with the model group， the Cuscutae Semen group had shortened average latency duration， increased number of entries in the target quadrant， target quadrant duration and number of crossing the platform （P<0.01）， alleviated damage of hippocampal CA1 and CA3 neurons， fine structure of mitochondrial and endoplasmic reticulum， and clear， intact and dense synapses. And the expression levels of METTL3， METTL14， FTO as well as the total level of m⁶A were up regulated， while the expression level of ALKBH5 was down regulated in the Cuscutae Semen group （P<0.05，P<0.01）. ConclusionCuscutae Semen improved the learning and memory ability of the offspring of the rats affected by fear damaging kidney during pregnancy， protected hippocampal neurons， and up-regulated the expression levels of METTL3， METTL14， FTO and the total m⁶A level in hippocampus.

Objective:To establish preliminary quality specifications for emergency examination turnaround time (TAT).Methods:The National Center for Clinical Laboratories organized 31 provinces (autonomous regions and municipalities directly) and Xinjiang production and Construction Corps centers to launch a synchronous Quality Indicators (QIs)-External Quality Assessment (EQA) program and the collected data were reported via developed online EQA system. The essential information of the clinical laboratories, the data of pre-examination and intra-laboratory TAT quality indicators of emergency departments at each specialty (biochemistry, automatic immunity, three routines tests and coagulation) and four specific tests (blood potassium, troponin I/T, white blood cell count and international normalized ratio (INR)) were collected from 2019 to 2021. TAT returned the median and 90th percentile ( P90) of the specified month were calculated. The median (lower quartile, upper quartile) of the TAT returned laboratories were calculated and second result grading statistics for 2021 (2 422 tertiary hospital and 5 088 secondary hospital) were performed to understand the difference of pre-examination and the laboratory TAT between different tertiary hospitals. Results:From 2019 to 2021, there were 9 540 laboratories, 9 709 laboratories and 10 653 returned laboratories. The pre-examination TAT of each specialty was similar, and the results were relatively stable. The median distribution was about 15 (10, 30) min, and the monthly P90 distribution was about 20 (10, 30) min. The distribution results of the median intra-laboratory TAT in each specialty were as follows: automatic immunity≥biochemistry>coagulation>three routine tests. The distribution of the latest (second result in 2021) survey results of each specialty were as follows: automatic immunity 53 (30, 60) min, biochemistry 45 (30, 60) min, coagulation 30 (23, 40) min, and three routine tests 20 (11, 30) min. The median results of monthly P90 of intra-laboratory TAT were as follows: 60 min for automatic immunity and biochemistry specialty, about 38 min for coagulation specialty, and about 27 min for three routines tests. The hierarchical statistical results showed that the monthly P90 distribution of laboratory TAT of the pre-examination and intra-laboratory TAT from the tertiary hospital was higher than that of the secondary hospital. The pre-examination TAT of each specialty of the tertiary hospital/secondary hospital was as follows: biochemistry 35 (22, 60)/20 (11, 30) min, automatic immunity 33 (20, 60)/20 (10, 30) min, three routine tests 30 (20, 49)/20 (10, 30) min and coagulation 31 (20, 58)/20 (10, 30) min, the intra-laboratory TAT of each specialty of the tertiary hospital/secondary hospital was as follows: biochemistry 65 (50, 91)/60 (40, 70) min, automatic immunity 75 (55, 113)/60 (40, 90) min, three routine tests 30 (23, 38)/28 (19, 30) min and coagulation 53 (36, 72)/35 (30, 57) min. In terms of the distribution results of the median of intra-laboratory TAT of the four specific tests, 96.76% (9 484/9 801) of the blood potassium and 95.96% (8 733/9 101) of the troponin I/T medical institutions were TAT within 69 min in the laboratories, 95.34% (9 679/10 152) of the white blood cell count medical institutions were TAT within 31 min in the laboratories, and 98.85% (9 462/9 572) of the INR medical institutions were TAT within 66 min in the laboratories. Conclusions:This survey provides a preliminary quality specification for the emergency department turnaround time at each specialty. Lower quartile, median and upper quartile of the monthly P90 at the tertiary and secondary hospitals can be used to define the best, appropriate and minimum performance levels, respectively.