Postthrombotic syndrome (PTS) is a complication of deep vein thrombosis (DVT) characterized by chronic pain, swelling, and heaviness, and may result in ulceration. Elastic compression stockings (ECS) worn daily after DVT have been shown to reduce the incidence and severity of PTS. The aim of our study was to investigate practices and perceptions of physicians regarding adjunct therapies to anticoagulation in patients diagnosed with lower extremity DVT.

A national online survey was conducted of Canadian emergency medicine staff physicians and residents (n=471) to investigate their attitudes toward the prescription of ECS post-diagnosis of DVT. A paper survey of patients in a thrombosis clinic (n=58) was also administered to better understand the patient experiences with ECS.

The majority of staff physician (62%) and resident (69%) respondents were unsure of whether ECS were effective in preventing PTS and managing venous symptoms. Only 6% of staff physicians and 7% of residents routinely prescribed ECS for above-knee DVTs. More than 78% of respondents were unsure about the optimal timing of initiation of ECS and duration of therapy. Although all patients noted symptomatic relief with ECS, only 50% were prescribed stockings by an emergency or family doctor, and 69% of those patients wore the stockings on a daily basis. Staff physicians most frequently identified poor fit as the reason for lack of patient compliance, whereas patients most frequently cited cost.

Our findings suggest that there is variability in practice among Canadian emergency medicine physicians and trainees and a need for widespread education regarding the latest evidence of the benefit of ECS after DVT.

Emergency department (ED) crowding is associated with adverse outcomes. Several jurisdictions have established benchmarks and targets for length-of-stay (LOS) to reduce crowding. An evaluation has been conducted on whether performance on Ontario’s ED LOS benchmarks is associated with reduced risk of death or hospitalization.

A retrospective cohort study of discharged ED patients was conducted using population-based administrative data from Ontario (April 2008 to February 2012). For each ED visit, the proportion of patients seen during the same shift that met ED LOS benchmarks was determined. Performance was categorized as <80%, 80% to <90%, 90% to <95%, and 95%–100% of same-shift ED patients meeting the benchmark. Logistic regression models analysed the association between performance on ED LOS benchmarks and 7-day death or hospitalization, controlled for patient and ED characteristics and stratified by patient acuity.

From 122 EDs, 2,295,256 high-acuity and 1,626,629 low-acuity visits resulting in discharge were included. Deaths and hospitalizations within 7 days totalled 1,429 (0.062%) and 49,771 (2.2%) among high-acuity, and 220 (0.014%) and 9,005 (0.55%) among low-acuity patients, respectively. Adverse outcomes generally increased among patients seen during shifts when a lower proportion of ED patients met ED LOS benchmarks. The adjusted odds ratios (and 95% confidence intervals) among high- and low-acuity patients seen on shifts when <80% met ED benchmarks (compared with ≥95%) were, respectively, 1.32 (1.05–1.67) and 1.84 (1.21–2.81) for death, and 1.13 (1.08–1.17) and 1.40 (1.31–1.49) for hospitalization.

Better performance on Ontario’s ED LOS benchmarks for each shift is associated with a 10%–45% relative reduction in the odds of death or admission 7 days after ED discharge.

Goal-directed point-of-care ultrasound (PoCUS) protocols have been shown to improve the diagnostic accuracy of the initial clinical assessment of the critically ill patient. The diagnostic impact of the Abdominal and Cardiac Evaluation with Sonography in Shock (ACES) protocol was assessed in simulated emergency medical scenarios.

Following a focused PoCUS training program, the diagnostic accuracy, confidence, and precision of 12 medical learners participating in standardized scenarios were tested using high-fidelity clinical and ultrasound simulators. Participants were assessed during 72 simulated cardiorespiratory scenarios. Differential diagnoses were collected from participants before and after PoCUS in each scenario, and confidence surveys were completed. Data were analysed using R software.

Prior to PoCUS, 45 (62.5%) correct primary diagnoses were made compared with 64 (88.9%) following PoCUS (χ2=14, 1df, p=0.0002). PoCUS was also shown to increase participants’ confidence in their diagnoses. The mean confidence in diagnosis score pre-PoCUS was 52.2 (SD=14.7), whereas post-PoCUS it was 81.7 (SD=9.5). The estimated difference in means (−28.36) was significant (t=−7.71, p<0.0001). Using PoCUS, participants were further able to narrow their differential diagnoses. The median number of diagnoses for each patient pre-PoCUS was 3.5 (interquartile range [IQR]=3.8, 3.0) with a median of 2.3 (IQR=2.9,1.5) diagnoses post-PoCUS. The difference was significant (W=0, p<0.001).

This pilot study suggests that, in medical learners newly competent in PoCUS, the addition of an ACES PoCUS protocol to standard clinical assessment improves diagnostic accuracy, confidence, and precision in simulated cardiorespiratory scenarios. This is consistent with clinical studies and supports the use of ultrasound during medical simulation.

Diagnosing pulmonary embolism can be difficult given its highly variable clinical presentation. Our objective was to determine whether a decrease in oxygen saturation or an increase in heart rate while ambulating could be used as an objective tool in the diagnosis of pulmonary embolism.

This was a two-site tertiary-care-centre prospective cohort study that enrolled adult emergency department or thrombosis clinic patients with suspected or newly confirmed pulmonary embolism. Patients were asked to participate in a standardized 3-minute walk test, which assessed ambulatory heart rate and ambulatory oxygen saturation. The primary outcome was pulmonary embolism.

We enrolled 114 patients, including 30 with pulmonary embolism (26.3%). A ≥2% absolute decrease in ambulatory oxygen saturation and an ambulatory change in heart rate >10 beats per minute (BPM) were significantly associated with pulmonary embolism. An ambulatory heart rate change of >10 BPM had a sensitivity of 96.6% (95% confidence interval [CI] 83.3 to 99.4) and a specificity of 31.0% (95% CI 22.1 to 45.0) for pulmonary embolism. A ≥2% absolute decrease ambulatory oxygen saturation had a sensitivity of 80.2% (95% CI 62.7 to 90.5) and a specificity of 39.3% (95% CI 29.5 to 50.0) for pulmonary embolism. The combination of both variables yielded a sensitivity of 100.0% (95% CI 87.0 to 100.0) and a specificity of 11.0% (95% CI 6.6 to 21.0).

In summary, our study found that an ambulatory heart rate change of >10 BPM or a ≥2% absolute decrease in ambulatory oxygen saturation from baseline during a standardized 3-minute walk test are highly correlated with pulmonary embolism. Although the findings appear promising, neither of these variables can currently be recommended as a screening tool for pulmonary embolism until larger prospective studies examine their performance either alone or with pre-existing rules.

Traditional variables used to explain survival following out-of-hospital cardiac arrest (OHCA) account for only 72% of survival, suggesting that other unknown factors may influence outcomes. Research on other diseases suggests that neighbourhood factors may partly determine health outcomes. Yet, this approach has rarely been used for OHCA. This work outlines a methodology to investigate multiple neighbourhood factors as determinants of OHCA outcomes.

A retrospective, observational cohort study design will be used. All adult non-emergency medical service witnessed OHCAs of cardiac etiology within the city of Toronto between 2006 and 2010 will be included. Event details will be extracted from the Toronto site of the Resuscitation Outcomes Consortium Epistry—Cardiac Arrest, an existing population-based dataset of consecutive OHCA patients. Geographic information systems technology will be used to assign patients to census tracts. Neighbourhood variables to be explored include the Ontario Marginalization Index (deprivation, dependency, ethnicity, and instability), crime rate, and density of family physicians. Hierarchical logistic regression analysis will be used to explore the association between neighbourhood characteristics and 1) survival-to-hospital discharge, 2) return-of-spontaneous circulation at hospital arrival, and 3) provision of bystander cardiopulmonary resuscitation (CPR). Receiver operating characteristics curves will evaluate each model’s ability to discriminate between those with and without each outcome.

This study will determine the role of neighbourhood characteristics in OHCA and their association with clinical outcomes. The results can be used as the basis to focus on specific neighbourhoods for facilitating educational interventions, CPR awareness programs, and higher utilization of automatic defibrillation devices.

Following transient ischemic attack or acute minor stroke, does the combination of clopidogrel and aspirin reduce the risk of stroke greater than aspirin alone?

Wang Y, Wang Y, Zhao X, et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med 2013;369:11-9.

The primary outcome measured in this study was ischemic or hemorrhagic stroke at 90 days of follow-up in groups assigned to treatment with a combination of aspirin and clopidogrel or aspirin alone following transient ischemic attack or acute minor stroke. The secondary outcomes were new clinical vascular events, including vascular death.

We sought to 1) identify best practices for training and mentoring clinician researchers, 2) characterize facilitators and barriers for Canadian emergency medicine researchers, and 3) develop pragmatic recommendations to improve and standardize emergency medicine postgraduate research training programs to build research capacity.

We performed a systematic review of MEDLINE and Embase using search terms relevant to emergency medicine research fellowship/graduate training. We conducted an email survey of all Canadian emergency physician researchers. The Society for Academic Emergency Medicine (SAEM) research fellowship program was analysed, and other similar international programs were sought. An expert panel reviewed these data and presented recommendations at the Canadian Association of Emergency Physicians (CAEP) 2014 Academic Symposium. We refined our recommendations based on feedback received.

Of 1,246 potentially relevant citations, we included 10 articles. We identified five key themes: 1) creating training opportunities; 2) ensuring adequate protected time; 3) salary support; 4) infrastructure; and 5) mentorship. Our survey achieved a 72% (67/93) response rate. From these responses, 42 (63%) consider themselves clinical researchers (i.e., spend a significant proportion of their career conducting research). The single largest constraint to conducting research was funding. Factors felt to be positive contributors to a clinical research career included salary support, research training (including an advanced graduate degree), mentorship, and infrastructure. The SAEM research fellowship was the only emergency medicine research fellowship program identified. This 2-year program requires approval of both the teaching centre and each applying fellow. This program requires training in 15 core competencies, manuscript preparation, and submission of a large grant to a national peer-review funding organization.

We recommend that the CAEP Academic Section create a process to endorse research fellowship/graduate training programs. These programs should include two phases: Phase I: Research fellowship/graduate training would include an advanced research university degree and 15 core learning areas. Phase II: research consolidation involves a further 1-3 years with an emphasis on mentorship and scholarship production. It is anticipated that clinician scientists completing Phase I and Phase II training at a CAEP Academic Section-endorsed site(s) will be independent researchers with a higher likelihood of securing external peer-reviewed funding and be able to have a meaningful external impact in emergency medicine research.