Road salting and natural brine migration revealed as major sources of groundwater contamination across regions of northern Appalachia with and without unconventional oil and gas development.

High methane and salt levels in groundwater have been the most widely cited unconventional oil and gas development (UOGD) related water impairments. The attribution of these contaminants to UOGD is usually complex, especially in regions with mixed land uses. Here, we compiled a large hydrogeochemistry dataset containing 13 geochemical analytes for 17,794 groundwater samples from rural northern Appalachia, i.e., 19 counties located on the boundary between Pennsylvania (PA; UOGD is permitted) and New York (NY; UOGD is banned). With this dataset, we explored if statistical and geospatial tools can help shed light on the sources of inorganic solutes and methane in groundwater in regions with mixed land uses. The traditional Principal Component Analysis (PCA) indicates salts in NY and PA groundwater are mainly from the Appalachian Basin Brine (ABB). In contrast, the machine learning tool - Non-negative Matrix Factorization (NMF) highlights that road salts (in addition to ABB) account for 36%-48% of total chloride in NY and PA groundwaters. The PCA fails to identify road salts as one water/salt source, likely due to its geochemical similarity with ABB. Neither PCA nor NMF detects a regional impact of UOGD on groundwater quality. Our geospatial analyses further corroborate (1) road salting is the major salt source in groundwater, and its impact is enhanced in proximity to highways; (2) UOGD-related groundwater quality deterioration is only limited to a few localities in PA.

Geochemical Evidence of Potential Groundwater Contamination with Human Health Risks Where Hydraulic Fracturing Overlaps with Extensive Legacy Hydrocarbon Extraction.

Unconventional oil and gas development (UOGD) sometimes impacts water resources, including incidents of methane (CH4) migration from compromised wells and spills that degrade water with salts, organics, and metals. We hypothesized that contamination may be more common where UOGD overlaps with legacy coal, oil, and gas extraction. We tested this hypothesis on ∼7000 groundwater analyses from the largest U.S. shale gas play (Marcellus), using data mining techniques to explore UOGD contamination frequency. Corroborating the hypothesis, we discovered small, statistically significant regional correlations between groundwater chloride concentrations ([Cl]) and UOGD proximity and density where legacy extraction was extremely dense (southwestern Pennsylvania (SWPA)) but no such correlations where it was minimal (northeastern Pennsylvania). On the other hand, legacy extraction of shallow gas in SWPA may have lessened today's gas leakage, as no regional correlation was detected for [CH4] in SWPA. We identify hotspots where [Cl] and [CH4] increase by 3.6 and 3.0 mg/L, respectively, per UOG well drilled in SWPA. If the [Cl] correlations document contamination via brines leaked from wellbores, impoundments, or spills, we calculate that thallium concentrations could exceed EPA limits in the most densely developed hotspots, thus posing a potential human health risk.

Blue Liver: Case Report of Blue Liver.

BACKGROUND Although many cases of unusual liver discoloration exist, such as blue liver syndrome which is linked to oxaliplatin-based chemotherapy, our finding was seen in a patient who was not on chemotherapy. A 39-year-old male who presented with jaundice was found to have blue liver discoloration. CASE REPORT A 39-year-old male presented with jaundice of one-month's duration evidenced by elevated total and direct bilirubin. An ultrasound and magnetic resonance cholangiopancreatography (MRCP) demonstrated thickened gall bladder wall but no common bile duct stones. A robotic-assisted laparoscopic cholecystectomy with liver biopsy was performed. Intraoperatively, the liver was noted to be unusually blue in color. During his postoperative course, the patient developed excessive incisional bleeding associated with an increase in international normalized ratio (INR) and increasing direct hyperbilirubinemia. This was managed with blood transfusions, and ursodeoxycholic acid was begun, which resulted in improvement of his bilirubin levels and overall recovery. CONCLUSIONS Drug induced cholestasis and liver injury is a common cause of elevated liver enzymes. However, the unusual blue appearance of the liver should prompt an evaluation for other unusual and rare causes of obstructive jaundice.

Robotic versus Laparoscopic Cholecystectomy: Case-Control Outcome Analysis and Surgical Resident Training Implications.

Background The robotic approach in surgery is becoming more widely used in many subspecialties. Robot-assisted laparoscopic procedures provide potential improvements in clinical outcomes due to improved visualization and enhanced surgical ergonomics. In this study, we measured and compared outcomes of robot-assisted laparoscopic cholecystectomy with the conventional laparoscopic technique, as well as the implications for the training of surgical residents. Method We compared a total of 244 patients undergoing minimally invasive cholecystectomies performed by one surgeon between July 2013 and June 2016 examining relevant clinical outcomes including operative room (OR) time, length of hospital stay (LOS), readmission to the hospital, post-operative emergency department (ED) visits, and post-operative pain between laparoscopic single-incision cholecystectomy and robot-assisted laparoscopic cholecystectomy. A chi-square test and Student's t-test were used to compare these variables between the two groups. Propensity score matching (PSM) was used using gender, age, and body mass index (BMI) as variables. Results From the total number of procedures of 244, 144 were included in the laparoscopic group and 100 in the robot-assisted group. The robot-assisted patients had a shorter post-operative LOS (mean: 0.8 vs. 1.6 days; p = 0.002). There was no significant difference in the OR time (mean: 64.8 vs. 65.0 minutes; p = 0.945), readmissions (4.0% vs. 3.5%; p = 0.830), post-operative ED visits (7.0% vs. 7.6%; p = 0.851), or post-operative pain (13.0% vs. 21.3%; p= 0.137). Robotic cholecystectomy patients were younger (mean: 46 vs. 52 years; p = 0.023) and had lower BMIs (mean: 31 vs. 33; p = 0.038). Because of these differences, we compared the two groups using PSM that confirmed the shorter LOS in the robotic group (mean: 0.9 vs. 1.9; p = 0.009). Conclusions These results demonstrate that robotic cholecystectomies can reduce LOS for patients undergoing laparoscopic cholecystectomy, without increasing OR time. Increased surgeon experience with robotic procedures and improved OR efficiency will allow greater opportunities for resident participation. Robotic training curricula need to be employed and objectively evaluated to improve surgical resident skill acquisition and provide earlier and progressive clinical participation in robotic procedures.

A benign gastric ulcer eroding into a splenic artery pseudoaneurysm presenting as a massive upper gastrointestinal bleed.

Upper gastrointestinal (UGI) bleeding secondary to a ruptured splenic artery (SA) pseudoaneurysm into the stomach is a rare but a life-threatening condition. Owing to the low prevalence, it remains a diagnostic and therapeutic challenge. A frail 77-year-old Caucasian female presented with epigastric pain and hematemesis. Endoscopy was non-diagnostic for an etiology. She then underwent diagnostic angiography that revealed an SA pseudoaneurysm with active contrast extravasation into the stomach. Subsequent transcatheter arterial coil embolization was conducted of the SA. The patient was subsequently taken for a partial gastrectomy, distal pancreatectomy and splenectomy. She had an uncomplicated postoperative course. Diagnosis of an UGI bleeding secondary to a ruptured SA pseudoaneurysm into the stomach remains difficult. However, we report that in a hemodynamically stable patient, a multidisciplinary approach can be taken, with interval optimization of the patient prior to definitive surgery for a satisfactory outcome.