Small Rare Earth Magnets Adhered to Pharyngeal Tissue in a Pediatric Emergency Department Patient.

BACKGROUND: Small rare earth magnets pose a known health risk to children and many cases of ingestion and aspiration with associated complications have been described. More unusual, but also seen in children, are retained foreign bodies in the oropharynx that require extraction. CASE REPORT: We present the case of a 3-year-old boy with persistent left-sided sore throat 1 h after ingestion of several 3-mm spherical rare earth magnets. No foreign bodies were visible in the oropharynx on examination; however, a chest radiograph revealed two adjacent magnets within the lower pharyngeal space, as well as four magnets linearly clumped within the small intestine. The patient was taken to the operating room, where visual inspection under general anesthesia revealed two magnets adhered to the pharyngoepiglottic folds (one on the laryngeal surface and one on the glottic surface). They were removed in full without issue, preventing aspiration. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the recent increase in incidence of rare earth magnet ingestion, emergency providers ought to be aware of the risks and complications associated with magnetic foreign body ingestion in children and the workup and considerations involved in their removal. Providers should also advocate for improved safety controls of these products, which have been found to be effective in the past.

A Comprehensive Update on the Treatment and Management of Postdural Puncture Headache.

PURPOSE OF REVIEW: The purpose of this manuscript is to provide a comprehensive review of postdural puncture headache (PDPH) with a focus on epidemiology, pathophysiology, treatment, and prophylaxis. RECENT FINDINGS: PDPH is an adverse iatrogenic complication of neuraxial anesthesia that occurs following inadvertent puncture of the dura after epidural or spinal anesthesia. The overall incidence of PDPH after neuraxial procedures varies from 6 to 36%. The occurrence of PDPH can lead to increased patient morbidity, delayed discharge, and increased readmission. PDPH is a self-limiting postural headache that most often will resolve within 1 week, without need for treatment. Various prophylactic measures have been studied; however, more studies have been recommended to be undertaken in order to establish a proven benefit. For mild PDPH, conservative treatments are currently focused around bed rest, as well as oral caffeine. For moderate-to-severe PDPH, epidural blood patch (EBP) remains the most effective treatment; however, this invasive treatment is not without inherent risks. Further less invasive treatments have been explored such as epidural saline, dextran 40 mg solutions, hydration, caffeine, sphenopalatine ganglion blocks, greater occipital nerve blocks, and surgical closure of the gap; all have shown promise. Further studies are essential to prove efficacy as well as safety over the proven treatment of epidural blood patches. There is still limited evidence in literature about the understanding of PDPH and optimal treatment.

Socioeconomic disparities in the utilization of spine augmentation for patients with osteoporotic fractures: an analysis of National Inpatient Sample from 2011 to 2015.

BACKGROUND CONTENT: Vertebral augmentation procedures are used for treatment of osteoporotic compression fractures. Prior studies have reported disparities in the treatment of patients with osteoporotic vertebral fractures, particularly with regards to the use of vertebroplasty and kyphoplasty. PURPOSE: The purpose of this study is to report updates in racial and health insurance inequalities of spine augmentation procedures in patients with osteoporotic fractures. METHODS: With the use of the National Inpatient Sample, we identified hospitalized patients with osteoporotic fractures between the period of 2011 and 2015. Patients with spine augmentation, defined by the utilization of vertebroplasty and kyphoplasty, were also identified. Our primary outcome was defined as the utilization of spine augmentation procedures across ethnic (white, hispanic, black, and asian/pacific islander) and insurance (self-pay, private insurance, Medicare, and Medicaid) groups. Variables were identified from the NIS database using International Classification of Diseases, Ninth and Tenth diagnosis codes. Univariate and multivariate regression analysis was used for statistical analysis with p value <.05 considered significant. A subgroup analysis was performed across the utilization of kyphoplasty, vertebroplasty, and Medicare coverage. RESULTS: We identified a total of 110,028 patients with a primary diagnosis of vertebral fracture between 2011 and 2015 (mean age: 74.4±13.6 years, 68% women). About 16,237 patients (14.8%) underwent any type of spine augmentation with over 75% of the patients receiving kyphoplasty. Multivariate analysis showed that black patients (odds ratio [OR]=0.64, 95% confidence interval [CI]: 0.58-0.70, p<.001), Hispanic patients (OR=0.79, 95% CI: 0.73-0.86, p<.001), and Asian/Pacific Islander (OR=0.79, 95% CI: 0.70-0.89, p<.001) had significantly lower odds for receiving any spine augmentation compared with white patients. Patients with Medicaid (OR=0.59, 95% CI: 0.53-0.66, p<.001), private insurance (OR=0.90, 95% CI: 0.85-0.96, p=.001), and those who self-pay (OR=0.57, 95% CI: 0.47-0.69, p<.001) had significantly lower odds of spine augmentation compared with those with Medicare. Comparative use of kyphoplasty was not significantly different between white and black patients (OR=0.85, 95% CI: 0.70-1.04, p=.12). However, Hispanic patients (OR=0.84, 95% CI: 0.71-0.99, p=.04) and Asian/Pacific Islander patients (OR=0.73, 95% CI: 0.58-0.92, p=.007) had significantly lower use of kyphoplasty compared with white patients. The comparative use of kyphoplasty among patients receiving spine augmentation was not significantly different across each insurances status when compared with patients with Medicare. CONCLUSIONS: Our study suggests that racial and socioeconomic disparities continue to exist with the utilization of spine augmentation procedures in hospitalized patients with osteoporotic fractures.

Electronic Medical Records in low to middle income countries: The case of Khayelitsha Hospital, South Africa.

INTRODUCTION: Electronic Medical Records (EMRs) have shown benefit for clinical, organisational, and societal outcomes. In low-to-middle-income countries, the desire for EMRs will continue to rise as increasing trauma and infectious disease rates necessitate adequate record keeping for effective follow-up. 114 nations are currently working on national EMRs, with some using both a full EMR (Clinicom) and a paper-based system scanned to an online Enterprise Content Management (ECM) database. METHODS: The authors sought to evaluate the ability and completeness of the EMR at Khayelitsha Hospital (KH) to capture all Emergency Centre (EC) encounters classified as trauma. Based on the high trauma rates in the Khayelitsha area and equally high referral rates from KH to higher-level trauma centres, an assumption was made that its rates would mirror nationwide estimates of 40% of EC visits. Records from July 2012 to June 2013 were examined. RESULTS: 3488 patients visited the EC in the month of July 2012. 10% were noted as trauma on Clinicom and within their records were multiple sections with missing information. The remaining months of Aug 2012-June 2013 had an average trauma load of 8%. On further investigation, stacks of un-scanned patient folders were identified in the records department, contributing to the unavailability of records from January 2013 to the time of study (June 2013) on ECM. CONCLUSION: The results highlight difficulties with implementing a dual record system, as neither the full EMR nor ECM was able to accurately capture the estimated trauma load. Hospitals looking to employ such a system should ensure that sufficient funds are in place for adequate support, from supervision and training of staff to investment in infrastructure for efficient transfer of information. In the long run, efforts should be made to convert to a complete EMR to avoid the many pitfalls associated with handling paper records.

INTRODUCTION: Les dossiers médicaux informatisés (DMI) ont prouvé leur intérêt en termes de résultats cliniques, organisationnels et sociétaux pour de nombreux hôpitaux. Dans les pays à faible et moyen revenu, la volonté de disposer de DMI continuera à progresser à mesure que les taux croissants de traumatismes et de maladies infectieuses exigent une tenue de dossiers adéquate afin d'assurer un suivi efficace. Cent quatorze pays travaillent actuellement à la mise en place de DMI nationaux, certains utilisant à la fois un système de DMI complet (Clinicom) ainsi qu'un système de documents au format papier scannés et ajoutés à une base de données de Gestion de contenu d'entreprise (GCE) en ligne. MÉTHODES: Les auteurs ont cherché à évaluer la capacité et l'exhaustivité du système de DMI au sein de l'hôpital de Khayelitsha (HK) à saisir toutes les visites classées comme traumatismes. Sur la base des forts taux de traumatisme enregistrés dans la région de Khayelitsha, et des taux de renvoi proportionnellement élevés du HK vers des centres de traitement des traumatismes de plus haut niveau, l'hypothèse a été émise que les taux enregistrés dans cet hôpital reflèteraient les estimations nationales de 40 % des visites au CU. Les archives de juillet 2012 à juin 2013 ont été examinées. RÉSULTATS: 3488 patients ont consulté au CU au mois de juillet 2012. Dix pour cent ont été enregistrés comme traumatismes dans Clinicom, plusieurs sections de leur dossier comportant des informations manquantes. Les mois suivants d'août 2012 à juin 2013 indiquaient une proportion de traumatismes de 8 %. Après examen plus approfondi, des piles de dossiers de patients non scannés ont été identifiées au sein du service des dossiers, ceci contribuant à l'indisponibilité des dossiers de janvier 2013 jusqu'au moment de l'étude (juin 2013) dans le GCE. CONCLUSION: Les résultats soulignent les difficultés associées à la mise en œuvre d'un système de tenue de dossiers double, car ni le DMI complet, ni le GCE ne pouvaient saisir avec précision la proportion estimée de traumatisme. Les hôpitaux qui cherchent à utiliser de tels systèmes devraient s'assurer que des fonds suffisants sont disponibles afin de permettre de soutenir adéquatement ce système, allant de la supervision et de la formation du personnel à l'investissement dans les infrastructures, afin de permettre un transfert d'informations efficace. À long terme, des efforts devraient être réalisés afin de pouvoir passer à un système de DMI et d'éviter les nombreux écueils associés à la tenue de dossiers au format papier.