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.

CERVICAL radicular pain is pain perceived in the upper limb caused by irritation of a cervical spinal nerve. It affects approximately 1 person per 1,000 population per year 1and is most often caused by a disc herniation or foraminal stenosis. Its natural history can be favorable, 2but not all patients recover naturally. Many remain severely disabled and require treatment.Surgery is the mainstay of treatment. 3,4For relieving cervical radicular pain, surgery has a good reputation, but scientifically, it is based only on multiple observational or descriptive studies. 2However, surgery is not without risks and constitutes a major undertaking for patients.Conservative therapy, typically including graduated exercise and oral analgesics, is supported only by observational studies, which have not controlled for natural history or nonspecific effects of treatment. Some have reported complete resolution of pain and neurologic dysfunction in as many as 80% of cases, 5,6but others have attested to resolution of radiculopathy in less than 40%. 7,8The controlled studies that have been conducted have shown no significant benefit for traction 9–11or exercises. 10The failure of conventional, conservative treatments to provide a cure for cervical radicular pain fostered the development of alternatives. Prominent among these has become transforaminal injection of steroids.The rationale for injecting steroids is that they suppress inflammation of the nerve, which, in many instances, is believed to be the basis for radicular pain. 12,13The rationale for using a transforaminal route of injection rather than an interlaminar route is that the injectate is delivered directly onto the target nerve. This ensures that the medication reaches the site of the suspected pathology in maximum concentration.At typical cervical levels, the ventral and dorsal roots of the spinal nerves descend in the vertebral canal to form the spinal nerve in their intervertebral foramen. The foramen faces obliquely forward and laterally. Its roof and floor are formed by the pedicles of consecutive vertebrae. Its posterolateral wall is formed largely by the superior articular process of the lower vertebra and in part by the inferior articular process of the upper vertebra and the capsule of the zygapophysial joint formed between the two articular processes. The anteromedial wall is formed by the lower end of the upper vertebral body, the uncinate process of the lower vertebra, and the posterolateral corner of the intervertebral disc. Immediately lateral to the external opening of the foramen, the vertebral artery rises closely in front of the articular pillars of the zygapophysial joint (fig. 1).The spinal nerve, in its dural sleeve, lies in the lower half of the foramen. The upper half is occupied by epiradicular veins. The ventral ramus of the spinal nerve arises just lateral to the intervertebral foramen and passes forward and laterally onto the transverse process. Radicular arteries arise from the vertebral artery and the ascending cervical artery and accompany the spinal nerve and its roots to the spinal cord.Cervical transforaminal injections can be performed with the patient lying in a supine, an oblique, or a lateral decubitus position, depending on operator preference and patient comfort. The position must allow adequate visualization of the cervical intervertebral foramina in anteroposterior, lateral, and oblique planes.The critical first step is to obtain a correct oblique view of the target foramen. In this view, the foramen is maximally wide transversely, and the anterior wall of the superior articular process projects onto the silhouette of the lamina. Through a puncture point overlying the posterior half of the target foramen, a needle is passed into the neck. Its tip should always lie over the anterior half of the superior articular process, lest it be inserted prematurely and too far into the foramen. When the needle has reached the superior articular process, the needle is then readjusted to enter the foramen tangential to its posterior wall, opposite the equator of the foramen (fig. 2A). Above this level, the needle may encounter veins; below it, the needle may encounter the spinal nerve and its arteries.Using an anteroposterior view, the tip of the needle should finally be adjusted to lie opposite the sagittal midline the articular pillars. Insertion beyond this depth risks puncturing the dural sleeve or thecal sac. The final position should be checked and recorded on an oblique view (fig. 2A), which documents placement against the posterior wall of the foramen, and on an anteroposterior view (fig. 2B), which documents depth of insertion.Under direct, real-time fluoroscopy in the anteroposterior view, a small volume of nonionic contrast medium (1.0 ml or less) is injected. The solution should outline the proximal end of the exiting nerve root and spread centrally toward the epidural space (fig. 3). Real-time fluoroscopy is essential to check for inadvertent intraarterial injection, which may occur even if the needle is correctly placed (fig. 4). Intraarterial injection is manifest by rapid clearance of the injected contrast. Contrast medium may also fill epiradicular veins, which are recognized by the slow clearance of the contrast, characteristic of venous flow.Only a small volume of contrast medium (1.0 ml or less) is required to outline the dural sleeve of the spinal nerve. As it spreads onto the thecal sac, the contrast medium assumes a linear configuration (fig. 3). Rapid dilution of the contrast medium implies subarachnoid spread, which may occur if the needle has punctured the thecal sac or a lateral dilatation of the dural root sleeve into the intervertebral foramen. When the target nerve has been correctly outlined, a small volume of a short-acting local anesthetic and corticosteroid are injected.The indication for cervical transforaminal injection of steroids is for the treatment of cervical radicular pain with or without radiculopathy. The difficulties in making this diagnosis have been reviewed elsewhere. 14The only constant feature of cervical radicular pain is pain in a dynatomal distribution (the distribution of referred symptoms caused by cervical root irritation), which may resemble the distribution of classic dermatomal maps for cervical nerve roots but not infrequently is provoked outside of the distribution of these classic dermatomal maps. 15Confidence in the diagnosis is enhanced if the patient also has radiculopathy, but this may not always be the case. Paresthesias, segmental numbness, weakness, and loss of reflexes are reliable and valid signs of radiculopathy that allow the diagnosis to be made clinically, without recourse to investigations. Disc protrusion and foraminal stenosis are the most common causes, but diagnostic imaging is required to exclude tumors and other infrequent causes such as infection, trauma, or inflammatory arthritides. 16In a prospective cohort study, Bush and Hillier 17treated 68 patients with cervical radiculopathy using a sequence of procedures in which patients who failed to respond to an injection of corticosteroids into the scalene region were treated with a transforaminal injection; those who failed to respond to transforaminal injection were, in turn, treated with an interlaminar injection of steroids. They reported that 76% of patients achieved complete relief of arm pain, but it is not possible from their report to derive what proportion responded explicitly to transforaminal injections.Slipman et al. 18reported a retrospective analysis of transforaminal injection of steroids in 20 patients with cervical radicular pain due to cervical spondylosis and clinical, radiographic, and electrodiagnostic findings consistent with nerve root involvement due to foraminal stenosis. Outcomes were measured using a functional outcome categorization that combined measures of pain, work status, medication use, and patient satisfaction. The investigators reported pain reduction, return to full-time work status, reduction or elimination in analgesic use, and satisfaction with treatment in 60% of patients at 12–45 months’ follow-up (average, 21.7 months) after treatment with an average of 2.2 injections.Using a prospective cohort design, Vallee et al. 19performed transforaminal injection of steroids in 30 patients with cervical radicular pain of more than 2 months’ duration and foraminal stenosis observed on computed tomography or magnetic resonance imaging. They observed greater than 75% diminution or complete resolution of pain in 53% of patients at 6 months after an average of 1.3 injections. At 3 months, 29% of patients had complete resolution of pain. This proportion persisted at 6 months but diminished to 20% at 12 months. At 3 months, an additional 29% of patients reported at least 50% diminution of their pain. This proportion persisted at 6 months but decreased to 18% at 12 months.Together, the studies of Slipman et al. 18and Vallee et al. 19suggest possible efficacy of cervical transforaminal injections of corticosteroids. They suggest that some 30% of patients can obtain partial but lasting relief of their pain, and a further 30% can obtain complete relief. However, these studies were observational studies without any comparison treatment. Their outcomes may be due to the natural history of cervical radicular pain syndromes or nonspecific treatment effects.Cervical epidural steroids placed by the interlaminar route have also been advocated for the treatment of radicular pain. 20–22The reported studies have been retrospective, often with short or unstated periods of follow-up. They attest to variable efficacy, with 0–29% of patients obtaining complete relief of pain and between 0 and 40% of patients achieving at least 75% relief after 6 months. 20–25There have been no studies published to date comparing translaminar versus transforaminal approaches to epidural steroid injection.Some investigators have reported no complications resulting from the use of cervical transforaminal injection of steroids. 26This has not been the case in other situations. The literature reports one case of fatal spinal cord infarction attributed to a transforaminal injection of corticosteroids. 27As well, the current authors are aware of three other cases in Australia, another in Europe, and 11 in the United States, in which patients have experienced severe neurologic sequelae, including spinal cord or brainstem infarction. These cases have not been published in the literature either because they are still sub judice or because lawyers and patients have declined to have their case records released into the medical literature.In some of the unpublished cases, it seems that steroids have been injected into the vertebral artery. Correct needle placement should ensure that the needle is not in the vertebral artery, and due attention to the flow of a test dose of contrast medium would reveal if it is.In the published case, and in most of the unpublished cases, no radiographic records are available to establish exactly where the needle was placed. In these cases, the basis for neurologic complications remains unclear. The leading conjecture has been that, somehow, a radicular artery was compromised.Baker et al. 28reported a case in which a transforaminal injection was initiated at the C6–C7 level. Digital subtraction, real-time fluoroscopic imaging revealed contrast medium filling a tiny vessel that ran transversely, directly to the spinal cord: clearly a radicular artery. On seeing this image, the operator promptly abandoned the procedure. The patient experienced no ill effects.These cases provide circumstantial evidence of the mechanism of spinal cord injury after cervical transforaminal injection of steroids. Material can be injected inadvertently into radicular arteries. It seems feasible that particulate matter in depot preparations of corticosteroids might act as an embolus, and if it enters an artery that happens to be a critical reinforcing supply to the anterior spinal artery, the spinal cord would be infarcted. Large caliber vessels that reinforce the anterior spinal artery are variable in incidence and in location and can occur anywhere from C3 to C8. 28Longitudinal spread of intraneuronally injected local anesthetic can lead to unexpected spinal anesthesia. 29It is also feasible that intraneuronal injection of steroid solution with longitudinal spread to the spinal cord could result in spinal cord injury.A compelling evidence base for conservative treatment of cervical radicular pain is lacking, and patients with severe pain may not benefit from conservative therapy. The choice then lies between surgery and transforaminal injection of steroids.There have been no controlled studies of cervical transforaminal injection of steroids. Consequently, their efficacy has not been established. Nevertheless, the results of observational studies render transforaminal injection of steroids an option.Similarly, the efficacy of surgery has not been demonstrated by a prospective, randomized, controlled trial. The one controlled trial, conducted in Scandinavia, found surgery to be no more effective than conservative therapy, 30but the outcomes from surgery in that study were considerably worse than those reported in observational studies conducted in the United States and Australia. 2Those observational studies variously attest to good or excellent outcomes in anywhere from 53% to more than 90% of cases. No studies, however, have reported exactly what proportions of patients are rendered completely pain free or for how long.The singular disadvantage of cervical transforaminal injection of steroids is the risk of serious complications. Were it not for the risk of spinal cord injury, cervical transforaminal injection of steroids would probably find a place in the management of cervical radicular pain, even in the absence of controlled studies.The incidence of serious complications from cervical surgery is not known. If these are similar in nature and similar in incidence to those of cervical transforaminal injections, some proponents of injections would argue that the risk of complications is not grounds for denying patients the option of treatment with injections.There is clearly a need for better data on the efficacy of cervical transforaminal injection of steroids as well as surgery for radicular pain. To this end, a comparison of surgery and cervical transforaminal injection of steroids in a prospective clinical trial is warranted. There is also a need for accurate data on the incidence of complications from either treatment.It is disappointing that lawyers, the practitioners involved, and their patients have not released the available material regarding complications. That information could shed light on how the complications occurred. Intraarterial injection might prove not to be the mechanism of injury. Nevertheless, practitioners who elect to continue using this procedure should be conscious of the hazards and ensure that their technique is optimal.Critical to the safety of cervical transforaminal injection of steroids is an understanding of the anatomy of the cervical intervertebral foramina and their contents, coupled with disciplined and accurate imaging. Under correct, oblique views, the needle must always remain in contact with the posterior wall of the foramen. This avoids contact with the spinal nerve, its roots, and their accompanying vessels (fig. 2A). Aspiration before injection is an unreliable means of detecting intravascular needle placement, perhaps because of the small caliber of the vessels in this region. Injection of a test dose of contrast medium is important to the safe execution of the procedure. Previously, this was used to indicate correct location of the injection and to exclude intrathecal injection, whereas it now also serves to identify inadvertent intraarterial injection. This must be done under real-time imaging because spot films taken after the injection may not show contrast medium that has been rapidly cleared.Because of the encouraging results of uncontrolled reports, cervical transforaminal injection of steroids is being used to treat patients with cervical radicular pain who do not have improvement with conservative therapy. There is a need for better data on both efficacy and safety because this treatment carries a risk of serious complications, including spinal cord injury. Critical to the safety of this technique is an understanding of the anatomy coupled with disciplined and accurate use of imaging.

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.

PURPOSE OF REVIEW: Disturbances in communication are a hallmark feature of severe mental illnesses. Recent technological advances have paved the way for objectifying communication using automated computerized semantic, linguistic and acoustic analyses. We review recent studies applying various computer-based assessments to the natural language produced by adult patients with severe mental illness. RECENT FINDINGS: Automated computerized methods afford tools with which it is possible to objectively evaluate patients in a reliable, valid and efficient manner that complements human ratings. Crucially, these measures correlate with important clinical measures. The clinical relevance of these novel metrics has been demonstrated by showing their relationship to functional outcome measures, their in-vivo link to classic 'language' regions in the brain, and, in the case of linguistic analysis, their relationship to candidate genes for severe mental illness. SUMMARY: Computer-based assessments of natural language afford a framework with which to measure communication disturbances in adults with severe mental illnesses. Emerging evidence suggests that they can be reliable and valid, and overcome many practical limitations of more traditional assessment methods. The advancement of these technologies offers unprecedented potential for measuring and understanding some of the most crippling symptoms of some of the most debilitating illnesses known to humankind.

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.

From 1948 through 1970, 164 histologically diagnosed cases of primary liver carcinoma were managed at Charity Hospital in New Orleans. The disease was five times more common in males, and most frequently occurred in the 6th and 7th decades of life. Weight loss, upper abdominal pain, anorexia, and jaundice made up the most significant symptom complex. Hepatomegaly was the most common physical finding. Approximately 85% of the cases were hepatocellular carcinoma. Extra-hepatic metastases were present in 55% of the 120 cases which came to autopsy. Lung, regional nodes, adrenals, and bone were the favored sites. Tumor was limited to one lobe in 32% of cases. Cirrhosis of the liver was diagnosed in 56%. Six patients underwent hepatic resection; 1 lived over 3 years, and 1 is alive 3 1/2 years after operation. Twelve patients received chemotherapy; 1 was alive at 2 1/2 years. Forty-nine patients had an intra-abdominal operative procedure. Over-all survival data for operated vs. non-operated cases did not vary significantly. Twenty-seven patients had percutaneous liver biopsy; the death of 3 was directly attributable to intra-abdominal hemorrhage after this procedure. Cancer 33:1624–1629, 1974.

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.

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

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.

FORCEFUL expiration against the closed glottis is commonly known as the "Valsalva experiment." The detailed report of Weber contrasts with the absence of documentation linking Valsalva with the experiment. We therefore consider the eponym not entirely suitable.Valsalva1 described a maneuver useful in expelling pus from the middle ear. It consisted of expiring against the closed nose and mouth. No observations of the circulatory effects were mentioned. Valsalva's original statement and our translation are as follows:... si, inquam, iste clauso ore et naribus aerem intro comprimere conetur; inde sanies in meatum auditorium ita copiose solet eodem actu protrudi, ut . . .

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.