An Exploratory Analysis of Referrals to a major Emergency Department in a developing country

Background: Hospital crowding, ED waiting times and high demand for unscheduled care all place significant burdens on secondary care services. This impacts on patient care, staff morale and overall functioning of the whole healthcare system. Patient referrals from other healthcare providers often is a result of limited access to resources, specialists or because of acuity. However, some referrals may be more suitable for lower acuity settings, with the benefit of better overall patient experience. In addition, duplication of contacts with a healthcare professional may not result in additional benefit to patients, but may necessarily add to the patient journey and contribute to crowding. Objectives: We aimed to determine the originator of referrals to the ED. We also aimed to determine the proportion of referred patients who received any meaningful intervention at the ED. Finally, we aimed to estimate the proportion of patients referred who may have been suitable for direct inpatient referral or management in a lower acuity setting. Methods: We conducted a prospective evaluation of all referrals to the ED of a large urban hospital over 7 days. Routine anonymised demographic, diagnosis and intervention data were collected and simple descriptive analysis was undertaken using Microsoft Excel®. A validated algorithm was applied to determine suitability for lower acuity settings, and contextual secondary analysis was applied to determine choice of altResults: There were 168 formal referrals during the period evaluated (mean 24/day), of which data was available for 151. Most referrals were on Monday and Thursday. 39.7% were referred from the four regional District Health Facilities (DHF). 12 % were referred by specialists. There were significantly higher referrals from Local Health Centres located more than 5km of the hospital compared with those closer, although this could have been due to greater numbers outside the 5 km radius. 5.5% were thought suitable for primary care management and 31% could have been referred directly to an inpatient team if this were available. The majority (51.3%) of referred patients received no significant intervention in the ED, with almost 1 in 7 suitable for outpatient management. Conclusions: A significant number of patients referred to the ED may have been more appropriately directed. Direct special admission, access to outpatient referral slots or telephone advice from senior ED or specialty clinicians may prevent up to a half of referrals being seen by an ED clinician. This may reduce unnecessary transport, improve time and resource utilization and decongest the ED and hospital. Further large scale evaluation is warranted to investigate the predictors of referral, control for seniority, and make more robust recommendations for improving the patient journey ernate pathways.

Lisch and the Importance of His Nodules.

Neurofibromatosis 1 is the commonest neurocutaneous autosomal dominant disorder with full penetrance, although expression may not be complete by the age of five years. Lisch nodules, however, are predominantly visible in children usually after the age of six years. Therefore, it is important to appreciate that their absence before this age does not pre-empt the diagnosis. A child being treated for hypertension of unknown aetiology with cafe au lait lesions presented to the ophthalmologist with blurred vision. Clinical examination revealed Lisch nodules which confirmed the suspicion of neurofibromatosis 1 as per National Institutes of Health criteria. The aim of this report is to highlight the importance of regular ophthalmic screening, both in suspected and confirmed cases, as these patients have long-term sequelae.

Odontogenic keratocyst in Jamaica: a review of five new cases and five instances of recurrence together with comparative analyses of four treatment modalities.

AIM: Five new cases of odontogenic keratocyst (OKC) together with five instances of recurrence are reviewed with special emphasis on radiology and surgical management. A comparative analysis offour different treatment modalities used in the treatment of OKC in these patients (new and recurrent cases) is reported. SUBJECTS AND METHODS: The case notes and radiographs ofpatients who had histological confirmation of OKC at both the Cornwall Regional Hospital and Kingston Public Hospital in Jamaica were reviewed for demographics, radiological presentation, treatment modalities and outcome of treatment. Cases of recurrence were separated from new cases. This study was conducted for the period 1980 to 2004. RESULTS: Five new cases and five instances of recurrence were documented over the 25-year period The new cases of OKC keratocyst accounted for 1.71% of the total jaw bone tumours and 12% of OKC keratocysts over the first 16 years. The posterior mandible appears to be the most favoured site. Of significance, one case of nevoid basal cell carcinoma syndrome (NBCCS) and a case of ameloblastomatous transformation in the wall of an OKC keratocyst were recorded The age range of the new cases was 12 to 44 years. CONCLUSION: The radiological finding from this review is similar to previous reports. However the authors record a unique and historic case of ameloblastomatous transformation of OKC. A case of OKC in NBCCS is also documented Of all four surgical treatment modalities compared, only cryosurgery was promising, so far with no recurrence after a follow-up period of six years.

Odontogenic keratocyst in Jamaica: a review of five new cases and five instances of recurrence together with comparative analyses of four treatment modalities / Queratoquiste odontogénico en jamaica: revisión de cinco casos nuevos y cinco casos reincidentes acompañados de análisis comparativos de cuatro modalidades de tratamiento

AIM: Five new cases of odontogenic keratocyst (OKC) together with five instances of recurrence are reviewed with special emphasis on radiology and surgical management. A comparative analysis offour different treatment modalities used in the treatment of OKC in these patients (new and recurrent cases) is reported. SUBJECTS AND METHODS: The case notes and radiographs ofpatients who had histological confirmation of OKC at both the Cornwall Regional Hospital and Kingston Public Hospital in Jamaica were reviewed for demographics, radiological presentation, treatment modalities and outcome of treatment. Cases of recurrence were separated from new cases. This study was conducted for the period 1980 to 2004. RESULTS: Five new cases and five instances of recurrence were documented over the 25-year period The new cases of OKC keratocyst accounted for 1.71of the total jaw bone tumours and 12of OKC keratocysts over the first 16 years. The posterior mandible appears to be the most favoured site. Of significance, one case of nevoid basal cell carcinoma syndrome (NBCCS) and a case of ameloblastomatous transformation in the wall of an OKC keratocyst were recorded The age range of the new cases was 12 to 44 years. CONCLUSION: The radiological finding from this review is similar to previous reports. However the authors record a unique and historic case of ameloblastomatous transformation of OKC. A case of OKC in NBCCS is also documented Of all four surgical treatment modalities compared, only cryosurgery was promising, so far with no recurrence after a follow-up period of six years.

Objetivo: Se examinan cinco casos nuevos de queratoquiste odontogénico (QQO) junto con cinco casos reincidentes, con énfasis especial en el tratamiento radiológico y quirúrgico. Se reporta un análisis comparativo de las cuatro diferentes modalidades de tratamiento usadas en el tratamiento del QQO en estos pacientes (los casos nuevos y los casos reincidentes). Sujetos y métodos: A fin de conocer la demografía, la presentación radiológica, las modalidades de tratamiento y los resultados del tratamiento, se examinaron las radiografías y las notas de los casos que tuvieron confirmación histológica de QQO, tanto en el Cornwall Regional Hospital como en el Kingston Public Hospital de Jamaica. Los casos de reincidencia fueron separados de los casos nuevos. Este estudio abarcó el periodo comprendido de.1980 a 2004. Resultados: Cinco nuevos casos y cinco casos reincidentes fueron documentados en ese período de 25 años. Los nuevos casos de QQO dieron cuenta del 1.71% del total de tumores de mandíbula y del 12% de los queratoquistes odontogénicos en los primeros 16 años. La mandíbula posterior parece ser el sitio más favorecido. De significación particular fue la documentación de un caso de síndrome de carcinoma basal celular nevoide (SCCBN), y un caso de transformación ameloblastomatosa en la pared de un queratoquiste odontogénico. El rango de la edad de los nuevos casos fue de 12 a 44 años. Conclusión: El hallazgo radiológico de este estudio, es similar al de reportes previos. Sin embargo, los autores documentan un caso único e histórico de transformación ameloblastomatosa del QQO. También se documenta un caso de QQO en SCCBN. De las cuatro modalidades de tratamiento comparadas, sólo la criocirugía ha sido promisoria hasta el momento, por cuanto no presentó reincidencias luego de un período de seguimiento de seis años.