Optical coherence tomography angiography findings in retinal cavernous hemangioma: New cases and review of the literature.

INTRODUCTION: Retinal cavernous hemangioma (RCH) is a rare retinal vascular disease characterized by grape-like clusters of saccular aneurysms, usually unilateral, asymptomatic and non-progressive. The diagnosis is made by multimodal imaging including conventional fluorescein angiography (FA). The recent introduction of swept source optical coherence tomography angiography (SS-OCTA) has allowed new insight into vascular diseases, allowing non-invasive, more precise visualization of retinal and choroidal blood flow, and represents a possible alternative to FA. METHODS: We herein describe two cases of RCH with multimodal imaging, including SS-OCTA, and compare our findings with those previously described. RESULTS: On OCTA, the presence of a draining vessel, a reduction in flow signal in the SCP and DCP, and a fluid level can be observed. CONCLUSION: These OCTA signs are in accordance with those described on conventional fluorescein angiography, allowing this invasive exam to be avoided in typical cases.

Uveitis in children: Epidemiological, clinical and prognostic characteristics.

PURPOSE: The purpose of this study is to describe the characteristics and prognostic factors of pediatric uveitis in a French university referral hospital. METHODS: We performed a retrospective study of all cases of all pediatric uveitis seen at our institution over a 7-year period. RESULTS: A total of 141 eyes of 86 children were included. The mean age was 10.7 years, and 61.6% were girls. The uveitis was bilateral in 64.0% of cases. Anterior uveitis (41.0%) and intermediate uveitis (32.0%) were the most frequent forms. The most frequent etiologies were idiopathic (27.9%), juvenile idiopathic arthritis (25.6%) and pars planitis (18.6%). During the follow-up period, systemic corticosteroids were received by 43.0% of children, immunosuppressive drugs by 31.4% and biological agents by 18.6%. At the final examination, complications were present in 67.0% of patients: 18.0% had cataracts, and 11.3% had intraocular hypertension. Posterior synechiae were present in 27.6% of eyes, optic disc edema in 10.5% and macular edema in 16.2%. At the last visit, visual acuity was better than 20/200 in 97.0% of cases. The presence of band keratopathy, cataract or glaucoma was an independent predictor of impaired visual outcomes at follow-up. CONCLUSION: Juvenile idiopathic arthritis is one of the most frequent and severe pediatric uveitides. Close monitoring and early treatment could prevent complications.

[Radiation-induced retinopathy: actual knowledge and new concepts]. / La rétinopathie radique : données actuelles et perspectives.

Radiation retinopathy is an occlusive vascular pathology following radiotherapy, generally targeted on the eye or peri-ocular structures. Despite increasingly precise techniques (stereotactic radiosurgery, proton therapy, etc.), the inclusion of the retina in the radiation field is sometimes unavoidable. This can lead to a severe pathology, which can ultimately cause blindness or even the anatomical loss of the eye when neovascular glaucoma occurs, due to the abnormal proliferation of neovessels. Radiation retinopathy have been described for more than a century, but it has recently seen great advances in both diagnosis and treatment. The advances of efficient and less invasive examinations in our clinical practice, such as OCT-angiography, allows for easier screening and diagnosis at earlier stages. Thus a new approach to the pathology is necessary, first of all through new definitions and classifications including previously undetected minimal forms. Furthermore, the recent appearance of intravitreal therapies by injection of anti-VEGF or dexamethasone implants has drastically changed the visual prognosis of these patients, who were previously treated only by retinal photocoagulation of the ischaemic areas. Recent studies have even shown the effectiveness of these new molecules in preventing the development of radiation retinopathy. This review of the literature provides an update on this disease and details how these recent diagnostic and therapeutic developments may play a role in the management of this complication.

Molecular Cytogenetic Characterization of a Karyotype of a Female Patient with Secondary Amenorrhea with a Cell Line Showing 46,X,+mar.

OBJECTIVES: Disorders of sex development (DSD) include a group of conditions in which genotypes do not correlate with the typical male and female phenotypes. Numerical and structural abnormalities involving both autosomes and sex chromosomes have been observed in DSD. Specifically, deletions, duplications, and translocations involving specific genes as well as point mutations and less common aberrations have been implicated in the pathogenesis of these conditions. Finally, recent advances in analytical tools, namely chromosomal microarrays and sequencing methods, have greatly enhanced the precision with which DSD are genetically characterized and phenotypically correlated. Herein we report a case of a 24-year-old female patient who presented with secondary amenorrhea. Cytogenetic studies of her peripheral blood showed an abnormal clone with 45,X in three cells and the other was initially observed by chromosome analysis as 46,X,+mar in 27 cells. Molecular cytogenetics were performed to characterize the marker chromosome that showed two copies of the SRY, two copies of the heterochromatin Yq12, and two copies of the Y centromere Yp11.1-q11.1 on the marker chromosome, resulting in the identification of an isodicentric Y chromosome. Females with a 46,XY karyotype have gonadal dysgenesis and typically present as mosaic, along with a 45,X cell line. Some show small deletions of the short arm of the Y chromosome. Further studies based on the clinical picture, as well as possible prophylactic gonadectomy due to an increased risk of gonadal malignancy, gonadoblastoma or dysgerminoma, are suggested. Genetic counseling was recommended.

Accuracy of peripapillary versus macular vessel density in diagnosis of early to advanced primary open angle glaucoma.

PURPOSE: To evaluate macular and peripapillary vessel density (mVD, pVD) using optical coherence tomography angiography (OCT-A) in healthy subjects, patients with ocular hypertension (OHT) and primary open-angle glaucoma (POAG) patients. METHODS: In this prospective observational study, OCT-A images were obtained from 60 eyes of 36 healthy, ocular hypertension (OHT), preperimetric glaucoma (PPG), early glaucoma (EG) and moderate and advanced POAG subjects. Superficial mVD was acquired over a 6×6-mm cube centered on the foveal avascular zone and pVD over a 4.5×4.5-mm cube centered on the optic disc. Peripapillary retinal nerve fiber layer (pRNFL) and ganglion cell complex (GCC) thickness was calculated using spectral-domain OCT. Correlations between vascular, structural and Humphrey VF indices were evaluated (Spearman's rank correlation coefficient). RESULTS: Median pVD and mVD in the PPG eyes were lower than in healthy eyes (51.87% and 47.23% versus 55.70% and 53.61%, respectively; P<0.001 and P=0.003), but higher than in mild glaucoma eyes (46.21% and 41.98%, P<0.001 compared to normal eyes) and moderate to advanced glaucoma eyes (37.45% and 39.89%, P<0.0001 compared to normal eyes). The highest correlations were found between structural parameters and pVD (r=0.87 and 0.86 for pRNFL and GCC, P<0.0001), followed by mVD (r=0.69 for both pRNFL and GCC, P<0.0001). Correlations with mean VF sensitivity were similar for pVD and mVD (r=0.61 and 0.56) and for GCC and pRNFL (r=0.60 and 0.52, P<0.0001 for all). CONCLUSIONS: VD measured with OCT-A shows reduction in POAG. Detection of this damage differentiates PPG from normal and perimetric POAG eyes with a high correlation with structural parameters. Peripapillary VD accuracy is higher than mVD in detecting the disease. These results suggest that OCT-A could improve POAG diagnosis and understanding of the pathophysiologic mechanisms behind glaucoma.

Connecting the dots between breast cancer, obesity and alcohol consumption in middle-aged women: ecological and case control studies.

BACKGROUND: Breast cancer (BC) incidence in Australian women aged 45 to 64 years ('middle-aged') has tripled in the past 50 years, along with increasing alcohol consumption and obesity in middle-age women. Alcohol and obesity have been individually associated with BC but little is known about how these factors might interact. Chronic psychological stress has been associated with, but not causally linked to, BC. Here, alcohol could represent the 'missing link' - reflecting self-medication. Using an exploratory cross-sectional design, we investigated inter-correlations of alcohol intake and overweight/obesity and their association with BC incidence in middle-aged women. We also explored the role of stress and various lifestyle factors in these relationships. METHODS: We analysed population data on BC incidence, alcohol consumption, overweight/obesity, and psychological stress. A case control study was conducted using an online survey. Cases (n = 80) were diagnosed with BC and controls (n = 235) were women in the same age range with no BC history. Participants reported lifestyle data (including alcohol consumption, weight history) over consecutive 10-year life periods. Data were analysed using a range of bivariate and multivariate techniques including correlation matrices, multivariate binomial regressions and multilevel logistic regression. RESULTS: Ecological inter-correlations were found between BC and alcohol consumption and between BC and obesity but not between other variables in the matrix. Strong pairwise correlations were found between stress and alcohol and between stress and obesity. BMI tended to be higher in cases relative to controls across reported life history. Alcohol consumption was not associated with case-control status. Few correlations were found between lifestyle factors and stress, although smoking and alcohol consumption were correlated in some periods. Obesity occurring during the ages of 31 to 40 years emerged as an independent predictor of BC (OR 3.5 95% CI: 1.3-9.4). CONCLUSIONS: This study provides ecological evidence correlating obesity and alcohol consumption with BC incidence. Case-control findings suggest lifetime BMI may be important with particular risk associated with obesity prior to 40 years of age. Stress was ecologically linked to alcohol and obesity but not to BC incidence and was differentially correlated with alcohol and smoking among cases and controls. Our findings support prevention efforts targeting weight in women below 40 years of age and, potentially, lifelong alcohol consumption to reduce BC risk in middle-aged women.

Gastrointestinal symptoms and association with medication use patterns, adherence, treatment satisfaction, quality of life, and resource use in osteoporosis: baseline results of the MUSIC-OS study.

SUMMARY: The Medication Use Patterns, Treatment Satisfaction, and Inadequate Control of Osteoporosis Study (MUSIC-OS) is a prospective, observational study of women with osteoporosis in Europe and Canada. At baseline, patients with gastrointestinal symptoms reported lower adherence to osteoporosis treatment, treatment satisfaction, and health-related quality of life, than those without gastrointestinal symptoms. INTRODUCTION: The aim of the study was to examine gastrointestinal (GI) symptoms and the association between GI symptoms and treatment adherence, treatment satisfaction, and health-related quality of life (HRQoL) among osteoporotic women in Europe and Canada. METHODS: Baseline results are reported here for a prospective study which enrolled postmenopausal, osteoporotic women who were initiating (new users) or continuing (experienced users) osteoporosis treatment at study entry (baseline). A patient survey was administered at baseline and included the occurrence of GI symptoms during 6-month pre-enrolment, treatment adherence (adherence evaluation of osteoporosis (ADEOS), score 0-22), treatment satisfaction (Osteoporosis Treatment Satisfaction Questionnaire for Medications (OPSAT-Q), score 0-100) and HRQoL (EuroQol-5 dimension (EQ-5D) utility, score 0-1; OPAQ-SV, score 0-100). The association between GI symptoms and ADEOS (experienced users), OPSAT-Q (experienced users), and HRQoL (new and experienced users) was assessed by general linear models adjusted for patient characteristics. RESULTS: A total of 2959 patients (2275 experienced and 684 new users) were included. Overall, 68.1% of patients experienced GI symptoms in the past 6 months. Compared with patients without GI symptoms, patients with GI symptoms had lower mean baseline scores on most measures. The mean adjusted differences were ADEOS, -0.43; OPSAT-Q, -5.68; EQ-5D, -0.04 (new users) and -0.06 (experienced users), all P < 0.01. GI symptoms were also associated with lower OPAQ-SV domain scores: physical function, -4.17 (experienced users); emotional status, -4.28 (new users) and -5.68 (experienced users); back pain, -5.82 (new users) and -11.33 (experienced users), all P < 0.01. CONCLUSIONS: Patients with GI symptoms have lower treatment adherence and treatment satisfaction and worse HRQoL than patients without GI symptoms.

Coverage of the vitamin A supplementation programme for child survival in Nepal: success and challenges.

BACKGROUND: Nepal's national vitamin A programme, which began in 1993 and continues twice yearly, targets pre-school-aged children in all districts of the country in an effort to reduce morbidity, mortality and nutritional blindness. OBJECTIVE: To characterize the coverage of the Nepal National Vitamin A Programme (NVAP) for pre-school-aged children in Nepal and to identify risk factors for failure to receive vitamin A supplementation. METHODS: The relationship between receipt of a vitamin A capsule and demographic and health indicators was examined in a cross-sectional study of 4013 children aged 12-59 months and their families who participated in the 2011 Nepal Demographic and Health Survey (NDHS), a nationally representative survey. Coverage of the vitamin A programme was compared with coverage estimates from surveys in 2001 and 2006. RESULTS: Coverage estimates of the national vitamin A programme for children aged 12-59 months as assessed by the 2001, 2006 and 2011 NDHS were 84.3%, 96.6% and 92.1%, respectively. Children who missed a vitamin A capsule were more likely to be younger and anaemic, have less educated parents, live in rural areas, and have higher child and infant mortality in the family. CONCLUSIONS: The national vitamin A supplementation programme in Nepal has relatively high coverage of children aged 12-59 months but still misses children in families with high child mortality. Further measures might be needed to sustain a high level of programme coverage.

Detection of mild papilloedema using spectral domain optical coherence tomography.

OBJECTIVE: To propose a method of diagnosis of mild papilloedema (PO) using peripapillary total retinal (PTR) thickness measurement by spectral domain optical coherence tomography (OCT). METHODS: 24 eyes in 24 patients with PO caused by increased intracranial pressure and 22 eyes in 22 normal subjects were studied. OCT high-quality fundus images were analysed and graded by three masked observers using the Modified Frisén Scale. Eyes with PO were divided into two subgroups: those with mild PO (n=18) and those with moderate-severe PO (n=6). Two methods of measurements were evaluated and compared: retinal nerve fibre layer (RNFL) thickness measurements using standard optic disc cube 200 × 200 acquisition protocol and PTR thickness measurements using the 'macular' cube 512 × 128 acquisition protocol centred on the optic disc. Thickness values were calculated globally and for each quadrant (temporal, superior, nasal, inferior) and compared among the three groups (control, mild PO, moderate-severe PO). The main outcome measures were RNFL and PTR thickness. RESULTS: Average RNFL and PTR thickness in the moderate-severe PO, mild PO and control groups were 299.3 ± 10.9, 112.4 ± 6.3, 96 ± 5.7 and 804.5 ± 17, 463.1 ± 9.8 and 332.4 ± 8.9 µm, respectively. Moderate-severe PO differed from mild PO and control groups using both RNLF thicknesses and PTR thicknesses measurements. Mild PO did not differ from controls using RNLF thickness measurement (p=0.17), but was statistically different using PTR thickness measurement (p<0.001). CONCLUSION: PTR thickness measurement increases the sensitivity of detection of mild PO compared with conventional RNFL measurement. This new way of using OCT may be useful for clinicians to detect mild PO.

Evidence for prospective associations among depression and obesity in population-based studies.

Obesity may lead to depression or be one of its consequences. We reviewed population-based studies in order to, first, identify the most commonly used research methods, and, second, to evaluate the strength of evidence for prospective associations among obesity and depression. We examined 25 studies, of which 10 tested 'obesity-to-depression' pathways, and 15 tested 'depression-to-obesity' pathways. Descriptive statistics summarized the frequency with which various measurements, designs and data analytic strategies were used. We tallied the number of studies that reported any vs. no statistically significant associations, and report on effect sizes, identified moderating variables within reports, and sought common findings across studies. Results indicated considerable methodological heterogeneity in the literature. Depression was assessed by clinical interview in 44% of studies, weight and height were directly measured in 32%, and only 12% used both. In total, 80% of the studies reported significant obesity-to-depression associations, with odds ratios generally in the range of 1.0 to 2.0, while only 53% of the studies reported significant depression-to-obesity associations. Sex was a common moderating variable. Thus, there was good evidence that obesity is prospectively associated with increased depression, with less consistent evidence that depression leads to obesity. Recommendations for future research regarding study samples, measurement and data analysis are provided.

Intentional weight loss and changes in symptoms of depression: a systematic review and meta-analysis.

OBJECTIVE: Obesity is related to increased risk of several health complications, including depression. Many studies have reported improvements in mood with weight loss, but results have been equivocal. The present meta-analysis examined changes in symptoms of depression that were reported in trials of weight loss interventions. Between-groups comparisons of different weight loss methods (for example, lifestyle modification, diet-alone and pharmacotherapy) were examined, as were within-group changes for each treatment type. METHOD: MEDLINE was searched for articles published between 1950 and January 2009. Several obesity-related terms were intersected with terms related to depression. Results were filtered to return only studies of human subjects, published in English. Of 5971 articles, 394 were randomized controlled trials. Articles were excluded if they did not report mean changes in weight or symptoms of depression, included children or persons with psychiatric disorders (other than depression), or provided insufficient data for analysis. Thirty-one studies (n=7937) were included. Two authors independently extracted a description of each study treatment, sample characteristics, assessment methods and changes in weight and symptoms of depression. Treatments were categorized as lifestyle modification, non-dieting, dietary counseling, diet-alone, exercise-alone, pharmacotherapy, placebo or control interventions. RESULTS: Random effects models found that lifestyle modification was superior to control and non-dieting interventions for reducing symptoms of depression, and marginally better than dietary counseling and exercise-alone programs. Exercise-alone programs were superior to controls. No differences were found for comparisons of pharmacologic agents and placebos. Within-group analyses found significant reductions in symptoms of depression for nearly all active interventions. A meta-regression found no relationship between changes in weight and changes in symptoms of depression in lifestyle modification interventions. CONCLUSIONS: On average, obese individuals in weight loss trials experienced reductions in symptoms of depression. Future studies should examine incidence and resolution of clinically significant depressive disorders with weight loss interventions.

Voluntary weight loss: systematic review of early phase body composition changes.

Weight loss follows when adult humans enter a phase of negative energy balance brought about by reducing energy intake and/or increasing energy expenditure. The weight loss period is usually viewed as a continuous process, ending when energy equilibrium is achieved at a lower weight or with death following depletion of fuel stores. However, growing evidence supports the expanded view that induction of negative energy balance leads to well-defined physiological effects characterized by three discrete phases (I-III). At present there are no comprehensive reviews of the 'early' phase of weight loss, a gap highlighted by recent interest in rapidly testing new treatments with short-term protocols. Herein we show from earlier reports and with new data that weight loss during phase I is: mathematically quantifiable with a t(1/2) < 1-week and 4- to 6-week duration; includes well-defined rapidly evolving body composition and energy expenditure changes; and is moderated by multiple factors including subject sex and activity level, nutrients ingested at baseline and during the negative energy balance period, and hormone and pharmacologic treatments. Our in depth review collectively characterizes phase I as a distinct weight loss period while revealing important knowledge gaps that can be filled with appropriately designed future studies.

[Clinical and etiological aspects of uveitis: a retrospective study of 121 patients referred to a tertiary centre of ophthalmology]. / Aspects cliniques et étiologiques des uvéites: étude rétrospective de 121 patients adressés à un centre tertiaire d'ophtalmologie.

PURPOSE: Uveitis consists of a large group of diseases characterized by intraocular inflammation involving the uveal tract. This heterogeneity makes the diagnosis and the treatment of uveitis frequently challenging. The purpose of this study was to describe the various clinical and etiologic aspects of uveitis, through the new standardized uveitis classification and the use of modern investigations for its diagnostic work-up. METHODS: The medical records of 121 new patients with uveitis referred to our tertiary ophthalmologic centre between January 2002 and December 2006 were retrospectively reviewed. Uveitis associated to human immunodeficiency virus and secondary to exogenous endophthalmitis were excluded. All patients had a complete ophthalmological examination and appropriate clinical and paraclinical examination. The diagnosis was established according to the recent international criteria. RESULTS: One hundred and twenty-one patients were included. The four main etiologies were: toxoplasmosis (14%), sarcoidosis (11.6%), spondylarthritis or HLA B27-associated uveitis (13.2%) and Herpes virus infections (9.1%) that represented almost half of the uveitis causes (47.9%). Various diseases constituted the remaining causes of the uveitis (20.9%). Uveitis remained unexplained in the remaining 36 patients (29.7%). Overall, associated systemic diseases were diagnosed in 35.5% of our uveitis patients (34 patients), associated infectious conditions in 26.4% (32 patients) and specific ocular diseases in 8.3% (12 patients). CONCLUSION: Despite a limited number of patients, our study showed an etiologic distribution similar to that of the main series reported in the literature. Nevertheless, we observed an elevated frequency of sarcoidosis and systemic diseases, which emphasizes a management that takes into account standardized clinical and paraclinical criteria and the usefulness of a collaboration with the internist.

[Unilateral acute endophthalmitis due to Staphylococcus epidermidis after simultaneous bilateral intravitreal injection using the same ranibizumab vial: a case report]. / Endophtalmie aiguë unilatérale àStaphylococcus epidermidis après injection intra-vitréenne bilatérale et concomitante de ranibizumab à partir d'un même flacon: à propos d'un cas.

PURPOSE: To report a case of unilateral acute endophthalmitis due to Staphylococcus epidermidis after simultaneous bilateral intravitreal injection using the same ranibizumab vial. CASE REPORT: A 68-year-old phakic man had uneventful bilateral sequential ranibizumab intravitreal injection for bilateral neovascular age-related macular degeneration using the same vial. All of the vial contents (0.3 mL) were withdrawn through the filter needle attached to a 1-cc tuberculin syringe. Using the same syringe but separate injection needles, 0.05 mL was administrated to the right eye before 0.05 mL was injected into the left eye. Sterile gloves, drape, and eyelid speculum were used for each eye. Early Staphylococcus epidermidis postoperative endophthalmitis developed 3 days later in the right eye (injected first) with intense vitreous inflammation, limiting visual acuity to light perception. Management included intravitreal antibiotic agents and pars plana vitrectomy. The patient achieved an excellent visual outcome. DISCUSSION: This case report demonstrates that bacterial endophthalmitis is a rare but potential complication of intravitreal anti-VEGF injection, that infection generally results from self-contamination of the patient from his or her own bacterial flora, and that simultaneous bilateral intravitreal injection should be avoided.

Attrition from randomized controlled trials of pharmacological weight loss agents: a systematic review and analysis.

Clinical trials of obesity treatments have been limited by substantial dropout. Participant-level variables do not reliably predict attrition, and study-level variables have not yet been examined. We searched MEDLINE and identified 24 large randomized controlled trials of weight loss medications. These trials were comprised of 23 placebo and 32 drug groups. Two authors independently extracted the following for each treatment group: (i) treatment received; (ii) design characteristics (inclusion of a lead-in period, selection of participants with weight-related comorbidities, study location and number of study visits); (iii) sample characteristics (sample size, % female, and mean baseline age and body mass index); and (iv) attrition (total, adverse event [AE]-related and non-AE-related) at 1 year. The primary outcome was total attrition, which was significantly related to treatment (i.e. 34.9%, 28.6%, 28.3% and 35.1% in placebo, orlistat, sibutramine and rimonabant groups, respectively, P < 0.0001). In adjusted multivariable models, total attrition was significantly lower in groups that completed a pre-randomization lead-in period than in those that did not (29.1% vs. 39.9%, P < 0.01). Gender also was significantly related to total attrition; groups with more women had higher dropout (P < 0.01). The pattern was similar for predicting non-AE-related attrition. Findings suggest ways to design studies that maximize retention.

How much may I eat? Calorie estimates based upon energy expenditure prediction equations.

How much may I eat? Most healthcare workers, when asked this question, have insufficient knowledge to educate their patients on a healthy energy intake level. In this review we examine the available methods for estimating adult energy requirements with a focus on the newly developed National Academy of Sciences/Institute of Medicine (NAS/IOM) doubly-labelled water total energy expenditure (TEE) prediction equations. An overview is first provided of the traditional factorial method of estimating energy requirements. We then extend this overview by exploring the development of the NAS/IOM TEE prediction models and their role in estimating energy requirements as a function of sex, age, weight, height and physical activity level. The NAS/IOM prediction models were developed for evaluating group energy requirements, although the formulas can be applied in individual 'example' patients for educational purposes. Potential limitations and interpretation issues of both the factorial and NAS/IOM methods are examined. This information should provide healthcare professionals with the tools and understanding to appropriately answer the question, 'How much may I eat?'

Risk of cancer in patients with scleroderma: a population based cohort study.

BACKGROUND: Previous studies have suggested an increased risk of cancer among patients with scleroderma. OBJECTIVE: To study a population based cohort of patients with scleroderma in South Australia. METHODS: Subjects with scleroderma were identified from the South Australian Scleroderma Registry established in 1993. All subjects on the scleroderma registry were linked to the South Australian Cancer Registry to identify all cases of cancer until 31 December 2000. Standardised incidence ratios (SIRs) for cancer for subjects with scleroderma were determined using the age- and sex-specific rates for South Australia. RESULTS: In 441 patients with scleroderma, 90 cases of cancer were identified, 47 of which developed after inclusion on the scleroderma registry. The SIRs for all cancers among these patients were significantly increased (SIR=1.99; 95% confidence interval (95% CI) 1.46 to 2.65) compared with the cancer incidence rates for South Australia. The SIRs for lung cancer (SIR=5.9; 95% CI 3.05 to 10.31) were also significantly increased. The SIRs for all cancers among the subgroups with diffuse scleroderma (SIR=2.73; 95% CI 1.31 to 5.02) and limited scleroderma (SIR=1.85; 95% CI 1.23 to 2.68) were significantly increased. CONCLUSIONS: This population based cohort study provides evidence that scleroderma is associated with cancer, and in particular, lung cancer. In addition, both diffuse and limited forms of scleroderma are associated with a similarly increased risk of cancer.

Prophylactic perioperative hypogastric artery balloon occlusion in abnormal placentation.

OBJECTIVE: The aim of this paper is to describe and evaluate the technique of prophylactic balloon occlusion of hypogastric arteries in abnormal placentation. Five patients with suspected placenta accreta, placenta percreta, or placenta increta underwent perioperative balloon occlusion of hypogastric arteries after classic cesarean delivery and before hysterectomy with hypogastric artery ligation. Two patients did not require transfusions; of the three who did, the estimated blood loss ranged from 1100 to 4000 mL. CONCLUSION: We conclude that balloon occlusion of the hypogastric arteries is a safe and effective adjunct to cesarean hysterectomy in an attempt to minimize blood loss in patients with abnormal placentation.

Development and optimisation of a flow injection assay for fluticasone propionate using an asymmetrical design and the variable-size simplex algorithm.

A flow injection analysis method is described to determine fluticasone propionate, based upon a novel adaptation of the reaction of o-phthalaldehyde with a thiol and a primary amine. The method, which allows both UV and fluorescence detection, has been optimised using experimental design. First a screening is executed to select the significant factors and in a second step these factors are optimised with the variable-size simplex algorithm. In the screening step, a two-level fractional factorial design is compared with an asymmetrical design containing the same number of experiments, but in which one factor is at three levels. It was found that in both designs the same significant variables are detected for the two-level factors, but that for the three-level factor the asymmetrical design confirms an expectation of having a (local) optimum in the examined domain, whilst from the two-level design this is not at all apparent. Complete optimisation was carried out for both UV and fluorescence detection. The two detection methods did not have the same significant variables. For the UV detection, the temperature and the pH adjustment on-line (concentration of sodium hydroxide and amount of boric acid) were the most critical parameters. For the fluorimetric detection the temperature and the fraction of methanol were critical. Moreover the conditions found to be optimal are different for both detection methods.