Harmonization service and global library of models to support country-driven global information on salt-affected soils.

Global distribution of salt-affected soils (SAS) has remained at about 1 billion hectares in the literature over the years despite changes in climate, sea levels, and land use patterns which influence the distribution. Lack of periodic update of input soil data, data gaps, and inconsistency are part of the reasons for constant SAS distribution in the literature. This paper proposes harmonization as a suitable alternative for managing inconsistent data and minimizing data gaps. It developed a new harmonization service for supporting country-driven global SAS information update. The service contains a global library of harmonization models for harmonizing inconsistent soil data. It also contains models for identifying gaps in SAS database and for showing global distribution where harmonization of available data is needed. The service can be used by countries to develop national SAS information and update global SAS distribution. Its data availability index is useful in identifying countries without SAS data in the global database, which is a convenient way to identify countries to mobilize when updating global SAS information. Its application in 27 countries showed that the countries have more SAS data than they currently share with the global databases and that most of their data require SAS harmonization.

Selective intraoperative cholangiography during laparoscopic cholecystectomy: how selective?

The necessity for intraoperative cholangiography during laparoscopic cholecystectomy has been debated for some time. Numerous retrospective studies favor selective intraoperative cholangiography. Surgeons in favor of the selective policy differ in their personal selective criteria. The aim of this prospective study was to evaluate whether intraoperative cholangiography can be safely omitted during laparoscopic cholecystectomy on all patients who fit a standard set of criteria: normal liver function tests, common bile duct diameter less than 10 mm, and no history of gallstone pancreatitis or jaundice. We undertook a prospective study on 155 consecutive patients treated in a county teaching hospital with symptomatic gallbladder disease who met the above standard set of criteria. One hundred and fifty-five patients meeting these criteria underwent laparoscopic cholecystectomy during a 2-year period from February 1996 through February 1998. Data analyzed included patient history, laboratory and ultrasound findings, operative results, postoperative stay, and intraoperative and postoperative complications. The patients were followed by periodic interviews, physical examination, liver function tests, and/or biliary ultrasound for up to 3 1/2 years with a mean follow-up of 26 months for retained common bile duct stones. Intraoperative cholangiography was performed in only one of the 155 patients studied to confirm common bile duct injury. There were four postoperative complications (2.6%) and one common bile injury (0.6%). Postoperative stay averaged one day. No patients, by history, biliary ultrasound, liver function tests or endoscopy, were found to have retained common bile duct stones during the follow-up period. Our study shows that intraoperative cholangiography is not necessary for patients undergoing laparoscopic cholecystectomy who have normal liver functions tests, common bile duct diameter less than 10 mm, and no history of gallstone pancreatitis or jaundice.

A case of jejunal intussusception with gastrointestinal bleeding caused by metastatic testicular germ cell cancer.

BACKGROUND/AIM: We report an unusual case of metastatic testicular germ cell tumor with its unusual presentation. METHOD: A patient presented to the San Joaquin General Hospital with gastrointestinal bleeding and obstruction and a testicular mass is described. The patient's clinical course is followed and the literature reviewed. RESULTS: The patient presented with jejunal intussusception due to metastatic testicular cancer. He was treated with orchiectomy and bowel resection followed by postoperative chemotherapy. CONCLUSION: This case illustrates the need to consider metastatic small-bowel obstruction and/or intussusception in patients presenting with testicular mass and abdominal pain.

Urinary catheter in laparoscopic cholecystectomy: is it necessary?

The aim of this prospective study was to evaluate the necessity or urinary catheterization in elective laparoscopic cholecystectomy. From April 1996 to April 1998, 261 patients undergoing elective laparoscopic cholecystectomy at a county hospital were randomized to either receive or not receive preoperative urinary bladder catheterization. Data analyzed included age and gender of patients, length of surgery, and intraoperative and perioperative complications such as visceral injury, urinary tract infection, and urinary retention. Our results showed, although not statistically significant, more urinary tract complications in the "with Foley" group than in the "without Foley" group (four vs one, respectively). There was no significant difference between the two groups with respect to length of operation and perioperative complications. There was no visceral injury or operative mortality in this study. We conclude that urinary catheterization can be omitted safely in elective laparoscopic cholecystectomy.

Common iliac artery injury from blunt trauma: case reports.

Common iliac artery injury from blunt trauma is uncommon. We describe two cases of common iliac artery injury from blunt abdominal trauma resulting in occlusion in one case and aneurysm in the other. The diagnosis of such injuries is based on clinical suspicion, the presence of bruits, pulse change or discrepancy, or continued unexplained blood loss. Vessel wall damage may not manifest itself initially but may result in thrombosis, subintimal hemorrhage, dissection, or aneurysmal dilatation. These can result in hemorrhage, pain, or ischemia developing remotely from the initial trauma.

Surgical management of subclavian artery injury.

During a 10 year period, we have had operative experience with 13 injuries to the subclavian artery. The factors that led to the successful management in 10 consecutive patients were analyzed. Nonspecific signs, such as pain and swelling, were present in all of the patients. Some aspect of vascular injury was present in each patient and included change in the quality of the distal pulse, hematoma, active hemorrhage, and bruit. Roentgenologic signs such as lung opacification, fractured clavicle, fracture of the first or second rib, and pulmonary opacification were present in each patient. Arteriograms were obtained from all stable patients in whom this injury was suspected. There were no false-positive or false-negative findings. The operative approach for the right subclavian vessels was midline sternotomy, whereas for exposure of proximal left subclavian injuries, anterolateral thoracotomy was utilized. Claviculectomy permitted excellent exposure for distal subclavian artery injuries. This exposure was associated with minimal blood loss and permitted direct repair of complex injuries of the arteries and veins. All patients who reached the emergency room with measurable vital signs survived, and all those who underwent subclavian vascular repair had circulation restored. Principal morbidity was due to associated brachial plexus and lung injuries. A high index of suspicion, rapid transportation, aggressive resuscitation, and proper surgical exposure and repair are essential for the successful management of these rare vascular injuries.

Assessment of gastric motility using meal labeled with technetium-99m sulfur colloid.

During a 2 year period, 83 patients with gastric motility problems were evaluated using radionuclide imaging. The patients presented with epigastric distress, postprandial fullness, pain, nausea, vomiting, and diarrhea; signs and symptoms suggestive of either gastroparesis or gastric outlet obstruction. Upper gastrointestinal series or endoscopy, or both, demonstrated no mechanical obstruction. After oral administration of a 300 g meal labeled with 600 muCi of technetium-99m sulfur colloid, a gastric emptying study consisting of serial images and data acquisition was performed. Of the patients studied, 52 had had peptic ulcer surgery, 17 were suspected of having gastroesophageal reflux, 8 were diabetic and suspected of having visceral enteropathy, and 6 had a history of irritable bowel syndrome. The normal mean gastric half emptying time was 77 +/- 16 minutes. Of the patients who had had gastric surgery, 90.4 percent had abnormal emptying: 69.2 percent had delayed gastric emptying and 21.2 percent had rapid gastric emptying time; 9.6 percent had normal emptying time. Of the gastroesophageal reflux group, all but two had normal gastric emptying time; 65 percent demonstrated gastroesophageal reflux within 15 minutes. Two of the patients with irritable bowel syndrome had prolonged emptying; the rest had normal emptying. All diabetic patients with gastroparesis had prolonged gastric emptying time, and all responded favorably to metoclopramide. Of the patients who previously had peptic ulcer surgery and had prolonged emptying time, 72 percent also responded favorably to metoclopramide. We conclude that radionuclide gastric imaging is a useful diagnostic test for the measurement of gastric emptying in patients with a variety of gastrointestinal motility disorders and may be helpful in assessing medical therapy and selecting those who may be candidates for surgery.

Comparison of ultrasonography, computerized tomography, and radionuclide imaging in the diagnosis of acute and chronic cholecystitis.

Seventy-five patients with abdominal pain in the right upper quadrant who were subsequently confirmed operatively and histologically to have acute or chronic cholecystitis underwent radionuclide imaging of the biliary tree, ultrasonography, and/or computerized tomography before operation. fifty-eight of the patients had acute cholecystitis and 17 had chronic cholecystitis and cholelithiasis. Analysis of our data indicates that ultrasonography is an accurate and better screening test than cholescintigraphy in the diagnosis of chronic cholecystitis and cholelithiasis, but it is less accurate in the detection of acute cholecystitis. On the other hand, radionuclide imaging is highly sensitive and specific in the early diagnosis of acute cholecystitis, but it is poor in the diagnosis of chronic cholecystitis and cholelithiasis unless the cystic duct is obstructed. CT scanning is more expensive than ultrasonography but may be extremely helpful in problematic cases such as the diagnosis of the cause in biliary obstruction or in imaging of the pancreas.

Effects of pH on in vitro gallbladder responses to cholecystokinin octapeptide.

We investigated the effect of pH change on octapeptide cholecystokinin's ability to contract guinea pig gallbladder strips. In the absence of exogenous drugs, pH changes had no demonstrable effect on gallbladder tension. However, when gallbladder strips were contracted with CCK-OP at pH 7.3, increasing the pH in the muscle bath to 7.8 produced further increases in tension at each dose studied (P less than 0.025). Subsequently, decreasing the bath pH to 6.9 decreased the strip tension to less than that observed at pH 7.3 (P less than 0.025). Reversing the order in which these pH alterations were made produced similar results; a pH decrease from 7.3 to 6.9 decreased the response to CCK-OP at the two highest doses (P less than 0.025), while subsequent elevation of pH raised the tension to levels greater than those observed at pH 7.3 (P less than 0.01). Furthermore, contracting the strips at pH 8.0 and slowly decreasing pH at a rate of 0.1 pH units per minute consistently produced an acceleration of tension decay as pH fell. After contracting the strip at pH 6.7, slow increases in pH reversed the tension decay and enhanced the contractile response as pH was increased from 6.7 to 8.0. These results demonstrate that pH changes alter the gallbladder contractile response to cholecystokinin. Although this phenomenon has been reported for a number of other physiologic agents, we believe this is the first such demonstration for a peptide hormone.

Clinical experience with 99mTc-disofenin as a cholescintigraphic agent.

99mTc-disofenin, a derivative of iminodiacetic acid, was used for cholescintigraphy in 6 volunteers (in addition to assessment of blood and urine clearance) and in 82 patients referred for evaluation of hepatobiliary tract disease. This radionuclide was cleared rapidly from the blood by the hepatocytes, which permitted satisfactory to excellent images of the hepatobiliary system; interference by renal activity was seen in only 9/82 patients (11%). Acute cholecystitis was correctly diagnosed in 20 patients, although 9 (45%) had jaundice; bilirubin levels ranged from 1.2 to 7.6 mg/dl. The biliary tract was normal in 16 of the 27 patients with jaundice (60%).

Pathogenesis of cholesterol gallstones.

The factors leading to cholesterol cholelithiasis are probably multiple. Although the secretion of bile supersaturated with cholesterol seems to be a common feature among all patients who form cholesterol stones, a variety of pathophysiologic events can produce an increase in lithogenicity. Dietary factors, particularly in the grossly obese, lead to an absolute increase in secretion of cholesterol into bile. Occasionally, excessive loss of the bile salt pool, for example with regional ileitis, may decrease the ability of bile salts to solubilize cholesterol. In many other, subtle alterations in the enterohepatic circulation of bile salts may adversely affect solubility by both decreasing the secretion of bile salts and increasing the secretion of cholesterol. Regardless of its cause, supersaturation of bile with cholesterol appears to be a prerequisite for gallstone formation. However, additional factors within the gallbladder, such as increased secretion of glycoprotein, increased absorption of fluids, infection, and stasis, appear to contribute to the formation of macroscopic stones.

Radionuclide imaging of the biliary tree.

The new 99mTc biliary scintigraphy agents are highly sensitive and specific in detecting biliary tract disease and use of them is the initial procedure of choice in evaluating patients with suspected acute cholecystitis. Other clinically useful indications are evaluation of biliary kinetics; evaluation of patients with suspected traumatic bile leakage, gallbladder perforation, or postsurgical biliary tract complications; and evaluation of patients with suspected biliary obstruction. In 99mTc we have a simple radiopharmaceutical of low radiation for evaluating congenital abnormalities and neonatal jaundice. In the Orient 99mTc cholescintigraphy is extremely important in evaluating patients with suspected intrahepatic stones. The overall advantages of this technique include availability, safety, simplicity, and accuracy. In addition, it may be performed in those patients who are allergic to iodinated contrast agents.

Acute suppurative cholangitis.

Acute suppurative cholangitis is characterized by obstruction, inflammation, and pyogenic infection of the biliary tract associated with the clinical pentad of fever (and chills), jaundice, pain, shock, and central nervous system depression. The disease occurs most commonly in the elderly who have a history of calculous biliary tract disease. The disease represents a true surgical emergency. Appropriate antibiotic therapy and immediate surgical decompression of the biliary tract are essential and carry a mortality rate of approximately 33 per cent. Nonoperative management is uniformly fatal. If inadequately treated or untreated, the disease follows a fulminant course of progressive systemic sepsis, hepatic abscess formation, and heptic failure leading ultimately to death. Acute suppurative cholangitis, the most serious sequela of calculous biliary tract disease, is preventable by early elective surgical treatment for benign biliary tract disease.

Renal clearance and extraction parameters of ortho-iodohippurate (I-123) compared with OIH(I-131) and PAH.

o-[131I] iodohippurate [OIH(I-131)] has been used for many years in the estimation of effective renal plasma flow. This compound suffers from low photon yield and poor images when the quantity used is limited to stay within a reasonable radiation dose. To test the validity of substituting I-123 for I-131, a series of experiments was performed in a surgically prepared dog model. The extraction ratios and clearance values OIH(I-123) prepared from radionuclidically pure I-123 were compared with those of commercial OIH(I-131) and PAH. The extraction ratios for OIH(I-123) and OIH(I-131) were 0.65 and 0.67, representing 0.86 and 0.88 that of PAH, respectively. The clearance values (cc/min/kg) for the I123 and I-123) can be used to estimate effective renal plasma flow; moreover, because of the high yield within an acceptable radiation dose range, images of good quality can be produced.

Selective embolization for control of gastrointestinal hemorrhage.

Transcatheter embolization using Gelfoam plugs or autologous clot is an alternative or adjunct to the conventional management of gastrointestinal hemorrhage. During a 12 month period we successfully treated 10 patients who had massive gastrointestinal hemorrhage with selective embolization; 6 patients had upper gastrointestinal hemorrhage and 4 had bleeding from the colon. Most of these patients were critically ill and were poor surgical candidates. Hemorrhage was controlled by selective catheterization of the bleeding vessel, followed by injection of Gelfoam pledgets. Since the procedure was accomplished with ease and prolonged hemostasis obtained, we recommend it for gastrointestinal hemorrhage, especially in patients who are poor surgical risks or are unresponsive to vasopressin infusion, or both. Operative intervention for the primary disease could subsequently be performed electively, if necessary, days or weeks after transcatheter embolization.

Malignant schwannoma: report of a case mimicking lumbar disk disease.

Primary neurogenic retroperitoneal tumors in the adult are rare. This case presentation reviews an unusual history of a patient who presented with pain and neurologic deficits suggesting lumbar disk disease but who was unrelieved by laminectomy and disk removal. Later he was found to have a malignant schwannoma arising from the right L nerve root. Experience such as this reminds physicians that when the result of treatment is not as expected the original diagnosis must be questioned.

Biodistribution studies of labeled tryptophan: a potential pancreas-scanning agent.

The in vivo organ distributions of dl- and l-[side 3-14C]-tryptophan and dl-(75Se)-selenomethionine were studied in normal Long-Evans rats to determine which tryptophan isomer had the best pancreas/liver ratio. The commercially available radiochemical agents were injected into the tails of adult rats, and three animals were sacrificed for each compound at 15, 30, 45, 60, and 90 minutes. Samples of blood, pancreas, liver, kidney, spleen, and flank muscles were excised, weighed wet, digested, and counted by standard liquid scintillation technics. A standard fraction of the injected dose was also counted so that results could be reported as per cent injected dose per gram tissue (per cent ID/gm) and per whole organ. The spleen and muscle concentrations (per cent ID/gm) were indistinguishable for the three compounds at all times studied. The kidney concentration of dl-tryptophan was higher than that of l-tryptophan at 60 and 90 minutes, reflecting the renal excretion of the nonmetabolic isomer. The concentration of l-tryptophan was two to three times higher than that of dl-tryptophan and selenomethionine in the pancreas at the earlier times, but after 1 hour they became equivalent. All three compounds had equivalent concentrations in the liver, except for l-tryptophan at 15 minutes. We conclude that pancreas/liver ratios are much higher for tryptophan than for selenomethionine and that for l-tryptophan they are at least tenfold higher. Since the rat is able to partially metabolize d-tryptophan via an inversion step, differences between l- and dl-tryptophan might be even larger for humans. L-tryptophan labeled with a short-lived gamma-emitting nuclide (13N or 11C) should, therefore, be a much better radiopharmaceutical agent for pancreatic scintigraphy.