Gallbladder torsion with gangrenous cholecystitis: a case report.

A woman in her nineties presented with a 7-day history of right upper quadrant pain, nausea and anorexia. Examination findings included tenderness in the right upper quadrant and a positive Murphy's sign. Laboratory studies were unremarkable with normal white cell count, C-reactive protein and liver functions tests. Ultrasound of the abdomen, however, demonstrated a distended gallbladder containing sludge and a thickened gallbladder wall. The patient's symptoms worsened with associated elevation of inflammatory markers despite initial treatment with intravenous antibiotics for 24 h. It was decided to proceed to laparoscopic cholecystectomy. Intraoperatively, 360° clockwise torsion of a gangrenous gallbladder on an elongated mesentery was noted. Laparoscopic cholecystectomy was completed without complication and the patient was discharged home after completion of a course of intravenous antibiotics. Histopathological examination demonstrated acute cholecystitis with extensive mural necrosis.

Readability and Quality of Online Health Information Regarding Parathyroidectomy.

Objective: Assessment of the readability and quality of online health information regarding parathyroidectomy. Study Design: Cross-sectional analysis. Setting: Websites providing patient-oriented health information regarding parathyroidectomy obtained via the Google search engine. Methods: The top 75 Google search results for "parathyroidectomy,""parathyroid surgery," and "parathyroid gland removal" were reviewed. Websites were categorized by website type and country of origin. Readability was assessed by Flesch-Kincaid Grade Level and Simple Measure of Gobbledygook. Website quality was assessed per JAMA benchmark criteria and the DISCERN instrument. Results: A total of 74 unique websites were evaluated. The mean readability of the assessed websites exceeded the recommended sixth-grade reading level on the Flesch-Kincaid Grade Level and Simple Measure of Gobbledygook (P < .001). Readability did not vary significantly by website type. Websites originating from the United Kingdom were significantly more readable than those from the United States. The majority of assessed websites were of poor quality (n = 42, 56.8%) on assessment based on the DISCERN instrument. Quality varied significantly by website category on the JAMA benchmark criteria (P < .001) and DISCERN score (P = .049) with commercial websites receiving the highest scores. DISCERN score also varied significantly by country of origin (P = .036) with UK sites receiving highest mean DISCERN scores. Conclusion: Online health information regarding parathyroidectomy is largely of poor quality and is poorly readable for many patients. Institutions utilizing well-defined guidelines for development of patient educational resources may provide online health information of greater quality and readability.

Special type trocar-site hernia with evisceration of the appendix following laparoscopic repair of a perforated duodenal ulcer.

Trocar-site hernia is an uncommon complication of laparoscopic surgery and can be classified as early-onset, late-onset or special type. Special type hernias usually occur in the early postoperative period and result in evisceration of intra-abdominal contents through all layers of the abdominal wall without an overlying hernia sac. We present a case of special type herniation of the appendix through a 5-mm trocar site in the right iliac fossa following laparoscopic repair of a perforated duodenal ulcer. In this case, herniation occurred after removal of a drain inserted through the trocar site intraoperatively and was treated with emergent open appendicectomy. A number of patient and technical factors may be associated with an increased risk of trocar-site herniation including increasing age, elevated body mass index, increasing trocar size, longer procedure duration and absence of fascial closure. These factors must be borne in mind when planning trocar placement and number to reduce the risk of herniation.

Physician incentive plan boosts physician/patient satisfaction. 5-year-old plan at priority health shows success.

Physician involvement is crucial to creating a healthy physician incentive program. Look at how one large, Michigan-based managed care organization established their program.