Improving the annual monitoring rates of testosterone replacement therapy patients in primary care.

INTRODUCTION: Testosterone replacement therapy (TRT) is the treatment of choice for male hypogonadism. British Society for Sexual Medicine (BSSM) guidelines on adult testosterone deficiency recommend that TRT patients undergo annual monitoring of their testosterone levels and potential complications of treatment; though evidence suggests that substantial numbers of men on TRT are not monitored adequately. METHODS: Review of the electronic patient record from a single general practice in southwest Scotland revealed that only 1 of 26 (4%) TRT patients had been monitored as per BSSM guidelines in the previous 12 months. Additionally, when monitoring was undertaken there was inconsistency in the blood tests requested. The use of quality improvement (QI) tools including process mapping and cause-and-effect diagram identified staff and patient knowledge of monitoring requirements and the lack of an effective recall system as areas for improvement. We tested three change ideas: the utilisation of an existing recall system for long-term therapies; a TRT Ordercomms blood group template (OBGT) to standardise monitoring; and a patient information leaflet (PIL) to improve patient education. The aim of this project was to achieve 60% annual monitoring rate. RESULTS: The percentage of patients monitored for testosterone levels and potential TRT complications increased from 4% (1/26) to 65% (17/26) over a 7-week test period. The utilisation of the existing recall system was a particularly effective intervention, leading to an increase from 4% (1/26) to 31% (8/26) in the first 2 weeks. CONCLUSION: The use of QI tools was associated with over 60% of male TRT patients receiving comprehensive annual monitoring, as per BSSM guidelines. Our findings support the hypothesis that a patient recall system, combined with an OBGT and a PIL led to this increase.

Teledermatology to reduce face-to-face appointments in general practice during the COVID-19 pandemic: a quality improvement project.

Teledermatology is an important subspecialty of telemedicine that continues to evolve with advances in telecommunication and mobile phone technology. A 19-week primary care quality improvement project collected baseline data and tested three change ideas, using the Model for Improvement method, with primary and secondary aims: to increase the weekly percentage of remote dermatological consultations with supporting images that were successfully concluded remotely to greater than 80% and to reduce the weekly percentage of dermatological face-to-face consultations to less than 50%. We hypothesised that by improving the quality of patient images and the confidence of reception staff in triaging skin complaints, there would be a decrease in the weekly number of face-to-face dermatological appointments, thereby decreasing the risk of COVID-19 transmission within the practice and community. Two change ideas focused on supporting patients to improve image quality by introducing '4 Key Instructions' and a patient information leaflet (PIL). The third focused on increasing reception staff confidence in triaging skin complaints by introducing a triage pathway guidance tool. A total of 253 dermatological consultations were analysed: 170 of these were telephone consultations with 308 supporting images. Process measures showed clear improvements in the quality of images provided by patients which likely contributed to an increase in completed remote consultation. Our primary outcome measure was achieved. Our secondary outcome measure suggested that in the absence of high-quality images, it might not be possible to reduce dermatological face-to-face consultations much below 50% in primary care. Process measures showed clear improvements in the quality of images provided by patients which likely contributed to the increase in remote consultation. The implications of these findings for the theory of change are discussed.

Draft genomes and reference transcriptomes extend the coding potential of the fish pathogen Piscirickettsia salmonis

Background: Draft and complete genome sequences from bacteria are key tools to understand genetic determinants involved in pathogenesis in several disease models. Piscirickettsia salmonis is a Gram-negative bacterium responsible for the Salmon Rickettsial Syndrome (SRS), a bacterial disease that threatens the sustainability of the Chilean salmon industry. In previous reports, complete and draft genome sequences have been generated and annotated. However, the lack of transcriptome data underestimates the genetic potential, does not provide information about transcriptional units and contributes to disseminate annotation errors. Results: Here we present the draft genome and transcriptome sequences of four P. salmonis strains. We have identified the transcriptional architecture of previously characterized virulence factors and trait-specific genes associated to cation uptake, metal efflux, antibiotic resistance, secretion systems and other virulence factors. Conclusions: This data has provided a refined genome annotation and also new insights on the transcriptional structures and coding potential of this fish pathogen.

The recognition and use of patient expertise on a unit for older people.

There is growing recognition in health care of the expertise patients bring to the management of their own illness or condition. But some patient groups, including older people, may need encouragement to see their own coping strategies as expertise, and nurses have an important role to play in ensuring that patients' experiences are acknowledged and made central to the care offered. This article describes a study of patients' and professionals' views of patient expertise. It concludes that although disruption can occur when older people are admitted to hospital, this can be minimised if they are perceived as experts in their own condition and information supplied to them is based upon such acknowledgement.