Search

Background The declaration of a nationwide COVID-19 lockdown resulted in rapid adaptations to the NHS, including Paediatric Outpatient Consultations. At short notice, many Trusts converted consultations in General Paediatric outpatients from traditional face-to-face to telephone consultations. General Practitioners have been using this method of assessment, with the backing of the British Medical Association, as a safe and acceptable practice for many years. Objectives We set out to perform a retrospective review of the lessons learned from Paediatric outpatient telephone consultations during COVID-19 and how these can be applied to improve the outpatient clinical pathway. Our aims and objectives evaluated: The proportion of patients successfully contacted by telephone. The proportion of presenting complaints which had resolved by the time of the appointment. The proportion of patients who could be discharged from the General Paediatric clinic through telephone consultation. The number of patients who we arranged to see in a face-to-face appointment within a few weeks (as deemed necessary by the phoning clinician). The number of patients who needed further investigations. Methods Two registrars (ST6+) and one senior house officer (ST2), with guidance from a dedicated General Paediatric Consultant, was assigned to conduct telephone consultations for all new patients booked into General Paediatric clinics between the 24/03/2020 to 31/05/2020. Most patients had been referred and appointments booked pre-COVID but urgent (2 -week) referrals from GPs were also seen. Patients/parents/carers were called at least 3 times on 3 different occasions over at least 2 days. If they did not answer they were listed as ‘was not brought’. Calls were made between 9am to 5pm Monday to Friday. Results 262 new patients had new General Paediatric Clinic appointments and 235 (90%) were successfully contacted. 27 (10%) of patients ‘were not brought’. These 27 patients were excluded from on-going analysis. Following one telephone consultation, 105 (45%) contacted patients could be discharged from the General Paediatric clinic with parental agreement. Of these 27 (11%) patients had a complaint which had resolved by the time of the appointment and 19 (8%) patients had already been seen by a private consultant or other NHS consultant. Thus 46 (20%) of the contacted patients did not need their General Paediatric appointment. Only 7 (3%) patients needed urgent face-to face-review of which 4 were urgent 2-week wait referrals by the GP. 155 (66%) patients needed no investigations. Conclusions The NHS is going through unchartered, challenging time. However, this provides opportunities to adapt and evolve services, improving efficiency of care for both the families we look after and health service staff. The data above highlights that almost half of the new General Paediatric outpatients could be successfully discharged from clinic after one telephone consultation. During a time of significant anxiety and uncertainty families avoided hospital contact. A similar system when we return to normality could lead to fewer absences from school and less time off work for parents. Out experience suggests that initial telephone consultations with new General Paediatric patients may be an efficient way to make first patient contact.

A 9-month-old boy of South Asian origin presented to the emergency department with a head injury after falling out of his parents’ bed onto a carpeted floor. On examination, he had a 2 cm×2 cm smooth concavity in the right parietal region. He was playful, with an otherwise normal examination. The skull bones did not appear soft or brittle when pressed. There was nothing in the presentation that warranted a safeguarding investigation. He had recently completed 12 weeks of treatment for presumed latent …

Breast density is positively linked to the risk of developing breast cancer. We have developed a semi-automated, stepwedge-based method that has been applied to the mammograms of 1,289 women in the UK breast screening programme to measure breast density by volume and area. 116 images were analysed by three independent operators to assess inter-observer variability; 24 of these were analysed on 10 separate occasions by the same operator to determine intra-observer variability. 168 separate images were analysed using the stepwedge method and by two radiologists who independently estimated percentage breast density by area. There was little intra-observer variability in the stepwedge method (average coefficients of variation 3.49% - 5.73%). There were significant differences in the volumes of glandular tissue obtained by the three operators. This was attributed to variations in the operators' definition of the breast edge. For fatty and dense breasts, there was good correlation between breast density assessed by the stepwedge method and the radiologists. This was also observed between radiologists, despite significant inter-observer variation. Based on analysis of thresholds used in the stepwedge method, radiologists' definition of a dense pixel is one in which the percentage of glandular tissue is between 10 and 20% of the total thickness of tissue.

If breast density is to be incorporated into breast cancer risk prediction models, the technique used for measurement must be quantitative, accurate, objective and reproducible We present a semi-automated method that has been used by three independent operators to measure glandular volume from the digitised mammograms of 29 women (116 images) Additionally, one operator used the method on 10 separate occasions on a sample of 24 images Intra-observer variability was found to be acceptably low, with coefficients of variation ranging from 3.5 – 5.7% depending on mammographic view (intra-class correlation coefficient close to 1 in all cases) However, inter-observer variability was greater with significant differences in glandular volume recorded between observers This was attributed to the method of breast edge detection The development of a new automatic breast edge detection algorithm has resolved the issue The average difference in glandular volume measurement between two independent operators in the cranio-caudal view is -0.89cm3 (95% confidence interval -2.77 – 0.99 cm3) using the new method, compared to 5.99cm3 (95% confidence interval 2.72 – 9.76 cm3) using the old method.