Those of you that read your emails, are eagle eyed, obsessive surfers or just plain interested will have noted a major new link on the front page of the EMJ website. With the help of BMJ Learning we have entered the realm of on-line learning and our first interactive session is now up and running. Epistaxis is the first subject to be tackled. Like all BMJ learning interactive sessions this is based on a published paper – in this case the excellent review of the no frills management of bleeding noses by Leong et al, published in this journal in July last year. We are grateful to the authors of the paper who were induced (by promises of fame rather than of money I hasten to add) to put even more work into their subject so that this venture could get up and running. More are in preparation. I know many clinicians find this type of learning extremely helpful—so if you haven’t tried it yet then register, log in and give it a go. It will be 30 minutes extremely well spent.

In this issue we include the PRIMA study reported by Dr Keating and colleagues from Oxford and Bristol. This diagnostic cohort study investigated the clinical utility of Ischaemia Modified Albumin on presentation, in the management of low risk cardiac chest pain. The authors use 8-hour Troponin I as a gold standard and conclude that IMA alone has no utility as shown in the RoC curve (see fig 1).

View larger version (7K): [in this window] [in a new window]   Figure 1  Receiver operating characteristic curve for the frozen ischaemia-modified results.

Their index test of IMA combined with admission Troponin I was also judged to be insufficiently sensitive to be used. The specificity (at 13.6%) left a lot to be desired as well. The search for a highly sensitive, highly specific early diagnostic strategy for these patients goes on.
See p 764

We are all pleased to see the increasing recognition of emergency departments as key providers of education, and it is good to see the academic work that is going on to investigate and validate this. In this issue we have three papers that report various educational issues. Antonio Celenza looks at the uses of a formal bedside teaching program, Simon Smith compares the outcome of induction delivered continuously over 3 days with a phased approach using the same material over 2 weeks and finally Professor Ronald Harden reviews the future of postgraduate medical education. We are all teachers and need to use the evidence to improve. Read it here.
See p 769, 794 and 798

It seems that there’s no fun without injury. The dark side of what is often part of Halloween trick and treating is reported by Stewart et al from Liverpool. They prospectively recorded attendances of patients with eye injuries caused by eggs over a 14 month period. Thirteen injuries were recorded over that time, with a slightly blurred cluster in October. This is no laughing matter, with 8 of the 13 injuries being serious and 4 having permanent sequelae. The authors compare the attitude of society to these injuries with the yearly hand-wringing and anger towards those caused by fireworks. They suggest a similar public information and safety campaign to inform the public of the dangers of this activity.
See p 756

Cooke and Fletcher report their finding that intravenous drug users are at very high risk of DVT. While many practitioners have "known" this for some time, it hasn’t been formalised by inclusion in many of the risk scores we use to drive diagnostic strategies in the emergency department. The authors suggest we should formally consider all intravenous drug users as high risk for diagnostic purposes. This seems eminently sensible.
See p 777

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