Louisiana State University Hospital

PURPOSE: To update the 2008 International Classification of Corneal Dystrophies (IC3D) incorporating new clinical, histopathologic, and genetic information. METHODS: The IC3D reviewed worldwide peer-reviewed articles for new information on corneal dystrophies published between 2008 and 2014. Using this information, corneal dystrophy templates and anatomic classification were updated. New clinical, histopathologic, and confocal photographs were added. RESULTS: On the basis of revisiting the cellular origin of corneal dystrophy, a modified anatomic classification is proposed consisting of (1) epithelial and subepithelial dystrophies, (2) epithelial-stromal TGFBI dystrophies, (3) stromal dystrophies, and (4) endothelial dystrophies. Most of the dystrophy templates are updated. The entity "Epithelial recurrent erosion dystrophies" actually includes a number of potentially distinct epithelial dystrophies (Franceschetti corneal dystrophy, Dystrophia Smolandiensis, and Dystrophia Helsinglandica) but must be differentiated from dystrophies such as TGFBI-induced dystrophies, which are also often associated with recurrent epithelial erosions. The chromosome locus of Thiel-Behnke corneal dystrophy is only located on 5q31. The entity previously designated as a variant of Thiel-Behnke corneal dystrophy on chromosome 10q24 may represent a novel corneal dystrophy. Congenital hereditary endothelial dystrophy (CHED, formerly CHED2) is most likely only an autosomal recessive disorder. The so-called autosomal dominant inherited CHED (formerly CHED1) is insufficiently distinct to continue to be considered a unique corneal dystrophy. On review of almost all of the published cases, the description appeared most similar to a type of posterior polymorphous corneal dystrophy linked to the same chromosome 20 locus (PPCD1). Confocal microscopy also has emerged as a helpful tool to reveal in vivo features of several corneal dystrophies that previously required histopathologic examination to definitively diagnose. CONCLUSIONS: This revision of the IC3D classification includes an updated anatomic classification of corneal dystrophies more accurately classifying TGFBI dystrophies that affect multiple layers rather than are confined to one corneal layer. Typical histopathologic and confocal images have been added to the corneal dystrophy templates.

Insulinomas are rare malignant functional pancreatic tumors of the β cells that retain the ability to produce and secrete insulin. Insulinomas are the most common pancreatic neuroendocrine tumor in dogs that can induce a variety of clinical signs that result from hypoglycemia and secondary neuroglycopenic and adrenergic effects. Diagnosis and treatment is considered challenging, and the prognosis can be extremely variable depending on the therapeutic choices. This review aims to summarize and update classic knowledge with current trends in the diagnosis, treatment, and prognosis of insulinomas.

Many gunshot wounds (GSW's) to the brachial plexus do not improve spontaneously with time and are therefore candidates for surgery. Over an 18-year period, 141 patients with GSW's were evaluated, 90 of whom were operated on; 75 of the surgical cases were followed for 2 years or more. Thirty operative patients had initial vascular repair, while eight required thoracotomies. Total plexus palsy was present in 19 of those selected for operation. The average interval between injury and operation was 17 weeks. Six patients required early operation for an expanding aneurysm with progressive neural loss. Persistent complete loss of function in the distribution of one or more elements and/or noncausalgic pain not managed by medications provided the major operative indications. Four patients required sympathectomies for causalgia. Of 166 lesions in continuity believed to be complete, based on clinical examination and electromyography, 48 with preserved intraoperative nerve action potentials (NAP's) were spared resection or were treated with a split repair with excellent eventual results on a weighted grading system. By comparison, only seven of 55 elements believed to have incomplete loss or to be recovering did not have NAP's and required repair. Fifty-three of 98 lesions repaired by grafts and 18 of 26 wounds with suture repair recovered to a Grade 3 level or better. Most elements were in continuity but 14 were found "blown apart" and required repair, usually by grafting. The best outcome was achieved with upper trunk and lateral and posterior cord lesions, but recovery occurred with some C-7 to middle trunk and medial cord to median repairs. Results with lower trunk and most medial cord lesions were poor unless early regeneration was proved by operative NAP's, in which case either neurolysis or split repair could be performed. Surgery is warranted for selected GSW's to the plexus.

The variety and distribution of skeletal pathology in children with acute lymphoblastic leukemia is rarely seen in other disease states. Skeletal radiographic changes associated with and/or suggestive of acute leukemia include diffuse osteopenia, metaphyseal bands, periosteal new bone formation, geographic lytic lesions, sclerosis, mixed sclerosis/lysis, and permeative destruction. This retrospective analysis of 83 children with acute lymphoblastic leukemia suggests that children without radiographic skeletal abnormalities have an "aggressive" form of leukemia. Children with one to four lesions have an "indolent" form of leukemia that is of short duration. Children with five or more lesions have an indolent form of leukemia that is of longer duration. The longer duration of symptoms before diagnosis reduces the survival rate to that of the aggressive form of leukemia. It is therefore imperative that physicians who treat children recognize the orthopaedic/radiographic manifestations of acute leukemia (the most common pediatric malignancy) to facilitate diagnosis, and, thereby, improve survival.

Hepatitis B disease has caused a heavy burden worldwide. The development of an immunogenic, efficacious and safe vaccine to combat this problem has already eased this burden to some extent. The incorporation of the vaccine into the infant and childhood immunization schedule has led to a decrease in the number of new hepatitis B cases reported each year, and there has been a significant decline in hepatocellular carcinoma in children. This implies that the future will see less hepatitis B disease as the infant and adolescent population that has been immunized ages, meaning that the disease burden should fall even further.

A case-control study of oral and pharyngeal cancer involving interviews with 108 cases and 286 controls was carried out in the University Hospital of Montevideo, Uruguay. The study was restricted to males and cases afflicted with lip, salivary gland and nasopharyngeal cancer were excluded. Point estimates of RR associated with smoking variables, alcohol variables, nutritional items and ingestion of hot infusions of the herb Ilex paraguariensis ('Mate') were obtained by logistic regression analysis. Dark tobacco smokers showed a RR 3.4 times higher than light tobacco users and heavy drinkers of wine displayed an OR of 17.2. Mate exposure showed a significant dose-response, after adjustment for age, tobacco and alcohol intake, with a fivefold increase in risk for heavy consumers. Joint exposure to black tobacco and wine displayed very high risks and no significant interactions were observed. The results suggest that the high rates of oropharyngeal cancer could be explained by the multiplicative effect of black tobacco smoking, wine drinking and mate ingestion.

Abstract Ricinoleic and acid oleic acid derivatives were screened for their antimicrobial activity, under optimum growing‐conditions, against several species of bacteria, yeasts, and molds. Several ricinoleic acid derivatives and petroselinic (iso‐oleic) acid exhibited considerable activity; in fact, their activity against some micro‐organisms was comparable to sorbic and 10‐undecenoic acid, known antimicrobial agents, as indicated by this test.

Canine multi-centric B-cell lymphoma shares similarities with diffuse large B-cell (Non-Hodgkin's) lymphoma (NHL) in people. In people with NHL, lymphopenia at diagnosis and first relapse and neutrophil/lymphocyte ratio (N:L) > 3.5 are negative prognostic factors for survival. The objective of this study was to determine if lymphocyte concentration at diagnosis and first relapse and N:L were prognostic for survival in dogs with newly diagnosed multi-centric lymphoma. Medical records of 77 dogs with multi-centric lymphoma treated with a CHOP-based chemotherapy protocol were retrospectively evaluated. Absolute lymphocyte concentration and N:L ratio at presentation of dogs pre-treated with steroids was not significantly different from dogs who had not received steroids. On multivariate analysis, only immunophenotype remained significant for progression-free survival (PFS), whereas no variables remained significant for ST. A prospective study of these haematologic variables is warranted to assess their true significance.

DiVINCENTI, FRANK C. M.D.; RIVES, JAMES D. M.D.; LABORDE, ELMO J. M.D.; FLIMEING, IRVIN D. M.D.; COHN, ISIDORE JR. M.D. Author Information

This study examines spatial accessibility of pharmacies in Baton Rouge, Louisiana. Two popular geographic information systems ()—based methods are compared: the proximity method uses the distance (travel time) from the nearest pharmacy, and the two‐step floating catchment area (2) method considers the match ratio between providers and population as well as the complex spatial interaction between them. The study indicates that disproportionally higher percentages of African‐Americans are in areas with shorter travel time to the nearest pharmacies than whites, but suffer from poorer accessibility measured by the 2 method—that is, fewer pharmacies per 10,000 residents. Seniors, particularly those of seventy‐five years or older, tend to be disproportionally concentrated in areas that not only are closer to pharmacies, but also have more pharmacies per 10,000 residents. The two methods used in the study capture different elements in spatial accessibility: one being physically close to a facility and another adding the crowdedness in service. Both properties can be valuable for residents. The two may not always coincide with each other in spatial variability, as it is the case for racial disparity in our study area. However, when they do, as in the case for seniors, it may imply a true (dis)advantage for a demographic group in terms of both properties of spatial accessibility.

During the 2004 field season, blood was collected from Eastern massasauga rattlesnakes (Sistrurus catenatus catenatus) in the Carlyle Lake (Carlyle, Illinois, USA) and Allerton Park (Monticello, Illinois, USA) populations to derive baseline complete blood count and plasma biochemistry data and to assess the prevalence of antibodies to West Nile virus (WNV) and ophidian paramyxovirus (OPMV). Massasaugas were located for sampling through visual encounter surveys. Body weight, snout-vent length, total protein, globulins, sodium, and potassium were normally distributed among the survey population. Aspartate aminotransferase, creatine kinase, albumin, calcium, uric acid, white blood cell count, heterophils, lymphocytes, monocytes, eosinophils, and basophils were non-normally distributed within these animals. Female snakes had significantly shorter tail lengths; lower blood glucose, packed cell volumes, and absolute azurophil counts; and higher plasma calcium and phosphorus concentrations than did males. None of the snakes tested (n=21) were seropositive for WNV, whereas all (n=20) were seropositive for OPMV.

In normal adults, following a single intravenous injection of BSP, the logarithmic decline of plasma BSP levels is rectilinear. In patients with hepatic disease, the plotted values are curvilinear with flattening of the curve, or "saturation," occurring at high plasma BSP concentration. The use of the excretion curve provides a dynamic representation of the hepatic uptake of dye throughout the test, avoids the theoretic objections to the 45 minute test, and obviates the necessity for plasma volume determinations. Thirty-five healthy prematures of varying age and weight were the subjects of a study of liver function by the bromsulphalein excretion test. As measured by the BSP excretion test, there is progressive maturation of liver function with age in prematures which does not necessarily correlate with weight. The excretion curves obtained in prematures 18 to 28 hours of age resemble those of older patients with severely impaired hepatic function. Clearance of dye in these subjects is slow throughout the test. With increasing age there is a gradual change in the pattern of the curves characterized by the appearance of the initial sharp slopes coincident with rapid dye removal. "Saturation," or flattening of the curves, persists until a later age and takes place at progressively lower plasma levels. This biphasic pattern is apparent in the prematures over 4 days of age. The normal adult pattern is not attained until about 6 to 8 weeks although the 45 minute retention values become normal at three weeks. The gradual development of normal excretion curves in premature infants may be explained by the progressive maturation of the anatomic and physiologic factors involved in the mechanism of BSP clearance. The increasing size of the capillary network in the liver that occurs with advancing age in effect increases hepatic blood flow and exposes a greater volume of blood in the sinusoids to the activity of the liver. The appearance of the initial sharp slopes, representing rapid dye removal, probably results from this increasing vascularity and possibly from maturation of the hepatic uptake mechanism. The continuance of the biphasic character of the curves probably results from inability to excrete the dye efficiently into bile.

Chronic hypertrophic pyloric gastropathy was diagnosed using ultrasound in six dogs that were presented for chronic vomiting. An evenly thick hypoechoic layer surrounding the pyloric lumen was visualized ultrasonographically in dogs with grades 1 or 2 chronic hypertrophic pyloric gastropathy. This was histologically found to correspond with a thickened muscular layer. Gastric wall thickness was greater than or equal to 9 mm in all six dogs. In dogs with grade 1 or 2 chronic hypertrophic pyloric gastropathy, the hypoechoic muscular layer was greater than or equal to 4 mm.

A 12-year-old stallion was evaluated because of pollakiuria; endoscopy of the urinary tract during general anesthesia revealed that the urinary bladder was intact. After recovery, the stallion developed clinical and biochemical signs of bladder rupture, which was confirmed by endoscopy. Cystoplasty in adult stallions represents a unique surgical dilemma; the large distance between the incision site and the bladder necessitates the repair be accomplished under maximum tension with minimal exposure. Because traditional surgical approaches through ventral midline or paramedian incisions provide limited access and viewing, laparoscopy was used to provide a definitive diagnosis, good viewing, easy access, tension-free dissection, and a secure repair. Lack of surgical complications and postoperative discomfort, rapid and uncomplicated healing, and patient-client satisfaction make laparoscopic cystoplasty the preferred method for surgical repair of ruptured urinary bladder in adult stallions.

From the Department of Surgery, Louisiana State University Medical School, the Louisiana State University Service, Charity Hospital, and the Verterans Administration Hospital, New Orleans, Louisiana

Department of Anesthesia, Charity Hospital of Louisiana and Department of Surgery, Louisiana State University, New Orleans, La. *Presented before the Twenty-Ninth Congress of Anesthetists, Annual Meeting of the Members of the International Anesthesia Research Society, Los Angeles, Calif., October 11–14, 1954.

Employing a regression discontinuity (RD) approach on gubernatorial elections in the United States over the last three decades, this paper investigates the causal effects of governors' party affiliation (Democrat versus Republican) on unionization of workers, and unionized workers' working hours and earnings. Surprisingly, we find no significant impact from the party affiliation of governors on union membership and union workers' labor‐market outcomes.

Tympanometry is a method for evaluation of the mobility of the ear drum and the functional condition of the middle ear. This is performed by measuring the ability of the tympanic membrane to reflect a probe tone in response to gradually changing air pressure in the ear canal. Four tympanometric characteristics were measured in a series of 100 normal ears. These results were compared with those obtained in patients with different types of conductive pathology. The observed patterns in these patients with different audiological diagnoses were confirmed by surgery and by comparison with a series of fresh human temporal bones in which discrete lesions were created.

Figure 2. Placenta; the cotyledonary villi are extensively necrotic, with clumps of cellular debris (large arrow) and thrombosis (small arrow). HE, bar 5 50 mm. Figure 1. Marked vasculitis involving the arterioles of the placenta. There are fibrinoid necrosis (arrow) and severe infiltrates of the media, composed of leukocytes, mainly neutrophils. The surrounding placental tissue is necrotic. HE, bar 5 80 mm. Many microbial agents have been incriminated as causes of abortion in cattle. Implication of one of these agents in a given case is often problematic. This report deals with abortion in a university-maintained teaching dairy herd that averages about 100 lactating cows. The herd is split into 3 production groups on concrete lots and is fed a total mixed ration according to production level. During previous Dairy Herd Improvement (DHIA) sampling periods, the herd had an average production per cow of 8,325 kg of milk. Average somatic cell count and body condition score are 180,000 and

INTRODUCTION: Lactate measurement has been used to identify critical medical illness and initiate early treatment strategies. The prehospital environment offers an opportunity for very early identification of critical illness and commencement of care. HYPOTHESIS: The investigators hypothesized that point-of-care lactate measurement in the prehospital aeromedical environment would: (1) identify medical patients with high mortality; (2) influence fluid, transfusion, and intubation; and (3) increase early central venous catheter (CVC) placement. METHODS: Critically ill, medical, nontrauma patients who were transported from September 2007 through February 2009 by University of Massachusetts (UMass) Memorial LifeFlight, a university-based emergency medical helicopter service, were eligible for enrollment. Patients were prospectively randomized to receive a fingerstick whole-blood lactate measurement on an alternate-day schedule. Flight crews were not blinded to results. Flight crews were asked to inform the receiving attending physician of the results. The primary endpoint was the ability of a high, prehospital lactate value [> 4 millimoles per liter (mmol/L)] to identify mortality. Secondary endpoints included differences in post-transport fluid, transfusion, and intubation, and decrease in time to central venous catheter (CVC) placement. Categorical variables were compared between groups by Fisher's Exact Test, and continuous variables were compared by t-test. RESULTS: Patients (N = 59) were well matched for age, gender, and acuity. In the lactate cohort (n = 20), mean lactate was 7 mmol/L [Standard error of the mean, SEM = 1]. Initial analysis revealed that prehospital lactate levels of ≥ 4 mmol/L did show a trend toward higher mortality with an odds ratio of 2.1 (95% CI, 0.3-13.8). Secondary endpoints did not show a statistically significant change in management between the lactate and non lactate groups. There was a trend toward decreased time to post-transport CVC in the non lactate faction. CONCLUSION: Prehospital aeromedical point-of-care lactate measurement levels ≥ 4 mmol/L may help stratify mortality. Further investigation is needed, as this is a small, limited study. The initial analysis did not find a significant change in post-transport management.