We have shown previously that both octamer binding transcription factors, namely the ubiquitous Oct‐1 and the B cell‐specific Oct‐2A protein, can be enhanced in transcriptional activity by their association with the B cell‐specific coactivator protein Bob1, also called OBF‐1 or OCA‐B. Here we study the structural requirements for ternary complex formation of DNA‐Oct‐Bob1 and coactivation function of Bob1. In analogy to DNA‐bound transcription factors, Bob1 has a modular structure that includes an interaction domain (amino acids 1–65) and a C‐terminal domain (amino acids 65–256), both important for transcriptional activation. A mutational analysis has resolved a region of seven amino acids (amino acids 26–32) in the N‐terminus of Bob1 that are important for contacting the DNA binding POU domain of Oct‐1 or Oct‐2. In contrast to the viral coactivator VP16 (vmw65), which interacts with Oct‐1 via the POU homeosubdomain, Bob1 association with Oct factors requires residues located in the POU‐specific subdomain. Because the same residues are also involved in DNA recognition, we surmised that this association would affect the DNA binding specificity of the Oct‐Bob1 complex compared with free Oct factors. While Oct‐1 or Oct‐2 bind to a large variety of octamer sequences, Bob1 ternary complex formation is indeed highly selective and occurs only in a subset of these sequences, leading to the differential coactivation of octamer‐containing promoters. The results uncover a new level in selectivity that furthers our understanding in the regulation of cell type‐specific gene expression.
BackgroundIn several western countries patients’ use of Emergency Departments (EDs) is increasing. A substantial number of patients is self-referred, but does not need emergency care. In order to have more influence on unnecessary self-referral, it is essential to know why patients visit the ED without referral. The goal of this systematic review therefore is to explore what motivates self-referred patients in those countries to visit the ED.MethodsRecommendations from the PRISMA were used to search and analyze the literature. The following databases; PUBMED, MEDLINE, EMBASE, CINAHL and Cochrane Library, were systematically searched from inception up to the first of February 2015. The reference lists of the included articles were screened for additional relevant articles. All studies that reported on the motives of self-referred patients to visit an ED were selected. The reasons for self-referral were categorized into seven main themes: health concerns, expected investigations; convenience of the ED; lesser accessibility of primary care; no confidence in general practitioner/primary care; advice from others and financial considerations. A random-effects meta-analysis was performed.ResultsThirty publications were identified from the literature studied. The most reported themes for self-referral were ‘health concerns’ and ‘expected investigations’: 36% (95% Confidence Interval 23–50%) and 35% (95% CI 20-51%) respectively. Financial considerations most often played a role in the United States with a reported percentage of 33% versus 4% in other countries (p < 0.001).ConclusionsWorldwide, the most important reasons to self-refer to an ED are health concerns and expected investigations. Financial considerations mainly play a role in the United States.
Admission probability for ED patients can be calculated using a prediction tool. Further research must show whether using this tool can improve patient flow in the ED.
BackgroundTo influence self-referral, it is crucial to know a patient’s motives to directly visit the emergency department (ED). The goal of this study is to examine motives for self-referral to the ED and compare these motives in relation to appropriateness.MethodsAll self-referred patients visiting the ED of a Dutch hospital over four separate months in a 1-year period were included. Patients were handed questionnaires that included questions on their reasons to visit the ED directly and where they would seek medical help next time. Additionally, the motives of patients that either appropriately or inappropriately visited the ED were compared. In a previous study on the same patient cohort, the appropriateness of the ED visits was determined using predefined criteria.ResultsA total of 3196 self-referred patients were included, and 48.9 % completed the questionnaires. The majority of patients (28.0 %) attended the ED without a referral because they thought they would get help faster; the next reason was the easier access to radiologic and laboratory investigations (answered by 23.8 %); and the third was the symptoms were considered too severe to visit a general practitioner (GP) (answered by 22.7 %). The majority (78.5 %) would attend the ED the next time they are faced with similar symptoms. Appropriate visits were significantly more seen in females, elderly, and patients in higher triage categories. Patients who expect investigations are necessary, think their symptoms are too severe to visit a GP, or would return to the ED next time were more often appropriately visiting the ED.ConclusionsThe choice of patients to self-refer to an ED is often an explicate decision. Patients are looking for specialist help and want fast and easy access to radiologic and laboratory investigations. Even though the primary care network is well developed in the Netherlands, the reasons for self-referral are similar to the reasons found in previous literature based in other countries. Patients who visit the ED because of health concerns visit the ED more often appropriately than patients visiting for practical reasons.
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