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.

Dietary supplementation of n-3 PUFA reduces weight gain and improves postprandial lipaemia and the associated inflammatory response in the obese JCR:LA-cp rat.

BACKGROUND: Postprandial dyslipidaemia occurs in obesity and insulin resistance (IR), and is associated with an increased risk of developing cardiovascular disease. We have recently established that the JCR:LA-cp rodent model develops postprandial dyslipidaemia concomitant with complications of the metabolic syndrome. Dietary n-3 polyunsaturated fatty acids (n-3 PUFAs) are proposed to modulate plasma lipids, serum hormone levels, lipoprotein metabolism and the inflammatory state; however, results remain inconsistent during conditions of IR. AIM: To assess the acute metabolic and inflammatory effects of dietary fish oil supplementation on existing postprandial dyslipidaemia in the JCR:LA-cp model. METHODS: JCR:LA-cp rats (14 weeks of age) were fed either a control, isocaloric, lipid balanced diet (15% w/w total fat, 1.0% cholesterol, P:S ratio 0.4), a lipid balanced diet with 5% n-3 PUFA [fish oil derived eicosapentaenoic acid (EPA)/docosahexaenoic acid (DHA)] or a lipid balanced diet with 10% n-3 PUFA for 3 weeks. Fasting plasma lipid, cytokine levels, postprandial chylomicron (apoB48) metabolism and the postprandial inflammatory response [haptoglobin and lipopolysaccharide binding protein (LBP)] were assessed following a standardized 'oral fat challenge'. RESULTS: n-3 PUFA treatment resulted in a significant improvement (i.e. decrease) in the postprandial response for triglyceride (45%) (p < 0.05), apoB48 (45%) (p < 0.03) and LBP (33%) (p < 0.05) compared to controls (measured as area under the clearance curve). In contrast, we observed a significant elevation in postprandial haptoglobin (165%) (p < 0.001) in obese rats supplemented with 10% n-3 PUFA. Treatment with 5% n-3 PUFA in the JCR:LA-cp obese animals resulted in a complementary decrease in total body weight gain (6%) (p < 0.001) and an increase (i.e. improvement) in adiponectin (33%) (p < 0.05) compared to controls, without a concomitant reduction in food intake. CONCLUSION: Acute dietary n-3 PUFA dietary supplementation can improve fasting as well as postprandial lipid metabolism and components of the associated inflammatory response in the JCR:LA-cp rat. Further, moderate dose n-3 PUFA supplementation may reduce corresponding body weight during conditions of hypercholesterolaemia and/or modulate inflammation associated with obesity and the metabolic syndrome.

Expression, translation, and localization of a novel, small growth hormone variant.

A novel transcript of the GH gene has been identified in ocular tissues of chick embryos. It is, however, unknown whether this transcript (small chicken GH, scGH) is translated. This possibility was therefore assessed. The expression of scGH mRNA was confirmed by RT-PCR, using primers that amplified a 426-bp cDNA of its coding sequence. This cDNA was inserted into an expression plasmid to transfect HEK 293 cells, and its translation was shown by specific scGH immunoreactivity in extracts of these cells. This immunoreactivity was directed against the unique N terminus of scGH and was associated with a protein of 16 kDa, comparable with its predicted size. Most of the immunoreactivity detected was, however, associated with a 31-kDa moiety, suggesting scGH is normally dimerized. Neither protein was, however, present in media of the transfected HEK cells, consistent with scGH's lack of a signal sequence. Similar moieties of 16 and 31 kDa were also found in proteins extracted from ocular tissues (neural retina, pigmented epithelium, lens, cornea, choroid) of embryos, although they were not consistently present in vitreous humor. Specific scGH immunoreactivity was also detected in these tissues by immunocytochemistry but not in axons in the optic fiber layer or the optic nerve head, which were immunoreactive for full-length GH. In summary, we have established that scGH expression and translation occurs in ocular tissues of chick embryos, in which its localization in the neural retina and the optic nerve head is distinct from that of the full-length protein.