All new patients attending a Dublin Hospital's Accident and Emergency (A&E) Department were surveyed to document their reasons for attending and to make comparisons between self-referred and GP referred groups. Of the 557 responders 395 (70.9%) were self-referred. Four-fifths of this group said they had a GP but only 6.6 per cent attempted to contact the GP before attending. Compared with GP referred patients the self-referred group were more likely to be under 45 (74.6 per cent v 59.8 per cent, P< 0.01) and have soft tissue injuries (57 per cent v 32.9 per cent, P < 0.01). They were less likely to require laboratory investigation or to be admitted to hospital (11 per cent v 31.2 per cent, P < 0.01). It is likely many of the self-referred patients could have been managed by a GP. However, A & E departments remain popular sources of treatment for patients with a wide variety of conditions. Current methods of delivering health care to patients with minor conditions require assessment so that patient demands for both a responsive minor injury and emergency service can be met. Almost 70 per cent of all hospital admissions originated from the A&E department. This makes rational planning and management of booked admissions difficult. GPs who refer patients for admission should have an alternative route to hospital beds besides the A&E department.
The diagnosis of esophageal carcinoma carries an extremely poor prognosis. Even after apparently curative resection, with histologically normal resection margins, there is a high incidence of locally recurrent disease. This study was performed to determine if cell surface morphological abnormalities, indicative of a "field change," are present in the esophageal mucosa of patients with squamous carcinoma of the esophagus. Seven patients with squamous cell carcinoma of the esophagus and seven patients with a normal esophagus were studied. Biopsies were examined using both light and scanning electron microscopy; they were taken from the midesophagus in the normal group and from the tumor, the normal mucosa adjacent to the tumor, and the proximal surgical resection margin in the tumor group. There was a characteristic pattern of abnormalities present in both the mucosa adjacent to tumor and the resection margin, indicative of a field change. The microplicae on the cell surfaces were reduced in number and were unfolded, and defects were found in the extracellular matrix giving rise to intercellular fissures. These changes reflect increased cell turnover and increased cell exfoliation. We conclude that scanning electron microscopy can detect widespread changes in the esophageal mucosa of patients with esophageal cancer that are not detectable by light microscopy. The fact that such field changes exist as far as the proximal surgical resection margin may help explain locally recurrent disease after apparently curative surgery.
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