How good is GLASOD?

The Global Assessment of Soil Degradation (GLASOD) has been the most influential global appraisal of land quality in terms of environmental policy. However, its expert judgments were never tested for their consistency and could not be reproduced at unvisited sites, while the relationship between the GLASOD assessments of land degradation and the social and economic impact of that degradation remains unclear. Yet, other methodologies that could respond to urgent calls for an updated assessment of the global environmental quality are not operational or, at best, in progress. Therefore, we evaluate the reliability and social relevance of the GLASOD approach and assess its candidacy for new global environmental assessments. The study concentrates on the African continent, capitalizing on new GIS data to delineate and define the characteristics of GLASOD map units. Consistency is tested by comparing expert judgments on soil degradation hazard for similar combinations of biophysical conditions and land use. Reproducibility is evaluated by estimating an ordered logit model that relates the qualitative land degradation classes to easily available information on explanatory variables, the results of which can be used to assess the land degradation at unvisited sites. Finally, a cross-sectional analysis investigates the relation between GLASOD assessments and crop production data at sub-national scale and its association with the prevalence of malnutrition. The GLASOD assessments prove to be only moderately consistent and hardly reproducible, while the counter-intuitive trend with crop production reveals the complexity of the production-degradation relationship. It appears that increasing prevalence of malnutrition coincides with poor agro-productive conditions and highly degraded land. The GLASOD approach can be improved by resolving the differences in conceptualization among experts and by defining the boundaries of the ordered classes in the same units as independent, quantitative land degradation data.

Appendicitis: why so complicated? Analysis of 5755 consecutive appendectomies.

A perceived high rate of complicated (gangrenous or perforated) appendicitis, despite advances in laboratory and radiographic diagnostic modalities, prompted a review of our experience with appendicitis followed by a prospective analysis that examined the time course from presentation to definitive treatment in 218 consecutive patients. In 5755 appendectomies, our overall rate of complicated appendicitis was 32 per cent; higher in males, in the young, and in the elderly; and relatively stable over each year reviewed. Prospectively, we determined that of the various time intervals, the time from the onset of symptoms to first seeking medical attention is the only significant predictor of complicated appendicitis (39.8 vs 16.5 hours for acute appendicitis). On the other hand, the time from surgical evaluation to operative intervention was significantly shorter for complicated appendicitis (3.8 vs 4.7 hours for acute appendicitis). The high rate of complicated appendicitis with its subsequent sequelae of increased morbidity and resource expenditure is primarily the direct result of patient delay in seeking medical attention and not the result of diagnostic dilemma or surgical delay. Public education, specifically targeting those groups at risk, may provide a substantial and significant solution to the complicated appendix.

Blunt splenic injuries: dedicated trauma surgeons can achieve a high rate of nonoperative success in patients of all ages.

BACKGROUND: Selective nonoperative management (NOM) of blunt splenic injuries is becoming a more prevalent practice. Inclusion criteria for NOM, which have been a source of controversy, continue to evolve. Age > or = 55 years has been proposed as a predictor for failure of and even a contraindication to NOM of blunt splenic trauma. Additionally, the high rate of NOM in children (up to 79%) has been attributed to their management by pediatric surgeons. We evaluated our experience with NOM of blunt splenic injury with special attention to these age groups. METHODS: By using our trauma registry, all patients with blunt splenic injuries (documented by computed tomography, operative findings, or both) cared for over a 36-month period, at a single American College of Surgeons verified Level I trauma center were reviewed. Detailed chart reviews were performed to examine admission demographics, laboratory data, radiologic findings, outcome measures, and patient management strategy. All patients were managed by nonpediatric trauma surgeons. We then compared our adult data with that in the recent literature and our pediatric data with that of the National Pediatric Trauma Registry over the same time period. RESULTS: We identified 251 consecutive patients with blunt splenic injuries. Eighteen patients who expired in the immediate postinjury period were excluded from statistical evaluation. No deaths occurred as a result of splenic injury. Of the remaining 233 patients, 73 patients (31%) required early celiotomy, 160 patients (69%) were selected for NOM, with 151 patients (94%) being successfully managed without operation. Blunt splenic injury occurred in 23 patients age 55 years or older. Eighteen patients (78%) were selected for NOM and 17 patients (94%) were successfully treated without operation. Blunt splenic injury occurred in 35 patients less than 16 years of age. Thirty-two patients (91%) were selected for NOM. Thirty-one patients (89% of all pediatric patients) were successfully treated without operation. CONCLUSION: Age > or = 55 years is not a contraindication to nonoperative management of blunt splenic injuries. Children with blunt splenic injuries can be successfully managed nonoperatively by nonpediatric trauma surgeons.

Prognostic factors after acute subdural hematoma.

Factors that have been shown to affect outcome after acute subdural hematoma (ASDH) include age, Injury Severity Score (ISS), intracranial pressure (ICP), direct admission to a trauma center, presence of subarachnoid hemorrhage, score on the Glasgow Coma Scale (GCS), and timing of operation. However, these data come from selected patient populations (e.g., operated, comatose, or minimally symptomatic patients, etc.). In an effort to evaluate factors that predict outcome for the entire spectrum of ASDH patients, we evaluated 211 patients with ASDH and GCS scores of 3 to 15. One hundred twenty-eight patients (61%) were managed nonoperatively (Nonop), whereas 83 (39%) were managed with craniotomy [operatively (Op)]. Op patients had more severe brain injuries, as evidenced by their lower GCS scores (Op 7.8 vs. Nonop 10.7, p = 0.0001), higher incidence of large ASDH with midline shift (Op 61% large ASDH, 83% midline shift vs. Nonop 16% large ASDH, 30% midline shift, p = 0.001 for each comparison), and higher incidence of basilar cistern effacement (Op 61% vs. Nonop 21%, p = 0.001). Thirty-five percent of the Op patients had their hematoma evacuated within 4 hours (early), whereas 65% did not (delayed). Early Op patients had a significantly lower incidence of functional survival (early = 24% vs. delayed = 51%, p = 0.02). The early patients seem to have had more significant head injuries, as evidenced by their lower GCS scores (early = 7.0 vs. delayed = 8.4), higher incidence of associated intracranial injuries (early = 1.14 vs. delayed = 0.85), and higher incidence of cistern effacement (early = 76% vs. delayed = 53%, p = 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)

Acute subdural hematoma: nonsurgical management of selected patients.

There is a current trend toward nonsurgical therapy for small, minimally symptomatic acute subdural hematomas (ASDH), but data supporting such a scheme have been lacking. We evaluated 83 patients with minimally symptomatic ASDH (Glasgow Coma Scale scores of 11-15) and found 58 managed nonsurgically (70%) and 25 managed with craniotomy (30%). Patients managed without surgery had a lower incidence of focal neurologic deficits (12% vs. 40%; p < .01), open cisterns (90% vs. 28%; p < .001), and small (< or = 1 cm) ASDHs (92% vs. 62%; p < .001). Ninety-three percent of patients managed nonsurgically had functional recovery compared with 84% of patients with craniotomy. Age and injury Severity Score were significantly associated with patient outcome. Timing of surgery had no association with outcome. Six percent of patients managed nonsurgically developed chronic SDH requiring craniotomy. We conclude that unless the hematoma is causing clinical evidence of intracranial hypertension or significant neurologic dysfunction, there appears to be no advantage in evacuating the clot. Selected patients with ASDH and GCS scores of 11-15 can safely be managed without craniotomy.

Effect of recombinant human insulin-like growth factor I and early total parenteral nutrition on immune depression following severe head injury.

OBJECTIVE: To determine the effects of insulin-like growth factor I (IGF-I) and aggressive nutrition on CD4/CD8 ratios following head injury. DESIGN: Randomized controlled trial. SETTING: An urban level 1 trauma center. PARTICIPANTS: Head-injured patients with a Glasgow Coma Scale score of 4 to 10 within 6 hours of hospital admission requiring no major extracranial surgery with the exception of isolated lower-extremity fracture fixation. Fourteen patients were recruited and 11 completed the study. INTERVENTIONS: Patients were randomized to a continuous infusion of saline or 0.01 mg/kg per hour of recombinant human (rh) IGF-I. Both groups received parenteral nutrition and rapidly advanced to a total protein intake of 2 g/kg per day and a maximum nonprotein calorie intake of 40 kcal/kg per day. The nonprotein prescription was 1.25 times the metabolic energy expenditure determined by metabolic cart not to exceed a nonprotein calorie intake of 40/kcal. MAIN OUTCOME MEASURES: The CD4/CD8 ratios and serum IGF-I levels on days 1, 7, and 14. RESULTS: Administration of early aggressive nutrition eliminated the depressed CD4/CD8 ratio usually seen after head injury; administration of IGF-I increased the CD4/CD8 ratio while IGF-I levels were elevated. CONCLUSIONS: Infusion of rhIGF-I and aggressive early intravenous nutrition affects the immunologic response of patients with severe head injury.