[Perception of the Emergency Department for Outpatient Care in a Rural Region in Saxony-Anhalt: A Qualitative Survey of Patients and General Practitioners]. / Bedeutung der Notaufnahme für die ambulante medizinische Versorgung in einer ruralen Region in Sachsen-Anhalt: Qualitative Befragung von Patienten und Hausärzten.

Background The increasing number of low-acuity visits to Emergency Departments (ED) is an important issue in Germany and contributes to ED crowding. A sustainable solution needs deeper knowledge of patients' underlying rationales. Methods To explore patients' motives we conducted 31 semi-structured face-to-face interviews with low-acuity ED patients in a rural region in Saxony-Anhalt. Subsequently we interviewed 12 General Practitioners (GP)s about their perspectives on patients visiting ED with low-acuity conditions and referring patients to ED. A qualitative content analysis approach was used for data analysis. Results All patients were connected to a GP. One third had visited ED because of 24/7 availability when consultation hours and working times overlapped. Another third had addressed EDs full range of laboratory and imaging technology with a subjective need for fast diagnosis. One group reported that they had been referred to the ED by their GP. The interviewed GPs classified patients' ED usage for time-constraints as impatience and growing demand, while they expressed greater understanding for patients striving to ED for anxiety reasons. Most GPs sometimes referred patients to ED for diagnostic reasons. Conclusion The findings demonstrate that ED usage with non-urgent conditions takes place for different reasons. Therefore, ED plays a pivotal role not only in emergency care, but also in ambulant care. The growing demand for ambulant care indicates a need for changed health care structures.

Patient motives behind low-acuity visits to the emergency department in Germany: a qualitative study comparing urban and rural sites.

OBJECTIVES: The increasing number of low-acuity visits to emergency departments (ED) is an important issue in Germany, despite the fact that all costs of inpatient and outpatient treatment are covered by mandatory health insurance. We aimed to explore the motives of patients categorised with low-acuity conditions for visiting an ED. METHODS: We conducted a qualitative study in two urban and one rural ED. We recruited a purposive sample of adults, who were assigned to the lowest two categories in the Manchester triage system. One-to-one interviews took place in the ED during patients' waiting time for treatment. Interview transcripts were analysed using the qualitative data management software MAXQDA. A qualitative content analysis approach was taken to identify motives and to compare the rural with the urban sites. RESULTS: A total of 86 patients were asked to participate; of these, n=15 declined participation and n=7 were excluded because they were admitted as inpatients, leaving a final sample of 40 female and 24 male patients. We identified three pathways leading to an ED visit: (1) without primary care contact, (2) after unsuccessful attempts to see a resident specialist or general practitioner (GP) and (3) recommendation to visit the ED by an outpatient provider. The two essential motives were (1) convenience and (2) health anxiety, triggered by time constraints and focused usage of multidisciplinary medical care in a highly equipped setting. All participants from the rural region were connected to a GP, whom they saw more or less regularly, while more interviewees from the urban site did not have a permanent GP. Still, motives to visit the ED were in general the same. CONCLUSIONS: We conclude that the ED plays a pivotal role in ambulatory acute care which needs to be recognised for adequate resource allocation. TRIAL REGISTRATION NUMBER: DRK S00006053.

Glucagon regulates orexin A secretion in humans and rodents.

AIMS/HYPOTHESIS: Orexin A (OXA) modulates food intake, energy expenditure, and lipid and glucose metabolism. OXA regulates the secretion of insulin and glucagon, while glucose regulates OXA release. Here, we evaluate the role of glucagon in regulating OXA release both in vivo and in vitro. METHODS: In a double-blind crossover study, healthy volunteers and type 1 diabetic patients received either intramuscular glucagon or placebo. Patients newly diagnosed with type 2 diabetes underwent hyperinsulinaemic-euglycaemic clamp experiments, and insulin-hypoglycaemia tests were performed on healthy volunteers. The primary endpoint was a change in OXA levels after intramuscular glucagon or placebo administration in healthy participants and patients with type 1 diabetes. Secondary endpoints included changes in OXA in healthy participants during insulin tolerance tests and in patients with type 2 diabetes under hyperinsulinaemic-euglycaemic conditions. Participants and staff conducting examinations and taking measurements were blinded to group assignment. OXA secretion in response to glucagon treatment was assessed in healthy and obese mice, the streptozotocin-induced mouse model of type 1 diabetes, and isolated rat pancreatic islets. RESULTS: Plasma OXA levels declined in lean volunteers and in type 1 diabetic patients injected with glucagon. OXA levels increased during hyperinsulinaemic hypoglycaemia testing in healthy volunteers and during hyperinsulinaemic euglycaemic conditions in type 2 diabetic patients. Plasma OXA concentrations in healthy lean and obese mice and in a mouse model of type 1 diabetes were lower after glucagon treatment, compared with vehicle control. Glucagon decreased OXA secretion from isolated rat pancreatic islets at both low and high glucose levels. OXA secretion declined in pancreatic islets exposed to diazoxide at high and low glucose levels, and after exposure to an anti-insulin antibody. Glucagon further reduced OXA secretion in islets pretreated with diazoxide or an anti-insulin antibody. CONCLUSIONS/INTERPRETATION: Glucagon inhibits OXA secretion in humans and animals, irrespective of changes in glucose or insulin levels. Through modifying OXA secretion, glucagon may influence energy expenditure, body weight, food intake and glucose metabolism.

A high normal TSH is associated with the metabolic syndrome.

OBJECTIVE: Obesity and insulin resistance are key features of the metabolic syndrome. In euthyroidism, the relationships between TSH and insulin resistance or the metabolic syndrome are less clear. We investigated the associations between TSH and the features and prevalence of the metabolic syndrome in euthyroid German subjects. METHODS: In a cross-sectional study, glucose metabolism was defined by an oral glucose tolerance test (oGTT) (except for those with evident diabetes) in 1333 subjects with TSH values between 0.3 and 4.5 mU/l who did not take any thyroid medication. Lipid parameters were measured, blood pressure and anthromopmetric parameters were taken, and insulin resistance was quantified as HOMA%S. RESULTS: TSH was weakly correlated with BMI (R = 0.061, P = 0.025). This association remained significant after adjustment for sex, age, and impaired glucose metabolism (P = 0.002). Subjects with a TSH in the upper normal range (2.5-4.5 mU/l, n = 119) had a significantly higher BMI (30.47 +/- 0.57 vs. 28.74 +/- 0.18 kg/m(2), P = 0.001) and higher fasting triglycerides (1.583 +/- 0.082 vs. 1.422 +/- 0.024 mmol/l, P = 0.023), and their likeliness for fulfilling the ATP III criteria of the metabolic syndrome was 1.7-fold increased (95% CI: 1.11- 2.60). CONCLUSION: In euthyroidism, subjects with a TSH in the upper normal range (2.5-4.5 mU/l) were more obese, had higher triglycerides, and had an increased likeliness for the metabolic syndrome. Therefore, a TSH below 2.5 mU/l is associated with a favourable metabolic profile. Whether lowering TSH to levels below 2.5 mU/l improves metabolism needs to be investigated in intervention trials.