253 Hospital Consultant Remote Consultations During COVID 19 - Experiences at a Large NHS Trust

Aim

COVID-19 has intensified the need for the NHS to almost utilise remote consulting technology overnight, with clinicians under increasing pressure to provide virtual services preferentially, in line with the NHS digital ideals. This study explores the clinician experience of virtual working during the pandemic in a large acute NHS Teaching Trust, and to identify the facilitators and barriers to remote consultations (RC).

Method

A multi-format online questionnaire was constructed and emailed to all 816 consultants across the trust. The survey was open for one month and during that time two reminders were sent. The data was tabulated and analysed using Microsoft excel.

Results

270 consultants responded to the questionnaire, giving a response rate of 33%, with 208 (77%) performing RCs. 92.8% of these (N=193) have increased the number of RC during the pandemic. 45.9% did not have their own office (N=124), with over half of those (N=63) sharing an office with 3 or more people. The majority of remote consultations were over telephone (82%) with only 54.4% feeling they had the right equipment for video consultations. The biggest barriers were patient related issues (technical, poor environment or not available at scheduled time).

Conclusion

The main challenges facing consultants, in the provision of virtual services were lack of appropriate hardware, an absence of a suitable environment, the prevalence of technical complications, and difficulties experienced by their patients. It is, therefore, important to recognise, both at an organisational level, and nationally, that virtual consultations may play a role in the worsening of health inequalities.

Partial repigmentation of a vitiliginous nipple areolar complex following therapeutic mammoplasty

We discuss the unusual repigmentation of a vitiliginous region of a nipple areolar complex following a therapeutic mammoplasty. We consider the autoimmune mechanisms behind the pathogenesis of vitiligo and their potential interplay with the immunological pathways involved in this patient's breast cancer and ultimately in the postoperative recovery period. This case highlights the potential interconnecting thread of immunological disruptions, which may provide a springboard for further discussion around the treatment for vitiligo. It also provides a useful point of note when counselling darker skin patients around scarring when undergoing surgical interventions.

An unusual "venous circle" of the internal mammary vein encountered during microvascular anastomosis and implications for practice

The internal mammary vessels are commonly used for anastomosis in breast reconstruction. The anatomy when using the 2nd ICS has been shown to be predictable and hence preferentially used by the senior author. We present an unusual case of internal mammary vein bifurcation and immediate confluence forming a 'venous circle'.

The ideal intercostal space for internal mammary vessel exposure during total rib-sparing microvascular breast reconstruction: A critical evaluation

BACKGROUND

Total rib-preserving free flap breast reconstruction (RP-FFBR) using internal mammary vessel (IMV) recipients usually involves vessel exposure in the second or third intercostal spaces (ICS). Although the third one is more commonly used, no direct comparisons between the two have hitherto been performed.

OBJECTIVES

To compare the in-vivo topography and vascular anatomy of second and third ICSs in patients undergoing FFBR using the rib-preservation technique of IMV exposure.

METHODS

An analysis of prospectively collected data on intercostal space distance (ISD), number and arrangement of IMVs, location of venous confluence, and vessel exposure time was conducted on a single surgeon's consecutive RP-FFBRs.

RESULTS

A total of 296 RP-FFBRs were performed in 246 consecutive patients. The second, third, or both second and third spaces were utilized in 282, 28, and 22 cases, respectively. The ISDs were 20.6 mm ± 3.52 for the second ICS and 14.0 mm ± 4.35 for the third ICS (p<0.0001, CI = 5.17-7.97, t-test). The second versus third ICS vein content was as follows: single 81.4% vs. 74%, dual 18.6% vs. 26%, and confluence 3.7% vs. 13%. The second ICS single vein was medial to the artery in 92.6%. The third ICS single vein was medial to the artery in 88.2% Vessel exposure times for second (47.2 mins ± 26.7) and third (46.5 mins ± 31.4) spaces were similar (p = 0.93). The overall intraoperative anastomotic revision rate was 9.1%, and the postoperative flap re-exploration rate was 4.0%, with 99.7% overall flap success.

DISCUSSION AND CONCLUSION

Preferential use of the second ICS is supported by its more predictable vascular anatomy, a broader space for performing the microanastomoses and a higher frequency of a single postconfluence (and thus larger) vein facilitating the microsurgery.

Spectrophotometric intracutaneous analysis for the assessment of burn wounds: A service evaluation of its clinical application in 50 burn wounds

INTRODUCTION

The assessment of burn depth can be challenging even to the experienced burn clinician. Clinical assessment is most widely used to determine burn depth. Because of this subjective nature, various imaging modalities have been invented. The use of photospectometry as a novel technique in burn wound depth analysis has been previously described but the literature is very limited.

METHODOLOGY

We carried out a single blinded non-randomized comparative study of healing potential of 50 burn wounds between tissue spectrophotometry analysis versus clinical evaluation.

RESULTS

ScanOSkin™ technology has an overall sensitivity of 75% and specificity of 86% in predicting healing potential of wounds. Analysis of Inter Rater Agreement (IRA) using Kappa calculations showed strengths of agreement varied from fair to moderate in perfusion and burn depth. IRA for assessing pigmentation however, was poor and this was reflected in user feedback.

CONCLUSION

There is a potential role for ScanOSkin™ tissue spectrophotometric analysis in burn depth assessment. Future studies comparing several imaging modalities with ScanOSkin^®, taking into account costs comparison may be useful for future health resources planning.

Spontaneous regression of subcutaneous in-transit malignant melanoma deposits of the lower leg after treatment with the carbon dioxide laser

Primary malignant melanoma (MM) is one of the few cancers that can show spontaneous regression, and although this is well described, the mechanisms behind this are unclear. Spontaneous regression of secondary metastatic deposits of melanoma is rare and there are only a handful of case reports supporting this phenomenon. We report a patient with in-transit MM metastatic disease of the leg, who underwent carbon dioxide (CO(2)) laser ablation, and subsequently developed remission of untreated deposits. We discuss the possible immunological mechanism for this phenomenon.

The controversy of birth order as a risk factor for epilepsy: a study from Saudi Arabia

PURPOSE

To evaluate the relationship between people with epilepsy and birth order.

METHODS

A case-control study of 336 epileptics, 15 years and above, and their 1961 full siblings. The data was analysed by birth order and then stratified by sibship size. The 95% confidence interval (CI) for each odds ratio (OR) was obtained. ORs were calculated in the 259 probands in whom the seizure and epileptic syndrome were classifiable against their corresponding 1313 siblings.

RESULTS

The OR in birth order 1 is 2.08 (1.6-2.8) on comparing probands to their unaffected siblings. In birth order 3 the OR was 1.64 (1.2-2.2) and ORs declined as birth order increased. The chi-square test for the decline was significant P < 0.05. OR in birth >2 in probands against unaffected sibs was 0.42 (0.2-0.62) in partial seizures and 0.27 (0.17-0.43) in the cryptogenic category, 86% of whom had partial seizures.

CONCLUSION

In spite of some limitations in the study it seemed that there is a significant association between low birth order and the risk of epilepsy when all cases were computed together. The cryptogenic type showed the clearest association between low birth order and the likelihood of epilepsy.

The correlation of agglutination titer with positive blood cultures in brucellosis: A comparison of two study periods

Brucellosis is an endemic zoonosis in Saudi Arabia. Correlation of Brucella agglutination antibody titer with positive blood culture was performed over 2 time periods (1986 and 1998). At the King Fahad National Guard Hospital we generally consider a titer value of 1:320 or greater as being diagnostic of Brucella. Using this cut-off, the positive predictive value of 39.3% (95% CI=31.5 to 47.6) in the 1986 study increased to 55.7% (95% CI=42.4 to 68.5) in the recent study (P=0.03). This improvement is probably due to parallel improvement in both methodologies.

Risk factors for spontaneous abortion among Saudi women

The objective of this study was to identify important risk factors for spontaneous abortion (SA) among Saudi women. It was a case-control study conducted at King Khalid University Hospital, Riyadh, Saudi Arabia. The cases were 226 consecutive women hospitalized for SA between October 1992 and January 1993. The controls were 226 consecutive women who had normal delivery in the same hospital during the same period. Bivariate analysis using chi-square tests and estimates of relative risks indicated a positive association of age at menarche with risk of SA (P < 0.01). Also, there was a significant higher risk of SA when a women was married to a blood related husband than if married to a non relative (RR = 2.1). The number of previous abortions was also positively related to the risk of SA in the current pregnancy (P < 0.01). Compared to primigravidas, the risk of SA was 3.2 times greater than if the outcome of the most recent pregnancy was also an SA. Other factors that had significant bivariate association with SA were a family history of SA, abdominal trauma, and infection during pregnancy. When multiple logistic regression was used to adjust for the effects of confounding variables, all the factors that showed significant bivariate association with SA (except outcome of the last pregnancy) remained significant. Early menarche may be protective, but further study is needed to confirm this. Greater attention should be given to pregnant women who had personal or family history of SA and those who had trauma and/or infection during pregnancy. Premarital counselling concerning consanguineous marriages is recommended.

Prevalence and pattern of substance use among undergraduates in a Nigerian University

The prevalence and pattern of substance use was investigated among undergraduate students of the University of Ilorin, Kwara State, Nigeria in June 1988. Six hundred and forty-nine students completed a 117-item self-report questionnaire 636 of which were analysed. Mean age and S.D. of respondents was 23 +/- 3.7 years; 69% were males. The most commonly used substances with their 'lifetime' prevalence rates were as follows: salicylate analgesics, 95.2%; alcohol, 77%; stimulants, 69.2%; antibiotics, 63.3%; hypno-sedatives, 49.4% and cigarettes, 37.4%. The corresponding 'current use' rates were relatively lower. Low use was recorded for cannabis, organic solvents, hallucinogens, cocaine and narcotic analgesics. Majority of the 'current users' use the substances on an occasional basis except for cigarettes where more than half reported weekly or daily use. Males were significantly more of 'current' users of cigarettes and alcohol while females tend to use stimulants more. The use of most of the substances started in primary school. The need for a comprehensive demand-reduction programme in Nigeria based on this and other local findings was advocated. Continuous monitoring, particularly of hard drug use, appears imperative.