Chronic traumatic diaphragmatic hernia with pericardial rupture and associated gastroesophageal reflux

Major thoracic and abdominal trauma damages the diaphragm 5% of the time. These injuries may be recognized when they occur but often are discovered months later during work up for related symptoms. Typically, the injury is to the left posterolateral aspect of the diaphragm. Rarely, rupture through the central diaphragmatic tendon into the pericardial space occurs and this results in different symptoms than the more common injury. We present the case of a patient who presented with chest pain, near syncopal episodes and refractory gastroesophageal reflux years after he was struck by a car and hospitalized. Radiographic imaging included a chest CT that demonstrated herniation of the transverse colon into the mediastinum. During exploration, a defect in the central diaphragm was found with free communication between the peritoneal and pericardial spaces. In this paper, we review our management of this unusual diaphragmatic hernia and the unique symptoms associated with it.

Bone-marrow-derived mesenchymal stem cells attenuate cognitive deficits in an endothelin-1 rat model of stroke

PURPOSE

Stroke is the third leading cause of death and permanent disability in the United States, often producing long-term cognitive impairments, which are not easily recapitulated in animal models. The goals of this study were to assess whether: (1) the endothelin-1 (ET-1) model of chronic stroke produced discernable cognitive deficits; (2) a spatial operant reversal task (SORT) would accurately measure memory deficits in this model; and (3) bone-marrow-derived mesenchymal stem cells (BMMSCs) could reduce any observed deficits.

METHODS

Rats were given unilateral intracerebral injections of vehicle or ET-1, a stroke-inducing agent, near the middle cerebral artery. Seven days later, they were given intrastriatal injections of BMMSCs or vehicle, near the ischemic penumbra. The cognitive abilities of the rats were assessed on a novel SORT, which was designed to efficiently distinguish cognitive deficits from potential motoric confounds.

RESULTS

Rats given ET-1 had significantly more cognitive errors at six weeks post-stroke on the SORT, and that these deficits were attenuated by BMMSC transplants.

CONCLUSIONS

These findings indicate that: (1) the ET-1 model produces chronic cognitive deficits; (2) the SORT efficiently measures cognitive deficits that are not confounded by motoric impairment; and (3) BMMSCs may be a viable treatment for stroke-induced cognitive dysfunction.

Demographic and intrapartum characteristics of term pregnancies with early-onset neonatal seizures

OBJECTIVE

To compare the demographic and intrapartum factors of term pregnancies in which early-onset neonatal seizures developed with the characteristics of a large, unselected control population.

STUDY DESIGN

Pregnancies delivered at term (gestational age > or = 37 weeks) in one birthing unit between 1984 and 1995 with a discharge diagnosis of neonatal seizures were identified. Maternal and neonatal charts of these patients were reviewed to confirm the diagnosis of early-onset seizure (EOS) which was defined as a clinical or EEG-diagnosed seizure within 72 hours of life. Demographic and intrapartum factors were compared between these EOS cases and all singleton term pregnancies delivered over the same time period in which there was no EOS. A regression model was then developed to determine factors predictive of EOS.

RESULTS

Of 80,561 total deliveries during the 11-year study period, there were 64,340 control and 62 EOS (0.1%) deliveries. Regression modeling identified NICU admission, depressed 1- and 5-minute Apgar scores, and neonatal intubation as predictors of EOS, but not operative vaginal, vaginal breech, or cesarean delivery.

CONCLUSION

Depressed condition at birth and/or the requirement for NICU care was the most important risk associated with early seizures in term infants.

Upgrading the service mix in primary care practices may increase revenue

Hospitals and health systems that own primary care physician networks want to optimize revenues when possible while still providing high-quality patient care. One way to accomplish this objective is to enhance the service mix for patients seen by the primary care practices. An analysis of the diagnosis and service mix of three primary care networks showed that the primary care practices mainly are involved with common acute and chronic conditions, which are associated with office visits that are paid at low- and mid-level rates. A comparison of the primary care networks' diagnosis and service mix with Medicare data on the mix of office visits for family practitioners, internists, and cardiologists showed, for example, that primary care physicians have more level 2 office visits and fewer level 4 office visits than cardiologists. By upgrading the patient office visits from the routine acute and chronic conditions associated with lower-level visits to more serious conditions associated with higher-level visits, primary care practices may increase total practice revenue.