Objectives-To determine the reasons for choosing between primary care out of hours centres and accident and emergency (A&E) departments for patients with primary care problems. Methods-Interviews using a semistructured approach of samples of patients attending A&E departments and general practitioner (GP) out of hours centres for primary care problems. Results-102 patient interviews were undertaken. Sixty two per cent of A&E attenders were unemployed compared with 41% of out of hours attenders. White people were more likely to attend A&E departments and Asians the out of hours centre (p<0.01) and unemployed were more likely to attend A&E departments (70% v 30%). Some 46.3% of A&E department attenders had not contacted their GP before attending; 81.3% of first time users of the out of hours centre found out about it on the day of interview. Those attending A&E thought waiting times at the out of hours centre would be 6.3 hours (median) compared with a median perceived time of 2.9 hours by those actually attending the out of hours centre. Actual time was actually much less. Conclusion-Once patients have used the GP out of hours centre they are more likely to use it again. Education should be targeted at young adults, the unemployed and white people. Patients should be encouraged to contact their GP before A&E department attendance for non-life threatening conditions. Waiting time perception may be an important reason for choice of service. (J Accid Emerg Med 2000;17:18-21) Keywords: out of hours care; primary care; patient choice General practice cooperatives are a comparatively new and successful provision of out of hours primary care in the United Kingdom. In these cooperatives groups of general practitioners (GPs) combine resources to provide emergency cover for their practices. Out of hours they usually run an emergency centre. Patients who telephone the GPs may be given advice, advised to attend the centre, or may receive a visit. However, patients continue to attend the accident and emergency (A&E) department with primary care problems out of hours. As primary care attenders to the A&E department can be managed more appropriately and more economically by the GP services, 1 the current state of aVairs represents a poor use of resources.Factors that have been shown to determine why patients choose A&E over general practice are travelling distance, 2 lack of knowledge of the range of GP services, 3 perceived need for immediate attention, 4 and more advanced technology. 5A small proportion of these patients are not registered with a GP, are visitors, or are homeless. 6 These results are from studies that were conducted before the inception of out of hours GP cooperatives, when GP deputising services were the mainstay of out of hours primary care. No study to date has determined the reasons for out of Figure 1 The age distribution of A&E and cooperative patients.

Background and Objectives: Thermo-mechanical fractional injury (TMFI) therapy (Tixel®; Novoxel®, Netanya, Israel) is an innovative technology. Along with its drug delivery enhancement features, it is widely used for facial skin rejuvenation. Our study explores the beneficial effect of the Tixel® on the different features of facial skin rejuvenation along with patients′ satisfaction rate, aiming to suggest practical recommendations for an optimal aesthetic result. Study Design/Materials and Methods: A retrospective chart review of 24 patients (20 women, 4 men, average age 56 years old) with skin types II-V who received 2 or 3 Tixel® treatments, 3-5 weeks apart in two medical centers (12 from Israel, 12 from the United Kingdom). Four experienced dermatologists compared standardized clinical photographs taken before each treatment and 3 months after the final treatment based on seven parameters that were set by 10 physicians and rated the difference on a scale of −1 to 4. Furthermore, epidemiology, treatment data, satisfaction, and safety were reviewed. Results: Out of the seven parameters that were compared (blood vessels and erythema, skin complexion, periorbital wrinkles, pigmentation and toning, pore size, vitality, wrinkles, and laxity), all features demonstrated an overall improvement, with the greatest improvement demonstrated in skin complexion (2.1± 0.49) and periorbital wrinkling (2.09 ± 0.65) followed by vitality (1.7 ± 0.49). Side effects were transient, including erythema and hyperpigmentation, and the average downtime was 1.7 days. Conclusion: TMFI is a safe and effective method for improving facial skin quality. Addressing patient′s expectations while maximizing the benefits of this novel technology will provide superior aesthetical results.

Aging of the skin incorporates textural changes, wrinkles, and pigmentation. Treatment options for skin photoaging are plentiful and include chemical peels and energy-based devices such as ablative and non-ablative fractional laser devices and radiofrequency-based devices. [1][2][3][4] The fact that there are so many treatments suggest that none are perfect and there is a continuing development of new treatments that can improve the effectiveness and/ or safety of existing treatments.