Offsite primary care providers using telehealth to support a sustainable workforce in rural and remote general practice: A rapid review of the literature.

INTRODUCTION: Rural and remote general practices face increasing demands for care without the workforce required to meet patient needs. The coronavirus pandemic has created an opportunity to explore sustainable, telehealth-driven solutions to this chronic and complex problem. OBJECTIVE: This review examined interventions using offsite primary care providers to deliver ongoing patient care via telehealth to support rural and remote general practices. We aimed to understand the impact of such interventions on the Quadruple Aim (patient experience, provider experience, health care costs, and health outcomes). DESIGN: A rapid review of studies published from 2011 and grey literature published from 2016. FINDINGS: Six studies met the eligibility criteria. No eligible Australian studies were identified. Most studies investigated ongoing primary care services provided via telehealth by offsite pharmacists. Patients and rural primary care staff reported positive experiences with the interventions. One study demonstrated potential return on investment for rural practices. While one study reported clinically and statistically significant improvements in health outcomes over time, two studies did not observe statistically significant differences in health outcomes between intervention and control cohorts. DISCUSSION: The Quadruple Aim should be carefully considered when designing, implementing, and evaluating interventions that involve offsite primary care providers using telehealth to support a sustainable workforce in rural and remote general practice. CONCLUSION: Sustainable solutions to workforce shortages in rural and remote general practice are needed urgently. Using offsite primary care providers to deliver telehealth and support practices in these regions is one possible solution that warrants further investigation, particularly in Australia.

Drugs that act on the respiratory tract

No published data from this past year provide new insight on the safety and tolerability of corticosteroids, β2-adrenoreceptor agonists, or phosphodiesterase inhibitors as they pertain to respiratory diseases. While systemic corticosteroids have become a valuable therapeutic agent in treating Covid-19 pneumonia, there have been no new or unexpected adverse events reported within this context. For the leukotriene modifying agents (LTMA), the safety of leukotriene receptor antagonists (LTRA) in pediatric patients was evaluated in a systematic review, providing confirmation of known psychiatric and gastrointestinal adverse events for this drug class. In addition, a retrospective study reported that parasthesia in the extremeties developed during montelukast use in pediatric patients. This adverse event has not been previously reported. For inhaled anticholinergic drugs, published reports have recently described the safety of umeclidinium, revafenacin, and glycopyrolate in Asian patients. In addition, new insight into the association between ipratropium and mydriasis has been described in a few case reports as well as a cohort study. For the antifibrotic drugs nintedanib and pirfenidone, new reports describe the safety of these drugs for new indications, including Covid-19 pneumonia. There are also case reports describing unique side effects of these drugs, including anti-cancer effects. Lastly, there are new reports describing the safety of a new monoclonal antibody therapy for severe asthma (tezepelumab), the safety of omalizumab in specific subpopulations, as well as a few reports describing the combination of mepolizumab and omalizumab for refractory severe asthma.

Telehealth, care access and workforce – are the stars finally aligning?

In 2021, an estimated 950 700 people aged 55-64 used telehealth services over a 12 month period.2 In particular, vulnerable populations such as the aged, disabled, remote, young families, and those without transport, have welcomed the ability to receive timely care via phone (97%) or video consultation (3%).3 This has included the convenience of escripts and emailing of repeat referrals, as well as greater receipt by the practice of important clinical data (such as home blood pressure and blood sugar monitoring). [...]an ability to adopt and mainframe the exciting telehealth and workforce innovation that has occurred over the past 2 years and expand it to 'whole of system' and workforce re-design. [...]listen to our health system leaders.

COVID-19: Pump-priming positive healthcare reform.

This case study of GP Shared Care provides an interesting lens though which to view the current opportunities for improved healthcare partnerships as we respond to the COVID-19 challenges.

A novel ACE2 isoform is expressed in human respiratory epithelia and is upregulated in response to interferons and RNA respiratory virus infection.

Angiotensin-converting enzyme 2 (ACE2) is the main entry point in airway epithelial cells for SARS-CoV-2. ACE2 binding to the SARS-CoV-2 protein spike triggers viral fusion with the cell plasma membrane, resulting in viral RNA genome delivery into the host. Despite ACE2's critical role in SARS-CoV-2 infection, full understanding of ACE2 expression, including in response to viral infection, remains unclear. ACE2 was thought to encode five transcripts and one protein of 805 amino acids. In the present study, we identify a novel short isoform of ACE2 expressed in the airway epithelium, the main site of SARS-CoV-2 infection. Short ACE2 is substantially upregulated in response to interferon stimulation and rhinovirus infection, but not SARS-CoV-2 infection. This short isoform lacks SARS-CoV-2 spike high-affinity binding sites and, altogether, our data are consistent with a model where short ACE2 is unlikely to directly contribute to host susceptibility to SARS-CoV-2 infection.

A Revised Protocol for Culture of Airway Epithelial Cells as a Diagnostic Tool for Primary Ciliary Dyskinesia.

Air-liquid interface (ALI) culture of nasal epithelial cells is a valuable tool in the diagnosis and research of primary ciliary dyskinesia (PCD). Ex vivo samples often display secondary dyskinesia from cell damage during sampling, infection or inflammation confounding PCD diagnostic results. ALI culture enables regeneration of healthy cilia facilitating differentiation of primary from secondary ciliary dyskinesia. We describe a revised ALI culture method adopted from April 2018 across three collaborating PCD diagnostic sites, including current University Hospital Southampton COVID-19 risk mitigation measures, and present results. Two hundred and forty nasal epithelial cell samples were seeded for ALI culture and 199 (82.9%) were ciliated. Fifty-four of 83 (63.9%) ex vivo samples which were originally equivocal or insufficient provided diagnostic information following in vitro culture. Surplus basal epithelial cells from 181 nasal brushing samples were frozen in liquid nitrogen; 39 samples were ALI-cultured after cryostorage and all ciliated. The ciliary beat patterns of ex vivo samples (by high-speed video microscopy) were recapitulated, scanning electron microscopy demonstrated excellent ciliation, and cilia could be immuno-fluorescently labelled (anti-alpha-tubulin and anti-RSPH4a) in representative cases that were ALI-cultured after cryostorage. In summary, our ALI culture protocol provides high ciliation rates across three centres, minimising patient recall for repeat brushing biopsies and improving diagnostic certainty. Cryostorage of surplus diagnostic samples was successful, facilitating PCD research.