Patterns in acute referral to hospital

This retrospective observational study aimed to assess factors affecting acute referral and subsequent admission to hospital by general practitioners. Data concerning 2,303 consecutive acute referrals to hospital from all GPs in a defined study area were collected over one month. Fund holding practices cared for 13% of the population referred 13% of all referrals resulting in 14% of admissions. Referral through the A&E resulted in significantly more patients being discharged upon initial assessment (p < 0.001). A telephone call accompanying referral dramatically increased the chance of hospital admission (p < 0.001). Referral to hospital was more likely the more socially deprived the patient (p < 0.001) but had no subsequent bearing on admission.     

Referrals for alternative therapies

BACKGROUND: The purpose of this study was to examine how allopathic physicians participate in the decision to refer patients for alternative therapies. METHODS: A pretested, self-administered, structured questionnaire was distributed simultaneously to all area physicians at community locations in Washington State, New Mexico, and southern Israel. The primary outcome measures were monthly and yearly rates of referral to alternative therapies. RESULTS: More than 60% of all physicians made referrals to alternative providers at least once in the preceding year and 38% in the preceding month. Referrals were generally based on patient requests, synergy between the alternative therapy and the patients' cultural beliefs, failure of conventional treatment, and the belief that patients have "nonorganic" or "psychological" disease. There was no relationship between the rate of referral and the referring physician's level of knowledge about, beliefs about the effectiveness of, or familiarity with alternative therapies. CONCLUSIONS: Primary care physicians are more likely than other medical specialists to be knowledgeable about, personally subscribe to, and refer patients for alternative therapies. Physicians who use alternative techniques for themselves and their families or who adopt complementary therapies into their practices have higher rates of referrals. Referral rates and patterns were similar between sites despite considerable cross-cultural and health system differences. Given the high rate of referral and the absence of an apparent internal logic for such recommendations, guidelines and physician education may be advisable.     

Urban ecological structure and perceived child and adolescent psychological disorder

This research examined the distribution and ecological correlates of referrals of children and adolescents to the Regional Children's Centre, a psychological assessment and treatment centre located in Windsor, Ontario, Canada. Referral data were collected by the Regional Children's Centre for the study period April 1992 through March 1994. The ecological structure of the study area was derived using principal components analysis of a set of socio-economic indicator variables from the 1991 Census of Canada and a cluster analysis of component scores. Referral rates were calculated for each ecological area for two referral subgroups; modi/conduct/stress-related concerns and neurophysiologically based concerns. The distribution of referrals was tested using the Poisson probability test. This test revealed that, for both subgroups analysed, the distribution of referrals in the study area was non-random. Stepwise multiple regression revealed a significant ecological relationship between the mood/conduct/stress-related concerns referral rate and the ecological structure of the study area. No such relationship was found, however, when examining referrals for neurophysiologically based concerns.     

The screening and referral of mentally disordered inmates in a state correctional system.

A process of shaping untrained personnel to make appropriate psychiatric referrals in a state correctional system is explained. The application of this process in the South Carolina Department of Corrections was evaluated by determining the percentage of appropriate referrals made by these untrained personnel (e.g., nurses, wardens, chaplains, psychometricians). All referrals made during March 1978 served as a sample of the effectiveness of the system. The personnel who made the referrals were interviewed with respect to both the specific referral(s) and the general decision rules employed in making the referrals to the psychiatric unit. Results indicate that the untrained personnel who had been shaped by the director of the psychiatric unit made a high percentage of appropriate referrals than those who had not been shaped. Other uses of this shaping procedure as well as the apparent lack of need for more highly trained personnel are discussed. (1 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contraceptive behavior in the population of the Czech Republic: results of a national survey

Using an anonymous questionnaire the authors investigated in a representative group of the Czech population above 15 years of age (862 men and 857 women) the use of the main contraceptive methods. During the first intercourse more than half the respondents did not use any contraception, a condom was used only by 19% men and 14% women. In a steady partnership the most frequent method of contraception is coitus interruptus, whereby experience with hormonal contraception was reported by cca one third and with a condom by two thirds of respondents. Among younger men and women there are more users of hormonal contraception and condoms. Only 5% of the examined men and 4% of the women opposed any type of contraception, almost one quarter of respondents use only so-called "natural methods" and almost three quarters of the respondents consider them an essential part of sex life. The attitudes of atheists and junior and more educated women are more liberal.     

Epidemiological and clinical aspects of voluntary interruption of pregnancy 2 years after passing of Law 194

Abortion has been legal in Italy since June 1978. At the Obstetrical and Gynecological Clinic of the University of Siena a doctor is assisted by a psychologist and by a social worker, who deal mostly with adolescents; all patients are given a brochure with information on the procedure and with detailed instructions for the postabortum period. Abortion is commonly carried out by vacuum aspiration and under total anesthesia in 98% of cases. 2171 abortions were done from June 1978 to June 1980; the 1st year there were 1138 abortions and 1107 live births; the second year there were 1133 abortions and 1190 live births. 30% of patients came from districts outside of the Siena region, 32.2% of patients were housewives and 15.29% students. Most abortions were done between the 9-10th gestational week because of the shortage of medical personnel at the clinic. All ages were more or less equally represented, with a slight majority of patients in the age group 25-35; minors were only 2.67% of all patients in the 1st year, but the percentage doubled in the 2nd year. In 86.87% of cases hospitalization was only 1 day. 10.78% of patients had had previous abortions; 68.17% of patients were married. 65.45% of women did not use any type of contraception, and 23.44% used coitus interruptus, or 88.89% of women without effective contraception. There were 35 cases of complications, or a rate of 1.61%, 2 requiring laparotomy and 1 requiring hysterectomy. From these data it seems obvious to conclude that many women use abortion as a fertility control method and information on birth control methods and family planning education are sorely lacking.     

Time for emergency contraception with levonorgestrel alone

The World Health Organization (WHO) multicenter, randomized trial reported in this issue of "The Lancet" confirms that levonorgestrel-only (two 750-mcg doses) is significantly more effective in preventing pregnancy after unprotected intercourse than the standard Yuzpe regimen (two doses of 500 mcg levonorgestrel and 100 mcg ethinyl estradiol) and is further associated with significantly less nausea and vomiting. When initiated within 24 hours of coitus, the failure rate was only 0.4% for levonorgestrel compared with 2.0% for the combined hormonal method. A further advantage of a progestogen-only emergency contraceptive method is avoidance of contraindications in women with past proven arterial or venous thrombosis or a current attack of migraine with focal aura. Although only one pharmaceutical company (Gedeon Richter in Budapest, Hungary) currently manufactures 750 mcg of levonorgestrel in a single tablet, others are likely to follow this example given the findings of the WHO study. Strong pressure exists to increase availability of postcoital contraception through trained nurses and retail pharmacists. However, potential users will still require counseling on the importance of selecting a long-term method of contraception and a family planning provider.     

Cloning and characterization of plastid ribosomal protein S16 gene from potato (Solanum tuberosum L. cv Désirée)

STUDY OBJECTIVE: To determine whether an intensive educational campaign of emergency department personnel on the organ donor and procurement process would result in both increased organ donor referrals and organs procured. METHODS: A retrospective review of the performance of an urban teaching ED in identifying and referring potential organ donor candidates was performed. Subsequently an intensive educational campaign of all ED staff, in conjunction with the Regional Organ Procurement Agency of Southern California (ROPA), was initiated. Physicians and nurses were educated about the procurement process, and a ROPA representative was on call 24 hours a day to assist in this process. The need for aggressive resuscitation and vital sign maintenance in potential donors as a strategy to promote organ recovery was emphasized. Reeducation by ROPA occurred every 2 to 3 months. The identification and referral rates were then retrospectively reviewed to evaluate any improvement. RESULTS: In 1994 the initial referral rate of potential organ donors from the ED was 30% (3 of 10) resulting in no organs procured. After the intervention the referral rate increased to 100% (25 of 25) in 1995 (P < .0001). The number of actual donors procured was 0 in 1994, 5 in 1995, and 9 in 1996. The increased ED referrals resulted in 14 and 32 organs procured in 1995 and 1996, respectively. CONCLUSION: Emergency physicians are in a unique position as first caregivers to interact with both potential donors and their families. With intensive education of ED staff, proper identification and referral, as well as timely intervention by organ procurement representatives, the consent and donation rate of organs for transplantation can be increased and maintained.     

Diagnostic ophthalmic cytopathology--past, present and future

OBJECTIVE: To assess whether accident and emergency (A&E) nurses using the Ottawa Ankle Rules could detect all ankle fractures. DESIGN: Prospective observational study. SETTING: A&E department of a university teaching hospital. SUBJECTS: All patients who presented with ankle injuries who were initially assessed by a nurse taught the Ottawa Ankle Rules. OUTCOME MEASURES: (1) The numbers of patients referred by the nurse for ankle radiography; (2) of these, the number with ankle fractures; (3) of those not sent for radiography initially by the nurse, the number who subsequently had x rays (ordered by the doctor) and had a fracture; (4) of those having no x rays, the number who reattended later. RESULTS: 324 patients were eligible; 238 had x rays at the request of the nurse (73%); 48 of these (20%) were diagnosed as having a fracture. Of those 86 patients not sent for radiography by the nurse, 19 subsequently had x ray examinations at the request of a doctor and no fracture was detected. Of the 67 not sent for radiography, none returned within the subsequent eight weeks. CONCLUSIONS: Nurses can apply the Ottawa Ankle Rules safely without missing acute fractures; that is, of those who were not sent for radiography by nurses, none subsequently reattended the A&E department or the trauma service of the Bristol Royal Infirmary during the following two months.     

Durable effects of implementation intentions: Reduced rates of confirmed pregnancy at 2 years.

Objective: To assess the long-term impact of implementation intention formation in reducing consultations for emergency contraception and pregnancy testing among teenage women. Design: Teenage women visiting a family planning clinic were randomly assigned to implementation intention versus control conditions. Main outcome measures: Objective measures of consultation outcomes were obtained from clinic records at 2-year follow-up (N = 227). Results: Rates of consultation for emergency contraception and pregnancy testing in the implementation intentions condition were 19% and 33% lower, respectively, compared to the rates observed in the control condition. Pregnancy rates were 43% lower. Intervention participants who consulted for emergency contraception and pregnancy testing at baseline were more than twice as likely to change to consulting for contraceptive supplies over the follow-up period compared to equivalent control participants (19% vs. 9%). Conclusion: The impact of implementation intention formation on reducing pregnancy risk among teenagers is durable over 2 years. Implementation intentions were successful in changing behavior among precisely those participants who were at greatest risk of becoming pregnant. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Direct admission to the coronary care unit by the ambulance service for patients with suspected myocardial infarction

BACKGROUND: Direct access to the coronary care unit (CCU) for general practitioner (GP) referred cases of suspected acute myocardial infarction (AMI) (fast track admission) substantially reduces the time to thrombolysis. Until now, this policy has been confined to GP referrals. OBJECTIVES: To determine the time taken to admission to CCU under the fast track policy (ambulance referrals and GP referrals) and the time taken to start administration of thrombolytics (ambulance referrals, GP referrals, and accident and emergency referrals). METHODS: Fast track admission policy was extended to include referrals from ambulance personnel who respond to emergency service calls. Ambulance personnel referred cases were also examined to see if they were referred appropriately to the CCU. RESULTS: 100 ambulance personnel referrals and 260 GP referrals to CCU with chest pain were studied. Forty accident and emergency referrals who had AMI requiring thrombolysis were also studied. In the ambulance referred group the time to admission from phone call was a median of 10 minutes (range 2 to 45), a saving of 30 minutes compared with GP referrals (median 40 minutes, range 2 to 217). The median diagnostic electrocardiogram (ECG) to thrombolysis time was longer in the accident and emergency referrals with AMI than either ambulance referrals or GP referrals admitted under the fast track policy. Diagnostic ECG to thrombolysis time: accident and emergency 50 minutes (range 15 to 385); ambulance referrals median 33 minutes (range 6 to 69); GP referrals median 29.5 minutes (range 5 to 110 minutes); (p = 0.056 accident and emergency compared with ambulance referrals, p < 0.002 accident and emergency compared with GP referrals). Of 100 ambulance referrals 52 patients exhibited symptoms suggestive of ischaemic heart disease (confirmed AMI, unstable angina, and angina) and a further 18 patients were required to stay in CCU for other cardiac problems. Thus a total of 70 (70%) were considered appropriate compared with 155 of 260 (55.8%) GP referred cases. CONCLUSIONS: Extending the fast track admission policy to ambulance personnel reduces delay to admission for patients with suspected MI without adversely affecting the appropriateness of admissions.     

Usefulness of abciximab for treatment of early coronary artery stent thrombosis

The clinical and angiographic outcomes of 10 patients who received abciximab as part of their therapy for early stent thrombosis was compared with 25 patients (using historical controls) who received conventional therapy. Although the angiographic outcome and the incidence of myocardial infarction in both groups was similar, there were no deaths or referral for emergency coronary bypass surgery in the abciximab-treated group versus 3 deaths and 10 referrals for emergency bypass surgery in the conventionally treated group.     

Benefits to a regional neurosurgical unit following the introduction of a decentralised imaging facility

OBJECTIVE: To determine whether the establishment of a peripheral computed tomography (CT) facility has an influence on the central referral neurosurgical unit, and particularly whether unnecessary referrals are avoided. DESIGN: The outpatient records of all patients referred from Umtata General Hospital (UGH) to the neurosurgical unit at Wentworth Hospital, Durban, were retrospectively analysed over a 4-year period--2 years before and 2 after the introduction of CT facilities at UGH. SETTING: Wentworth Hospital, Durban, which houses the sole neurosurgical referral centre for the region. PATIENTS: Eight hundred and forty patients were referred to the neurosurgical unit from UGH during the 4-year study period--July 1990 to June 1994. MAIN OUTCOME MEASURES: 1. The number of referrals to the neurosurgical unit before and after introduction of peripheral CT facilities at UGH. 2. The admission rate of the above referrals during the same periods, indicating appropriate referrals. RESULTS: 1. There were 536 patients referred from UGH to the neurosurgical unit over a 2-year period before the introduction of peripheral CT facilities, and 304 patients during the subsequent 2-year period after introduction of CT facilities at UGH. This represented a 43.3% decrease in patient referrals during a period in which referrals from all other areas increased by 2.6%. 2. The admission rate of patients (indicating appropriate referrals) being referred from UGH increased from 46.3% before CT facilities to 79.9% after the introduction of peripheral CT facilities. The admission rate of patients from other areas, excluding UGH, during the same periods, decreased from 50.3% to 46.4%. CONCLUSION: This audit reveals that following the introduction of CT facilities at UGH, the number of referrals to Wentworth Hospital's neurosurgical unit decreased by almost half (43.3%). Furthermore, the patients referred after introduction of the peripheral CT facility were more likely to be appropriate referrals (79.9%) than before (46.4%). Therefore, the provision of CT facilities at peripheral hospitals may effectively serve to exclude those patients who would otherwise be referred unnecessarily, and enable earlier referral of those patients who require urgent care at a tertiary neurosurgical unit.     

Children referred for specialist care: a nationwide study in Dutch general practice

BACKGROUND: Insight into referral patterns provides general practitioners (GPs) and specialists with a frame of reference for their own work and enables assessment of the need for secondary care. Only approximate information is available. AIM: To determine how often, to which specialties and for what conditions children in different age groups are referred, as well as how often a condition is referred given the incidence in general practice. METHOD: From data of the Dutch National Survey of Morbidity and Interventions in General Practice, 63,753 new referrals (acute and non-acute) were analysed for children (0-14 years) from 103 participating practices (161 GPs) who registered. Practices were divided into four groups. Each group of practices participated for three consecutive months covering a whole year altogether. We calculated referral rates per 1000 children per year and referability rates per 100 episodes, which quantifies the a priori chance of a condition being referred for specialist care. RESULTS: The referral rate varied by age from 231 for children under 1 year old to 119 for those aged 10-14 years (mean 159). The specialties mainly involved were ENT, paediatrics, surgery, ophthalmology, dermatology and orthopaedics. Referrals in the first year of life were most frequently to paediatricians (123); among older children the referral rate to paediatricians decreased (mean 36). Referrals to ENT specialists were seen particularly in the age groups 1-4 (71) and 5-9 (53). For surgery, the referral rate increased by age from 19 to 34. Differences between boys and girls were small, except for surgery. The highest referral rates were for problems in the International Classification of Primary Care (ICPC) chapters: respiratory (28); musculoskeletal (25); ear (24) and eye (21). Referability rates were, in general, low for conditions referred to paediatrics and dermatology and high for surgery and ophthalmology. The variation in problems presented to each specialty is indicated by the proportion of all referrals constituted by the 10 most frequently referred diagnoses: from 35% for paediatrics to 81% for ENT; for ophthalmology, five diagnoses accounted for 83% of all referrals. CONCLUSIONS: The need for specialist care in childhood is clarified with detailed information for different age categories, specialties involved and variation in morbidity presented to specialists, as well as the proneness of conditions to be referred.     

Progressive osseous heteroplasia: a case report

STUDY OBJECTIVE: To assess the impact of a breast clinic on a specific target population and evaluate early diagnosis performance indicators for breast cancer in the presence of a self referral policy. DESIGN: Women living in Florence between 1980 and 1989 who had undergone mammography at a self referral breast clinic were studied. Main outcome measures were the use of mammography in relation to age, symptoms, and the interval between two subsequent tests, and early diagnosis performance indicators were the detection rate (DR), the prevalence/incidence ratio, and the proportion of early detected cancers. Performance indicators were compared with those from formal screening programmes. SETTING: Florence, Italy. PATIENTS: All mammograms performed at the clinic from 1980-89 in 40-69 year old women living in Florence were examined (n = 42,226). Records included the date of birth and of the examination, the reason for testing (asymptomatic/presence of pain/presence of symptoms other than pain), and the TNM classification for breast cancer cases. MAIN RESULTS: The total number of mammograms performed per annum increased by 70% over the decade, but much of this was routine repeat mammography (54.1% in 1989). Rates of first examinations in asymptomatic women increased in the second half of the decade from 17 per 1000 in 1985 to 31 per 1000 in 1989. Mammographic coverage decreased with increasing age from 12.6% in 40-49 year olds to 6.0% in 60-69 years old. Performance indicators of the activity in asymptomatic women were comparable with those expected in service screening. The proportion of not advanced cancers detected in asymptomatic women was 62.3% with a DR of 5.3 per 1000, and the average prevalence/incidence ratio was 2.9. CONCLUSIONS: High quality mammography performed in a breast clinic in self referred asymptomatic women can achieve as good results as a formal invitation screening service. Only a few of these women will benefit, but those who do are likely to be younger (40-49 year old women).     

Impact of strain heterogeneity on Lyme disease serology in Europe: comparison of enzyme-linked immunosorbent assays using different species of Borrelia burgdorferi sensu lato

BACKGROUND: The gatekeeper function of the general practitioner (GP) in the pathway to specialized psychiatric services was investigated in this study, which is part of the Nordic Comparative Study on Sectorized Psychiatry. The question addressed in this paper is whether different sociodemographic and clinical factors as well as factors related to service utilization are associated with referral from the GP compared with self-referrals (including referrals from relatives). METHODS: The study comprised a total of 1413 consecutive patients, admitted during 1 year to five psychiatric centres in four Nordic countries. The centres included in this study were those that accepted non-medical referrals. Only new patients (not in contact with the service for at least 18 months) were included. RESULTS: Increasing age was the only sociodemographic factor significantly associated with referral by the GP. The clinical factors (psychosis, being totally new to psychiatry and being in need of in-patient treatment) and some treatment characteristics (planned out-patient treatment and involuntary in-patient treatment), were all significantly associated with referral by the GP. Some indication was found that self-referred patients have shorter episodes of care. CONCLUSIONS: The findings were remarkably stable across the different centres indicating a general pattern. This study extends previous work on the role of GPs in the pathway to specialized psychiatric services and indicates that the GP has an important gatekeeper function for the most disabled patients.     

The history of family planning among women who opt for surgical sterilization in the Social Security Fund of Panama

In this study, the previous history of family planning and prior usage of contraceptive methods are analyzed, in a sample of 175 women who voluntarily opted for surgical sterilization as a permanent method of fertility regulation, in the Panamanian Social Security System. A questionnaire was applied during the second trimester of pregnancy, by which information would be gathered in regard to knowledge, usage and adverse effects of the contraceptive methods used prior to the intervention. Results showed that 99% of the sample had heard, on some occasion about oral contraceptives (OC) and, in lesser proportion to intrauterine devices (IUD), barrier methods and hormonal inyectables. The first contraceptive method used, and the one of longest usage, was the combined OC, of which 43% begun between 17 and 25 years of age. In contrast, 7.4% initiated contraception with IUD, from the age of 26 years. The health personnel constituted the major source of recommendation for contraceptive usage and, despite the fact that 37% of the sample did not use contraception prior to the last pregnancy, over half of the subjects responded that combined OC were considered as the most secure method.     

Hormonal male contraception: progress and prospects for the 21st century

During the second half of the 20th century, progress in developing novel, practical contraceptive methods for men has lagged significantly behind developments for women. Despite the lack of reliable, reversible methods, men throughout the world continue to be strongly involved in family planning but a greater involvement will require more attractive and reliable contraceptive options for men. The closest to fruition are hormonal methods the features of which are reviewed. Landmark WHO contraceptive efficacy studies have established that hormonally-induced azoospermia provides highly effective and reversible contraception for at least 12 months with minimal short-term side effects. Even among the small subgroup of men who remain oligozoospermic during hormonal suppression, good contraceptive efficacy is achieved. The present goals are to develop improved second generation hormonal regimens which provide more uniform azoospermia to obviate the need for monitoring of sperm output and to develop long-acting depot testosterone formulations used alone or with additional gonadotrophin suppressive agents such as progestins or GnRH antagonists. Significant obstacles to progress are the flight of industry from contraceptive R&D dur to the financial deterrent posed by the product liability crisis as well as the low priority accorded male reproductive health. Together those will determine whether the range of contraceptive options available to our children in the 21st century will improve, or whether the historically recent unbalanced increase in reliance on women for family planning will continue.