Is the Pelvic Examination Still Crucial in Patients Presenting to the Emergency Department With Vaginal Bleeding or Abdominal Pain When an Intrauterine Pregnancy Is Identified on Ultrasonography? A Randomized Controlled Trial.

STUDY OBJECTIVE: We determine whether omitting the pelvic examination in emergency department (ED) evaluation of vaginal bleeding or lower abdominal pain in ultrasonographically confirmed early intrauterine pregnancy is equivalent to performing the examination. METHODS: We conducted a prospective, open-label, randomized, equivalence trial in pregnant patients presenting to the ED from February 2011 to November 2015. Patients were randomized to no pelvic examination versus pelvic examination. Inclusion criteria were aged 18 years or older, English speaking, vaginal bleeding or lower abdominal pain, positive ß-human chorionic gonadotropin result, and less than 16-week intrauterine pregnancy by ultrasonography. Thirty-day record review and follow-up call assessed for composite morbidity endpoints (unscheduled return, subsequent admission, emergency procedure, transfusion, infection, and alternate source of symptoms). Wilcoxon rank sum tests were used to assess patient satisfaction and throughput times. RESULTS: Only 202 (of a planned 720) patients were enrolled, despite extension of the study enrollment period. The composite morbidity outcome was experienced at similar rates in the intervention (no pelvic examination) and control (pelvic examination) groups (19.6% versus 22.0%; difference -2.4%; 90% confidence interval [CI] -11.8% to 7.1%). Patients in the intervention group were less likely to report feeling uncomfortable or very uncomfortable during the visit (11.2% versus 23.7%; difference -12.5; 95% CI -23.0% to -2.0%). CONCLUSION: Although there was only a small difference between the percentage of patients experiencing the composite morbidity endpoint in the 2 study groups (2.4%), the resulting 90% CI was too wide to conclude equivalence. This may have been due to insufficient power. Patients assigned to the pelvic examination group reported feeling uncomfortable more frequently.

Emerging options for emergency contraception.

Emergency post-coital contraception (EC) is an effective method of preventing pregnancy when used appropriately. EC has been available since the 1970s, and its availability and use have become widespread. Options for EC are broad and include the copper intrauterine device (IUD) and emergency contraceptive pills such as levonorgestrel, ulipristal acetate, combined oral contraceptive pills (Yuzpe method), and less commonly, mifepristone. Some options are available over-the-counter, while others require provider prescription or placement. There are no absolute contraindications to the use of emergency contraceptive pills, with the exception of ulipristal acetate and mifepristone. This article reviews the mechanisms of action, efficacy, safety, side effects, clinical considerations, and patient preferences with respect to EC usage. The decision of which regimen to use is influenced by local availability, cost, and patient preference.

Sonographic diagnosis of pneumothorax.

Lung sonography has rapidly emerged as a reliable technique in the evaluation of various thoracic diseases. One important, well-established application is the diagnosis of a pneumothorax. Prompt and accurate diagnosis of a pneumothorax in the management of a critical patient can prevent the progression into a life-threatening situation. Sonographic signs, including 'lung sliding', 'B-lines' or 'comet tail artifacts', 'A-lines', and 'the lung point sign' can help in the diagnosis of a pneumothorax. Ultrasound has a higher sensitivity than the traditional upright anteroposterior chest radiography (CXR) for the detection of a pneumothorax. Small occult pneumothoraces may be missed on CXR during a busy trauma scenario, and CXR may not always be feasible in critically ill patients. Computed tomography, the gold standard for the detection of pneumothorax, requires patients to be transported out of the clinical area, compromising their hemodynamic stability and delaying the diagnosis. As ultrasound machines have become more portable and easier to use, lung sonography now allows a rapid evaluation of an unstable patient, at the bedside. These advantages combined with the low cost and ease of use, have allowed thoracic sonography to become a useful modality in many clinical settings.