Enabling front line-driven perioperative quality improvement through organizational infrastructure built around the Comprehensive Unit Based Safety Program.

SUMMARY: Many surgical departments are interested in quality improvement (QI). For sustainable success, front-line involvement is crucial for improving culture. Without improved culture, any QI strategy will be a struggle. Designing an infrastructure to support these principles is important. We describe our process creating this infrastructure, the multidisciplinary teams that drive change in our department and some of the processes and outcomes we have been able to improve.

Patient-reported confidence in primary healthcare: are there disparities by ethnicity or language?

OBJECTIVE: To examine whether confidence in primary healthcare (PHC) differs among ethnic-linguistic groups and which PHC experiences are associated with confidence. DESIGN: A cross-sectional study where patient surveys were administered using random digit dialling. Regression models identify whether ethnic-linguistic group remains significantly associated with confidence in PHC. SETTING: British Columbia, Canada. MAIN OUTCOME MEASURES: Confidence in PHC measured using a 0-10 scale, where a higher score indicates increased confidence in the ability to get needed PHC services. PARTICIPANTS: Community-dwelling adults in the following ethnic-linguistic groups: English-speaking Chinese, Chinese-speaking Chinese, English-speaking South Asians, Punjabi-speaking South Asians and English-speakers of presumed European descent. FINDINGS: Based on a sample of 1211 respondents, confidence in PHC differed by ethnicity and the ability to speak English. Most of the differences in confidence by ethnic-linguistic group can be explained by various aspects of care experience. Patient experiences associated with lower confidence in PHC were: if care was received outside Canada, having to wait months to see their regular doctor and rating the quality of healthcare as good or fair/poor. Better patient experiences of their doctor being concerned about their feelings and being respectful and if they found wait times acceptable were associated with higher levels of confidence in PHC. The final regression model explained 30% of the variance. CONCLUSIONS: Improving the delivery of PHC services through positive interactions between patients and their usual provider and acceptability of wait times are examples of how the PHC system can be strengthened.

Psychologic distress in polymorphous light eruption and its relationship to patients' beliefs about their condition.

BACKGROUND: Skin disease can cause psychologic difficulties, but information is lacking on the emotional impact of the common photosensitivity condition, polymorphous light eruption (PMLE). OBJECTIVE: We sought to examine the emotional impact of PMLE, and its relationships with patients' beliefs about their PMLE and health-related variables. METHODS: Patients with PMLE who had attended a hospital dermatology department were mailed the Illness Perception Questionnaire-Revised during the summers of 2002 to 2004. RESULTS: Questionnaires were returned by 150 of 302 patients. Emotional distress attributable to PMLE was found in more than 40% of individuals. The emotional impact of PMLE was principally predicted by patients' beliefs about their condition (>50% of the variance), particularly regarding its consequences, whereas health-related variables played a lesser role. Women associated more severe consequences with their PMLE (z = -2.27, P = .02) and were more emotionally distressed (z = -2.17, P = .03) than men. LIMITATIONS: Hospital-based patients with PMLE may not be representative of the community. CONCLUSIONS: Psychologic factors should receive greater attention in PMLE management.

Histamine is released following aminolevulinic acid-photodynamic therapy of human skin and mediates an aminolevulinic acid dose-related immediate inflammatory response.

Acute skin inflammation occurs following topical aminolevulinic acid-photodynamic therapy (ALA-PDT), but its nature and mediation are ill defined. As we observed an urticarial response, a potential role for histamine was explored. In 13 healthy volunteers, we assessed the time course and dose-response of the acute cutaneous response(s) to ALA-PDT, the impact of H(1) antihistamine blockade, and measured dermal histamine release. An ALA dose series was iontophoresed into ventral forearm skin and exposed to red light. All participants exhibited an immediate urticarial response, both wheal and flare correlating with log ALA dose. Subsequently, a dose-related erythema developed at treatment sites by 3 hours and persisted at 24 hours. H(1) blockade with oral cetirizine doubled the median minimal urticating dose of ALA and reduced the slope of dose-response for wheal and flare, whereas at the highest ALA dose, mean wheal and flare areas reduced by 68 and 60%, respectively. In contrast, cetirizine did not influence the 24 hour minimal phototoxic dose or erythema dose-response. Histamine release after ALA-PDT mirrored the urticarial response, levels peaking within 30 minutes and returning to baseline by 24 hours. Thus, two discrete acute inflammatory responses to topical ALA-PDT occur in human skin; histamine mediates the immediate response, but does not appear involved in the delayed phototoxicity.

Retinoic acid receptor alpha expression and cutaneous ageing.

Intrinsic ageing of human skin is a subtle and gradual process that demonstrates few clinical or histological features until old age (>70 years). Initial work indicates that aged skin is "retinoid sensitive" but there is little data on the role of retinoic acid receptors (RARs) or retinoid X receptors (RXRs) in skin ageing. As nuclear retinoid receptors have been implicated in ageing in rodents, we studied the distribution of these receptors in intrinsically aged as compared to young, photoprotected human skin. We found that intrinsic ageing of skin in vivo is accompanied by significant increases of RAR alpha mRNA and protein whereas other isoforms show no alteration with age. In vitro transfection of COS-1 cells with the RAR alpha gene induces expression of matrix metalloproteinase-1 (MMP-1), an enzyme known to play an active role in remodelling of the dermis in intrinsically aged and photoaged skin. Furthermore, addition of all-trans retinoic acid (RA) to cultures of RAR alpha-transfected COS-1 cells diminishes RAR alpha and returns levels of MMP-1 to those approaching baseline. These results demonstrate that intrinsic ageing of human skin is accompanied by significant elevation in the content of RAR alpha and that over-expression of RAR alpha influences expression of MMP-1, an important mediator of skin ageing.