Small Bowel Obstruction Secondary to Migration of a Fractured Esophageal Stent.

Esophageal stent placement is commonly indicated for the management of inoperable esophageal malignancies, benign strictures, and esophageal perforations including Boerhaave's syndrome. We present a case of a 74-year-old female, who presented with small bowel obstruction secondary to a migrated esophageal stent, which was placed 20 weeks previously for Boerhaave's syndrome. She was surgically managed with laparotomy and retrieval of the fractured stent with local resection of the small bowel, followed by primary anastomosis.

Brachiocephalic artery aneurysm plaque rupture, stroke & repair.

A 70 year old left-handed man presented to his general practitioner with abnormal left arm movements, left hemianopia and loss of balance. He was found to have an isolated brachiocephalic artery aneurysm, measuring 3.5 cm, with associated plaque rupture, contributing to recurrent episodes of transient ischemic attack. He was discussed extensively by a multidisciplinary team. e concurrently had complete occlusion of the right internal carotid artery with distal reconstitution in its supraclinoid segment from collaterals. Stenting of the region would necessitate inappropriately covering the right vertebral artery which would further compromise intracerebral blood. Surgical intervention was deemed the only safe option and he was thus accepted for cardiothoracic surgery. Standard workup revealed left anterior descending artery stenosis. He underwent coronary artery bypass grafting, left atrial appendectomy and brachiocephalic artery resection with replacement with a interposition graft with 10 mm polytetrafluoroethylene graft. He recovered well. This case demonstrates the multi-disciplinary decision making in a rare cause of embolic stroke.

Thoracic Endovascular Aortic Repair for a Ruptured Mycotic Aortic Pseudoaneurysm Secondary to Esophageal Carcinoma.

A 47-year-old female presented to the emergency department with new episodes of hematemesis. She had a background of unresectable T4b + N1 + M0 esophageal squamous cell carcinoma. Contrast CT thoracic aorta diagnosed a ruptured mycotic aortic pseudoaneurysm of the descending aorta, forming a life threating aorto-esophageal fistula secondary to neoplasm. Due to the high risk of fatal haemorrhage, she underwent successful emergency thoracic endovascular aortic repair (TEVAR). Mycotic aortic pseudoaneurysms are a rare and often fatal complication of esophageal carcinomas. They represent a small subsection of aorto-esophageal fistulas. Early diagnosis with cross sectional imaging and vascular control of the sentinel bleed is essential for survival. TEVAR may be used as a bridge to palliative treatment in the case of unresectable esophageal carcinoma.

Management for Bony Mallet Thumb with a Single Extension Blocking Kirschner Wire.

INTRODUCTION: Mallet finger injury is defined by disruption of the terminal extensor tendon distal-to-distal interphalangeal (DIP) joint. While in the fingers, it is a relatively common injury, it is a rarely encountered entity when involving the thumb. Various conservative and operative treatment strategies have been reported for the management of mallet thumb with no consensus by clinicians. CASE REPORT: We present the case of a 27-year-old right hand dominant man with a left bony mallet thumb injury that occurred while playing hurling. Hurling is traditional Irish sport that is one of the fastest field games in the world, involving the use of a wooden Hurley and ball. Clinically, there was loss of active extension at the DIP joint of the non-dominant thumb with radiographs revealing an avulsion fracture involving more than one-third of the articular surface at the base of the distal phalanx. Closed reduction and percutaneous fixation using a single extension block Kirschner wire was performed without a transfixion wire across the DIP joint. Four months postoperatively, the patient had regained that good functional dexterity was able to return to playing hurling. CONCLUSION: A single K-wire technique may be beneficial with theoretical reduction of chance of iatrogenic nail bed, bone fragment rotation, chondral damage, and bone injury. To the best of our knowledge, no previous reports of its application to bony mallet thumb have been described.

Assessing the Quality and Readability of Online Resources for Plantar Fasciitis.

The Internet is utilized now more than ever to research medical conditions and treatments by patients and physicians alike. The aim of this study was to evaluate the quality and readability of information available online for plantar fasciitis. Web sites were identified using the search term "plantar fasciitis." The first 25 Web sites from 5 different search engines gave a total of 125 being evaluated. Readability of each Web site was assessed using the Flesch Reading Ease score, the Flesch-Kincaid grade level, and the Gunning Fog Index. Quality was assessed using the DISCERN instrument (www.discern.org.uk) and the Journal of the American Medical Association (JAMA) benchmark criteria. The presence of Health on the Net (HON) code certification was also assessed. The authorship of each Web site was categorized into 1 of 5 categories (Physician, Academic, Commercial, Allied health or Other eg, blogs). A total of 83 Web site pages were evaluated with the majority of the web sites being authored by physicians (32.53%) and blogs (25.30%). Only 24 Web sites were HON certified (28.91%). Physician and Academic Web sites were the most credible sources, with the highest mean DISCERN (p = .00001) and JAMA (p = .0278.) scores, respectively. These Web sites were also the most difficult to read according to the readability score testing. The information available on the Internet pertaining to plantar fasciitis is highly variable and provides moderate quality information about treatment choices. Given this variability in quality, health care providers should direct patients to known sources of reliable, readable online information.

Transjugular intrahepatic portosystemic shunt (TIPS) procedure: an assessment of the quality and readability of online information.

PURPOSE: Transjugular intrahepatic portosystemic shunt (TIPS) procedure is an established procedure carried out by interventional radiologists to achieve portal decompression and to manage the complications of portal hypertension. The aim of this study was to evaluate the quality and readability of information available online for TIPS procedure. METHODS: Websites were identified using the search terms "TIPS procedure", "TIPSS procedure", "transjugular intrahepatic portosystemic shunt procedure", with the first 25 pages from the three most popular search engines (Google, Bing and Yahoo) being selected for evaluation with a total of 225. Each Website was grouped by authorship into one of five categories: (1) Physician, (2) Academic, (3) For-profit, (4) Non-profit (including government and public health), or (5) Other (discussion/social media). Readability of each Website was assessed using the Flesch-Reading Ease score, Flesch-Kincaid grade level, Gunning-Fog Index, Coleman-Liau and SMOG index. Quality was calculated using the DISCERN instrument, the Journal of the American Medical Association (JAMA) benchmark criteria and the presence of Health on the Net (HON) code certification. RESULTS: After disregarding duplicate and non-accessible Websites a total of 81 were included. The mean DISCERN score assessing the quality of information provided by Websites was "good" (59.3 ± 10.2) with adherence to the JAMA Benchmark being 54.3%. Websites with HON-code certification were statistically significantly higher in terms of DISCERN (p = 0.034) and JAMA scores (p = 0.003) compared to HON-code negative sites. The readability scores of Websites ranged from 10 to 12th grade across calculators. Thirty-two out of the 81 Websites were targeted towards patients (39.5%), 46 towards medical professionals (56.8%) and 3 were aimed at neither (3.7%). The medical professional aimed Websites were statistically significantly more difficulty to read across all readability formulas (all p < 0.001). CONCLUSION: While quality of online information available to patients is "good", the average readability for information on the internet for TIPS is set far above the recommended 7th-grade level. Academic Websites were of the highest quality, yet most challenging for the general public to read. These findings call for the production of high-quality and comprehensible content around TIPS procedure, where physicians can reliably direct their patients for information.

Prevalence of Insomnia in an Oncology Patient Population: An Irish Tertiary Referral Center Experience.

BACKGROUND: The NCCN Guidelines for Survivorship recommend dedicated sleep assessment. Reported insomnia prevalence in the general Irish population is 6% to 15%. Reported insomnia prevalence internationally among new/recently diagnosed patients with cancer varies from 30.9% to 54.3%. Insomnia prevalence has not been previously quantified in an Irish oncology cohort. METHODS: A 40-item questionnaire was prospectively administered to ambulatory patients with cancer aged ≥18 years. Prespecified criteria to define insomnia syndrome combined those of the International Classification of Sleep Disorders, version 1, and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The Hospital Anxiety and Depression Scale-Depression/Anxiety (HADS-D/A) was used to screen for potential confounding variables. RESULTS: The response rate to the questionnaire was 87% (294/337). The predominant respondent age group was 55 to 64 years (26%; 77/294), 70.7% were female (208/294), and the most common cancer subtypes were breast (37.4%), colorectal (12.9%), and lung (12.2%). A total of 62% (183/294) of patients reported sleep disturbance after diagnosis, 63% (115/183) reported moderate/severe distress related to this disturbance, and 37% (61/183) reported a significant impact on physical function. Although 33% (98/294) met insomnia syndrome criteria, only 34% (33/98) of these patients had a preexisting history of sleep disturbance. Female sex, age <65 years, cancer subtype, alcohol consumption, and HADS-D/A ≥11 were associated with statistically significant higher odds ratios (OR) of insomnia syndrome. Multivariate analysis identified breast cancer (OR, 3.17; P=.01), age <65 years (OR, 1.8; P=.03), and alcohol consumption (OR, 2.3; P=.005) as independent predictors of insomnia syndrome. CONCLUSIONS: Insomnia syndrome prevalence in this cohort is comparable to that reported previously and supports dedicated sleep assessment. This study identifies potentially modifiable risk factors for insomnia and demonstrates additional utility of the HADS score in identifying patients at risk.