Is metformin still the most efficacious first-line oral hypoglycaemic drug in treating type 2 diabetes? A network meta-analysis of randomized controlled trials.

OBJECTIVES: The objective of the study is to compare the efficacy of hypoglycaemic drugs for type 2 diabetes mellitus (T2DM) by network meta-analysis of randomized controlled trials (RCTs). METHODS: We compared 11 major oral hypoglycaemic drugs under five categories evaluated by RCTs as drug monotherapy for the patients with T2DM, measuring glycosylated haemoglobin (%) or fasting plasma glucose (mmol L-1 ) as outcomes. RCT quality was assessed with the Cochrane risk of bias tool. Network meta-analysis estimated the mean differences and 95% credible intervals. Subgroup and sensitivity analyses were performed to determine the results robustness. The Grading of Recommendation, Assessment, Development, and Evaluation evidence strength was assessed. RESULTS: Seventy-five RCTs including 33,830 patients were identified. Their study quality was high. Regarding glycosylated haemoglobin, top three anti-diabetics were repaglinide (mean differences -1.39 [95% credible intervals -1.75 to -1.03]), gliclazide (-1.37 [-2.04 to -0.71]) and metformin (-1.13 [-1.37 to -0.90]), against placebo. Regarding fasting plasma glucose, top three anti-diabetics were repaglinide (-2.01 [-2.75 to -0.97]), metformin (-1.72 [-2.16 to -1.27]) and glipizide (-1.57 [-2.44 to -0.64]), against placebo. There was no difference between metformin and repaglinide. Subgroup and sensitivity analyses found the results to be robust. The evidence strength was moderate to high. CONCLUSION: This meta-analysis showed that repaglinide and metformin would be the most efficacious oral drugs for first-line monotherapy of T2DM.

Equivalent magnetic vector potential model for low-frequency magnetic exposure assessment.

In this paper, a novel source model based on a magnetic vector potential for the assessment of induced electric field strength in a human body exposed to the low-frequency (LF) magnetic field of an electrical appliance is presented. The construction of the vector potential model requires only a single-component magnetic field to be measured close to the appliance under test, hence relieving considerable practical measurement effort-the radial basis functions (RBFs) are adopted for the interpolation of discrete measurements; the magnetic vector potential model can then be directly constructed by summing a set of simple algebraic functions of RBF parameters. The vector potentials are then incorporated into numerical calculations as the equivalent source for evaluations of the induced electric field in the human body model. The accuracy and effectiveness of the proposed model are demonstrated by comparing the induced electric field in a human model to that of the full-wave simulation. This study presents a simple and effective approach for modelling the LF magnetic source. The result of this study could simplify the compliance test procedure for assessing an electrical appliance regarding LF magnetic exposure.

Prostaglandin E2 regulates renal function in C57/BL6 mouse with 5/6 nephrectomy.

AIMS: To investigate the roles of cyclooxygenases (COX) and their metabolites in C57/BL6 mice with 5/6 nephrectomy, an animal model of chronic renal failure. MAIN METHODS: C57/BL6 mice were grouped into sham-operated (2K), one kidney removal (1K) and 5/6 nephrectomy groups (5/6Nx). Renal resistive index was measured by ultrasonography. Blood, aortae, renal arteries and renal cortex were collected for measurement of kidney function, assessment of vascular responsiveness, Western blotting, immuohistochemistry and enzyme-linked immunosorbent assays. KEY FINDINGS: After four weeks, acetylcholine-induced relaxations were blunted in renal arteries of 1K and 5/6Nx mice; indomethacin, a non-selective COX inhibitor, improved the response in 5/6Nx, but not in 1K renal arteries. In 5/6Nx renal arteries, but not in 1K preparations, the protein presence of endothelial nitric oxide synthase (eNOS) was decreased, while that of COX-2 and its products [prostacyclin and thromboxane A2] were increased. The renal resistive index was lower in 5/6Nx mice, suggesting a lower resistance in the renal microvasculature. In the renal cortex of 5/6Nx mice, eNOS protein presence was increased; while the presence of COX-2 was not detectable. The prostaglandin E2 level was lower in the 5/6Nx cortex than in the other two groups. SIGNIFICANCE: The early stage of renal mass removal is associated with increased renal arterial constriction and reduced microvascular resistance. The former is due to downregulation of eNOS and upregulation of COX-2, leading to an increased production of prostacyclin and thromboxane A2. A reduced production of PGE2 in the renal cortex is important for maintaining normal renal function.

Endothelium-dependent hyperpolarization: age, gender and blood pressure, do they matter?

Under physiological conditions, the endothelium generates vasodilator signals [prostacyclin, nitric oxide NO and endothelium-dependent hyperpolarization (EDH)], for the regulation of vascular tone. The relative importance of these two signals depends on the diameter of the blood vessels: as the diameter of the arteries decreases, the contribution of EDH to the regulation of vascular tone increases. The mechanism involved in EDH varies with species and blood vessel types; nevertheless, activation of endothelial intermediate- and small-conductance calcium-activated potassium channels (IKCa and SKCa , respectively) is characteristic of the EDH pathway. IKCa - and SKCa -mediated EDH are reduced with endothelial dysfunction, which develops with ageing and hypertension, and is less pronounced in female than in age-matched male until after menopause. Impaired EDH-mediated relaxation is related to a reduced involvement of SKCa , so that the response becomes more dependent on IKCa . The latter depends on the activation of adenosine monophosphate-activated protein kinase (AMPK) and silent information regulator T1 (SIRT1), proteins associated with the process of cellular senescence and vascular signalling in response to the female hormone. An understanding of the role of AMPK and/or SIRT1 in EDH-like responses may help identifying effective pharmacological strategies to prevent the development of vascular complications of different aetiologies.

Transient Receptor Potential Channel Opening Releases Endogenous Acetylcholine, which Contributes to Endothelium-Dependent Relaxation Induced by Mild Hypothermia in Spontaneously Hypertensive Rat but Not Wistar-Kyoto Rat Arteries.

Mild hypothermia causes endothelium-dependent relaxations, which are reduced by the muscarinic receptor antagonist atropine. The present study investigated whether endothelial endogenous acetylcholine contributes to these relaxations. Aortic rings of spontaneously hypertensive rats (SHRs) and normotensive Wistar-Kyoto (WKY) rats were contracted with prostaglandin F2 α and exposed to progressive mild hypothermia (from 37 to 31°C). Hypothermia induced endothelium-dependent, Nω-nitro-l-arginine methyl ester-sensitive relaxations, which were reduced by atropine, but not by mecamylamine, in SHR but not in WKY rat aortae. The responses in SHR aortae were also reduced by acetylcholinesterase (the enzyme responsible for acetylcholine degradation), bromoacetylcholine (inhibitor of acetylcholine synthesis), hemicholinium-3 (inhibitor of choline uptake), and vesamicol (inhibitor of acetylcholine release). The mild hypothermia-induced relaxations in both SHR and WKY rat aortae were inhibited by AMTB [N-(3-aminopropyl)-2-[(3-methylphenyl)methoxy]-N-(2-thienylmethyl)-benzamide; the transient receptor potential (TRP) M8 inhibitor]; only those in SHR aortae were inhibited by HC-067047 [2-methyl-1-[3-(4-morpholinyl)propyl]-5-phenyl-N-[3-(trifluoromethyl)phenyl]-1H-pyrrole-3-carboxamide; TRPV4 antagonist] while those in WKY rat aortae were reduced by HC-030031 [2-(1,3-dimethyl-2,6-dioxo-1,2,3,6-tetrahydro-7H-purin-7-yl)-N-(4-isopropylphenyl)acetamide; TRPA1 antagonist]. The endothelial uptake of extracellular choline and release of cyclic guanosine monophosphate was enhanced by mild hypothermia and inhibited by HC-067047 in SHR but not in WKY rat aortae. Compared with WKY rats, the SHR preparations expressed similar levels of acetylcholinesterase and choline acetyltransferase, but a lesser amount of vesicular acetylcholine transporter, located mainly in the endothelium. Thus, mild hypothermia causes nitric oxide-dependent relaxations by opening TRPA1 channels in WKY rat aortae. By contrast, in SHR aortae, TRPV4 channels are opened, resulting in endothelial production of acetylcholine, which, in an autocrine manner, activates muscarinic receptors on neighboring cells to elicit endothelium-dependent relaxations in response to mild hypothermia.

Kaempferol enhances endothelium-dependent relaxation in the porcine coronary artery through activation of large-conductance Ca(2+) -activated K(+) channels.

BACKGROUND AND PURPOSE: Kaempferol, a plant flavonoid present in normal human diet, can modulate vasomotor tone. The present study aimed to elucidate the signalling pathway through which this flavonoid enhanced relaxation of vascular smooth muscle. EXPERIMENTAL APPROACH: The effect of kaempferol on the relaxation of porcine coronary arteries to endothelium-dependent (bradykinin) and -independent (sodium nitroprusside) relaxing agents was studied in an in vitro organ chamber setup. The whole-cell patch-clamp technique was used to determine the effect of kaempferol on potassium channels in porcine coronary artery smooth muscle cells (PCASMCs). KEY RESULTS: At a concentration without direct effect on vascular tone, kaempferol (3 × 10(-6) M) enhanced relaxations produced by bradykinin and sodium nitroprusside. The potentiation by kaempferol of the bradykinin-induced relaxation was not affected by N(ω)-nitro-L-arginine methyl ester, an inhibitor of NO synthase (10(-4) M) or TRAM-34 plus UCL 1684, inhibitors of intermediate- and small-conductance calcium-activated potassium channels, respectively (10(-6) M each), but was abolished by tetraethylammonium chloride, a non-selective inhibitor of calcium-activated potassium channels (10(-3) M), and iberiotoxin, a selective inhibitor of large-conductance calcium-activated potassium channel (KCa 1.1; 10(-7) M). Iberiotoxin also inhibited the potentiation by kaempferol of sodium nitroprusside-induced relaxations. Kaempferol stimulated an outward-rectifying current in PCASMCs, which was abolished by iberiotoxin. CONCLUSIONS AND IMPLICATIONS: The present results suggest that, in smooth muscle cells of the porcine coronary artery, kaempferol enhanced relaxations caused by endothelium-derived and exogenous NO as well as those due to endothelium-dependent hyperpolarization. This vascular effect of kaempferol involved the activation of KCa 1.1 channels.

Low-dose desmopressin improves hypothermia-induced impairment of primary haemostasis in healthy volunteers.

Mild hypothermia (34-35 °C) increases peri-operative blood loss. We have previously demonstrated the beneficial effect of in vitro desmopressin on impairment of primary haemostasis associated with hypothermia. This study evaluated subcutaneous desmopressin in 52 healthy volunteers, randomly assigned to receive either normal saline or desmopressin 1.5, 5 or 15 µg (with 13 in each group). Blood samples were collected before and 2 h after drug administration and incubated at 32 and 37 °C. Platelet function analyser PFA-100(®) closure times were measured. Hypothermia at 32 °C prolonged mean (95% CI) closure times (for adenosine diphosphate/collagen by 11.3% (7.5-15.2%) and for adrenaline/collagen by 16.2% (11.3-21.2%); these changes were reversed by desmopressin. A very small dose was found to be effective (1.5 µg); this dose did not significantly change closure times at 37 °C, but fully prevented its prolongation at 32 °C. Subcutaneous desmopressin prevents the development of hypothermia-induced impairment of primary haemostasis.

Effects of the aqueous extract of Salvia Miltiorrhiza (danshen) and its magnesium tanshinoate B-enriched form on blood pressure.

Danshen is the dried root and rhizome of the Chinese medicinal plant Salvia miltiorrhiza Bunge (Labiatae), which has been used to treat hypertension and myocardial infarction. One of its water-soluble active components is magnesium tanshinoate B (MTB). The present study examined and compared the cardiovascular effects of the water-soluble extract of danshen (SME) and its MTB-enriched form (containing 70% of MTB (MTB70)). Anaesthetized rats were infused intravenously with saline or phenylephrine to achieve a normal or elevated blood pressure, respectively. Different doses of SME, MTB70 or vehicle were then injected intravenously and their effect on blood pressure was monitored. The results indicate that SME and MTB70 reduce blood pressure dose-dependently. Independently of the initial blood pressure, SME caused a smaller reduction in blood pressure than MTB70. In rats infused with phenylephrine, MTB70 caused greater decreases in blood pressure than in rats infused with saline, while the responses to SME did not differ between the two groups. From these findings, it appears that MTB is one of the major components responsible for the cardiovascular effects of danshen, and that the beneficial cardiovascular effect of the extract is more prominent under conditions of elevated blood pressure.

Delayed spontaneous hepatogastric fistula formation following transcatheter arterial embolisation and radiotherapy for hepatocellular carcinoma.

A 58-year-old male patient with an unresectable 10 cm liver lesion that was a histologically proven hepatocellular carcinoma (HCC) underwent transcatheter hepatic artery embolisation (TAE). 4 months later, the patient was referred for salvage radiotherapy owing to local recurrence. The HCC became an encapsulated tumour with central necrosis after radiotherapy. The patient enjoyed a normal lifestyle for 9 years, with local control achieved by radiotherapy, until a hepatogastric fistula developed. Although the hepatogastric fistula resolved with surgical drainage, the patient later died from septic shock. Hepatogastric fistula is a rare but serious complication after TAE and radiotherapy for HCC. Development of fever, abdominal pain and jaundice after an initial symptom-free interval should arouse suspicion of hepatogastric fistula formation from an encapsulated necrotic HCC or a ruptured liver abscess. Because the mortality is high, aspiration of a suspected necrotic lesion should be performed as soon as possible. Patients with risk factors, including liver cirrhosis and large lesions close to the adjacent gastrointestinal tract, are especially vulnerable. Gas formation within a necrotic liver tumour requires immediate drainage.

Structure-activity relationships of flavonoids for vascular relaxation in porcine coronary artery.

Flavonoids are polyphenolic compounds that are widespread in the plant kingdom, and structure-activity relationships (SAR) for vascular relaxation effects were examined for 17 of them using porcine coronary arteries. Density functional theory was employed to calculate the chemical parameters of these compounds. The order of potency for vascular relaxation was as follows: flavones (apigenin and luteolin) >or= flavonols (kaempferol and quercetin)>isoflavones (genistein and daidzein)>flavanon(ol)es (naringenin)>chalcones (phloretin)>anthocyanidins (pelargonidin)>flavan(ol)es ((+)-catechin and (-)-epicatechin). SAR analysis revealed that for good relaxation activity, the 5-OH, 7-OH, 4'-OH, C2=C3 and C4=O functionalities were essential. Comparison of rutin with quercetin, genistin with genistein, and puerarin with daidzein demonstrated that the presence of a glycosylation group greatly reduced relaxation effect. Total energy and molecular volume were also predictive of their relaxation activities. Our findings indicated that the most effective relaxing agents are apigenin, luteolin, kaempferol and genistein. These flavonoids possess the key chemical structures demonstrated in our SAR analysis.

Prosthetic devices: challenges and implications of robotic implants and biological interfaces.

Although among designs of prosthetics there have been some successes in the design of functional robotic implants, there remain many issues and challenges concerned with the failure to meet the 'ideal' requirements of a satisfactory prosthetic. These 'ideals' require the device to be easy to control, comfortable to wear, and cosmetically pleasing. Because the literature on prosthetics and robotic implants are voluminous, this review focuses on four topics to determine key challenges and opportunities underlying these interdisciplinary research areas: firstly, an artificial hand as a biomimetic; secondly, prosthetic implants (electromyography signals and control); thirdly, prosthetic implants and tissue reactions to the material(s) of implants; fourthly, how inflammatory responses of cells and tissues surrounding implanted sensors interfere with the signal transmission of such sensors. This review also notes the importance of the biological interfaces that robotic implants and other prosthetic devices are in contact with and how an improved knowledge of pathophysiological changes at such biological interfaces will lead to improved and more biocompatible designs of prosthetics. This review concludes with the vision that, to develop a design that satisfies the above 'ideals', an interdisciplinary team of biomedical and tissue engineers, and biomaterial and biomedical scientists is needed to work together holistically and synergistically.

Three-dimensional conformal radiotherapy for the treatment of arteriovenous shunting in patients with hepatocellular carcinoma.

The objective of this study is to evaluate the efficacy of radiotherapy for the treatment of arteriovenous shunting (AVS) in patients with hepatocellular carcinoma (HCC). Between November 1997 and April 2005, 20 HCC patients with AVS were referred to our department for radiotherapy. The radiation was delivered with 10-15 MV X-ray given 5 days per week at 2 approximately 2.5 Gy per fraction. Total doses ranged from 45 to 64 Gy (median dose 60 Gy). The patients were followed up with color Doppler sonography. When non-invasive imaging suggested obliteration, X-ray angiography was performed to verify the results. Four of the 20 AVS proved to be completely obliterated at X-ray angiography in 1.9, 2.8, 1.8 and 2.9 months after radiotherapy. One of the remaining 16 showed obvious regression on Doppler sonography 0.5 months after radiotherapy, but X-ray angiography was not performed to verify the result. Radiation-related hepatic failure did not occur during the follow-up period. In conclusion, radiotherapy is a treatment alternative for AVS in HCC patients and gives patients with poor prognosis the chance to receive further transcatheter arterial embolization.

A randomised trial of carbetocin versus syntometrine in the management of the third stage of labour.

OBJECTIVE: Syntometrine is an effective uterotonic agent used in preventing primary postpartum haemorrhage but has adverse effects including nausea, vomiting, hypertension and coronary artery spasm. Carbetocin is a newly developed long-acting oxytocin analogue that might be used as an uterotonic agent. We compare the efficacy and safety of intramuscular (IM) carbetocin with IM syntometrine in preventing primary postpartum haemorrhage. DESIGN: Prospective, double-blinded, randomised controlled trial. SETTING: Delivery suite of a university-based obstetrics unit. POPULATION: Women with singleton pregnancy achieving vaginal delivery after and throughout 34 weeks. METHODS: Three hundred and twenty-nine eligible women were randomised to receive either a single dose of 100 microgram IM carbetocin or 1 ml IM syntometrine (a mixture of 5 iu oxytocin and 0.5 mg ergometrine) at the end of second stage of labour. MAIN OUTCOME MEASURES: Difference in haemoglobin drop measured 2 days after delivery between the two groups. RESULTS: There was no difference in the drop of haemoglobin concentration within the first 48 hours between the two groups. The incidence of additional oxytocic injections, postpartum haemorrhage (blood loss > or = 500 ml) and retained placenta were also similar. The use of carbetocin was associated with significant lower incidence of nausea (relative risk [RR] 0.18, 95% confidence interval [CI] 0.04-0.78), vomiting (RR 0.1, 95% CI 0.01-0.74), hypertension 30 minutes (0 versus 8 cases, P < 0.01) and 60 minutes (0 versus 6 cases, P < 0.05) after delivery but a higher incidence of maternal tachycardia (RR 1.68, 95% CI 1.03-3.57). CONCLUSIONS: IM carbetocin is as effective as IM syntometrine in preventing primary postpartum haemorrhage after vaginal delivery. It is less likely to induce hypertension and has a low incidence of adverse effect. It should be considered as a good alternative to conventional uterotonic agents used in managing the third stage of labour.

Kaempferol enhances endothelium-independent and dependent relaxation in the porcine coronary artery.

The vascular effects of kaempferol were investigated in isolated porcine coronary artery rings. U46619 (9,11-dideoxy-9alpha, 11alpha-methanoepoxy prostaglandin F2alpha, 30 nM) was used to contract porcine coronary arterial rings. Concentration relaxation curve of kaempferol (1 nM - 100 microM) was constructed and kaempferol demonstrated significant relaxation at high concentrations. At low concentration with no significant effect on relaxation, kaempferol (10 microM) enhanced relaxation produced by bradykinin, the calcium ionophore A23187, isoproterenol and sodium nitroprusside in endothelium-intact porcine coronary arteries. In endothelium-disrupt rings, kaempferol (10 microM) also enhanced the relaxation caused by isoproterenol, sodium nitroprusside, levcromakalim and nifedipine. On the other hand, antioxidant agents did not affect bradykinin-induced relaxation or the enhancement effect of kaempferol. In summary, a low concentration of kaempferol (10 microM), devoid of significant vascular effect, has the ability to enhance endothelium-dependent and endothelium-independent relaxations. This action of kaempferol is unrelated to its antioxidant property.

Retained products of gestation in miscarriage: an evaluation of transvaginal ultrasound criteria for diagnosing an "empty uterus".

OBJECTIVE: The purpose of this study was to compare clinical outcomes of conservative management versus surgical evacuation of retained products of gestation after misoprostol treatment for first trimester spontaneous miscarriage using less restrictive transvaginal ultrasound criteria for diagnosing "empty uterus," which were managed conservatively. STUDY DESIGN: This was a prospective, randomized, controlled trial. RESULTS: Forty-six patients who had sonographic features previously regarded as significant retained products of gestation after misoprostol treatment, ie, homogenous intrauterine dimension of more than 11 cm 2 in combined transverse and sagittal plane, or those with heterogeneous intrauterine contents were consented to randomization. The short-term complication rates of those managed conservatively were significantly higher than surgical evacuation ([9/24] 37.5% vs [0/21] 0%, P < .05). CONCLUSION: Our previously reported transvaginal ultrasound criteria of homogenous intrauterine dimension of less than 11 cm 2 in combined transverse and sagittal planes for defining "empty uterus," which requires no further treatment, cannot be "relaxed" without incurring additional complications.

Case study: a decade of changes in a small environmental engineering graduate program.

For a small graduate program in environmental engineering in a rural state in the US, it is important for the program curriculum to stay in the mainstream. While resident student enrollment is approaching a steady level, international student enrollment increases steadily, this is due in part to the out-of-state tuition waiver provided to the students. Part-time students are a significant part of the program, these students have special needs that are different from traditional full-time students that must be taken into consideration in program planning. A small program provides an attentive atmosphere for students' learning, but it also has problems that a larger program would not encounter, such as competitiveness, personal conflicts, program identity, etc. Despite success in the past, the program is likely to merge with other related programs in the university during times of budget restrictions.

Molecular epidemiology of the novel coronavirus that causes severe acute respiratory syndrome.

BACKGROUND: Severe acute respiratory syndrome (SARS) is a newly emerged disease caused by a novel coronavirus (SARS-CoV), which spread globally in early 2003, affecting over 30 countries. We have used molecular epidemiology to define the patterns of spread of the virus in Hong Kong and beyond. METHODS: The case definition of SARS was based on that recommended by WHO. We genetically sequenced the gene for the S1 unit of the viral spike protein of viruses from patients with SARS in Hong Kong (138) and Guangdong (three) in February to April, 2003. We undertook phylogenetic comparisons with 27 other sequences available from public databases (Genbank). FINDINGS: Most of the Hong Kong viruses (139/142), including those from a large outbreak in an apartment block, clustered closely together with the isolate from a single index case (HKU-33) who came from Guangdong to Hong Kong in late February. Three other isolates were genetically distinct from HKU-33 in Hong Kong during February, but none of these contributed substantially to the subsequent local outbreak. Viruses identified in Guangdong and Beijing were genetically more diverse. INTERPRETATION: The molecular epidemiological evidence suggests that most SARS-CoV from the outbreak in Hong Kong, as well as the viruses from Canada, Vietnam, and Singapore, are genetically closely linked. Three viruses found in Hong Kong in February were phylogenetically distinct from the major cluster, which suggests that several introductions of the virus had occurred, but that only one was associated with the subsequent outbreak in Hong Kong, which in turn spread globally.

Functional analysis of the hydrophobic patch on nuclear transport factor 2 involved in interactions with the nuclear pore in vivo.

Nuclear transport factor 2 (NTF2) is a small homodimeric protein that interacts simultaneously with both RanGDP and FxFG nucleoporins. The interaction between NTF2 and Ran is essential for the import of Ran into the nucleus. Here we use mutational analysis to dissect the in vivo role of the interaction between NTF2 and nucleoporins. We identify a series of surface residues that form a hydrophobic patch on NTF2, which when mutated disrupt the NTF2-nucleoporin interaction. Analysis of these mutants in vivo demonstrates that the strength of this interaction can be significantly reduced without affecting cell viability. However, cells cease to be viable if the interaction between NTF2 and nucleoporins is abolished completely, indicating that this interaction is essential for the function of NTF2 in vivo. In addition, we have isolated a dominant negative mutant of NTF2, N77Y, which has increased affinity for nucleoporins. Overexpression of the N77Y protein blocks nuclear protein import and concentrates Ran at the nuclear rim. These data support a mechanism in which NTF2 interacts transiently with FxFG nucleoporins to translocate through the pore and import RanGDP into the nucleus.

Linear accelerator based radiosurgery as a salvage treatment for skull base and intracranial invasion of recurrent nasopharyngeal carcinomas.

Nasopharyngeal carcinoma is a common disease entity in Taiwan. It can spread in the prestyloid, retrostyloid compartments, parapharyngeal space, and skull base, and induce paralysis of cranial nerves. We have treated more than 1,500 cases in the past 14 years. Since 1994, we have treated 11 cases of nasopharyngeal carcinomas with skull base invasion by linear accelerator-based stereotactic radiosurgery. There were six male and five female patients. The mean age was 48.4 years. Seven patients had symptoms of low cranial nerves. For these patients, conformal radiotherapy plus brachytherapy was used for the masses beyond the skull base. Stereotactic radiosurgery with a dose of 10 Gy to 19 Gy for one treatment was used for the masses invading the skull base. Eight patients died in follow-up periods from 5 months to 2 years 7 months. Approximately half of patients revealed good response of tumor to radiosurgery. Two patients demonstrated no response of tumors to radiosurgery. Stereotactic radiosurgery may be an adjuvant treatment for recurrent nasopharyngeal carcinomas with skull base and intracranial invasion.

Clinical characteristics of outpatients at a psycho-oncology clinic in a radiation oncology department.

BACKGROUND: Psychosocial care in cancer medicine has become increasingly important. The first psychiatric consultation-liaison (C-L) outpatient clinic in Taiwan was established in a department of radiation oncology in a medical center in Oct. 1998. METHODS: From October 1998 through January 2000, 121 patients were referred for psychosocial evaluation. Six referred patients were excluded because of cerebral complications of malignant disease or coincidental psychiatric disorder. The remaining 115 patients were referred because of psychological problems related to their malignant disease. These patients were divided into 'depression related disorder' and 'anxiety related disorder' groups according to psychiatric standard diagnoses. The records of these referred patients were retrospectively analyzed based on the psychiatric diagnoses. RESULTS: The outpatient utilization rate for psychiatric consultation escalated from 0% to 5.92% after the C-L clinic was established. Patients with nasopharynx, breast, and head and neck cancer had higher referral, rates (over 10%) than patients with other types of cancer. There were significant differences in major subjective psychiatric problems and psychological reactions between patients with psychiatric diagnosis and those without psychiatric diagnosis. Cancer patients who were diagnosed with 'depression related disorder' visited this clinic more times than those with 'anxiety related disorder'. The former received antidepressant drugs more frequently than the latter. There were also more multiple visits in the former group than the latter group. CONCLUSION: Locating a C-L clinic in a radiation oncology department improves access to psychiatric evaluation, early detection and continuous intervention can then be offered to cancer patients with anxiety or depression, especially those with 'depression related disorder'.