Diagnosis of Intrauterine Pregnancy Despite the Presence of Etonogestrel Implant.

While contraception is an important method to avoid pregnancy, it is not always effective. Our case details a 33-year-old-female with an etonogestrel implant who presented to the emergency department (ED) with a two-week history of vomiting and abdominal pain. Pelvic and transvaginal ultrasound confirmed a single, live intrauterine pregnancy. Our case serves as a reminder that ED providers should have a high index of suspicion for pregnancy in clinically relevant scenarios, despite contraceptive methods, until the appropriate confirmatory diagnostic evaluation for pregnancy is completed.

Capnocytophaga canimorsus meningitis in a 38-year-old immunocompetent woman from household pet exposure.

A 38-year-old otherwise healthy woman with no history of immunocompromise, recent travel, or concerning exposures presented to the ED with several days of nonspecific cold-like symptoms with associated generalized headache. After the patient was symptomatically treated and discharged, she returned several hours later with worsening of symptoms and new vomiting, confusion, and sensorineural hearing loss. Blood and cerebrospinal fluid cultures eventually returned positive for a Capnocytophaga canimorsus infection, a bacterial pathogen found in the saliva of dogs and cats. Only after that, the patient recalled being scratched and licked by her pets, two dogs and a cat. She was treated with a course of systemic steroids, antibiotics and discharged home.

Atlantoaxial rotatory subluxation presenting as acute torticollis after mild trauma.

Atlantoaxial rotatory subluxation (AARS) is a rare outcome of trauma in adults. We present a case of a 38-year-old female who presented with neck pain and stiffness after a mild trauma. On exam the patient had a "cock-robin" position, comparable to acute torticollis. Computerized tomography demonstrated findings consistent with AARS. Reduction was performed in the emergency department and the patient had no further neurological sequelae. Recognition of AARS after trauma requires a high index of suspicion and early diagnosis is important to best patient outcomes.

Sex-specific Outcomes in a Substance Use Intervention Program.

PURPOSE: We performed an emergency department (ED)-based substance use screening, motivational interview-based intervention, and treatment referral program with the goal of determining sex-specific outcomes. Specifically, in this quality improvement project, we aimed to determine whether there was a difference among sexes in the type of substances used; the frequency of positive screening results for substance use disorder; agreeing to an intervention; the type of follow-up evaluation, participation, and referral; and attempts to change substance use after intervention. METHODS: We prospectively studied a convenience sample of patients at 3 hospitals in Northeastern Pennsylvania from May 2017 through February 2018. Inclusion criteria for participation in this study were age ≥18 years; ability to answer survey questions; willingness and ability (not being too ill) to participate in intervention(s); and when screened, admitting to use of alcohol, tobacco, potentially addictive prescription drugs, or street drugs. Practitioners in the ED screened patients. For those with unhealthy substance use, a brief motivational interview was performed. Participants were each given referrals and information in accordance with the particular substance used and their assessed readiness to change. Individuals who completed the intervention were contacted by telephone for follow-up. Self-reported outcomes and the frequency of successful warm hand-off referrals were assessed. FINDINGS: Of the 2209 individuals screened, 976 (44.2%) were male. Overall, 547 patients screened positive for at least 1 of the unhealthy substances for a prevalence of 24.8% (95% confidence interval, 22.9%-26.6%). In this population, a greater proportion of men screened positive than women (30.5% vs 20.2%, P = 0.01). Although the finding was not statistically significant, men (106 [35.6%]) were more likely than women (81 [32.5%]) to agree to an ED intervention. At telephone follow-up, men were more likely to report participating in a treatment or support program than women (32.9% vs 18.2%, P = 0.035). Frequencies of warm hand-off referrals were 11 of 106 (10.4%) for men and 2 of 81 (2.5%) for women. IMPLICATIONS: Our small study found that unhealthy substance use rates were greater overall in men than women. Overall participation differences between men and women who agreed to take part in substance intervention and accepted a referral for follow-up treatment were not statistically significant. At telephone follow-up, more men reported participating in a treatment program than women. Direct referral (warm hand-off) rates to treatment programs were small in both sexes but greater in men than women.