Twenty-seven year old man presenting with a strangulated diaphragmatic hernia eight years after the initial injury

A 27-year-old man presented with a 5 day history of abdominal pain and distension, with associated constipation and vomiting. He had presented 8 years earlier following a traumatic injury to the left side of the chest, and no diaphragmatic injury was reported at that time. On this admission, a computed tomography scan showed herniation of the splenic flexure of the colon into the left hemithorax. Subsequently, he had an emergency laparotomy for resection, with formation of a loop ileostomy. The various imaging techniques all have advantages and disadvantages when diagnosing a traumatic diaphragmatic hernia. It is the clinician’s role to maintain a high index of suspicion when a patient initially presents with trauma where a traumatic diaphragmatic hernia may be a possibility

Growth hormone receptor polymorphism and growth hormone therapy response in children: a bayesian meta-analysis

Recombinant human growth hormone (rhGH) therapy is used in the long-term treatment of children with growth disorders, but there is considerable treatment response variability. The exon 3-deleted growth hormone receptor polymorphism (GHR(d3)) may account for some of this variability. The authors performed a systematic review (to April 2011), including investigator-only data, to quantify the effects of the GHR(fl-d3) and GHR(d3-d3) genotypes on rhGH therapy response and used a recently established Bayesian inheritance model-free approach to meta-analyze the data. The primary outcome was the 1-year change-in-height standard-deviation score for the 2 genotypes. Eighteen data sets from 12 studies (1,527 children) were included. After several prior assumptions were tested, the most appropriate inheritance model was codominant (posterior probability = 0.93). Compared with noncarriers, carriers had median differences in 1-year change-in-height standard-deviation score of 0.09 (95% credible interval (CrI): 0.01, 0.17) for GHR(fl-d3) and of 0.14 (95% CrI: 0.02, 0.26) for GHR(d3-d3). However, the between-study standard deviation of 0.18 (95% CrI: 0.10, 0.33) was considerable. The authors tested by meta-regression for potential modifiers and found no substantial influence. They conclude that 1) the GHR(d3) polymorphism inheritance is codominant, contrasting with previous reports; 2) GHR(d3) genotypes account for modest increases in rhGH effects in children; and 3) considerable unexplained variability in responsiveness remains