Teleconsultations in paediatric dermatology: a UK-wide clinician survey

The COVID-19 pandemic catapulted dermatology services into a digital era, with the rapid introduction of teleconsultations. Potential benefits include widening access to healthcare and environmental sustainability. Barriers to successful teleconsultations include reduced diagnostic accuracy and technical issues. National Health Service operational planning guidance recommends that >= 25% of consultations are delivered remotely (https://www.england.nhs.uk/wp-content/uploads/ 2021/03/B0468-implementation-guidance-21-22-prioritiesand- operational-planning-guidance.pdf). Yet there is a lack of data regarding the acceptability and effectiveness of paediatric dermatology teleconsultations. We conducted a survey to explore clinicians' experience of teleconsultations in paediatric dermatology, focusing on paediatric eczema, to inform a future clinical trial. The survey was created using an online platform (Microsoft Forms) and piloted by paediatric dermatologists. It was circulated via email to members of the British Society for Paediatric Dermatology, the British Association of Dermatologists and the UK Dermatology Clinical Trials Network (DCTN). It remained open for 7 weeks from July to September 2021. Descriptive analysis was undertaken using Microsoft Excel. There were 120 responses, the majority from consultant dermatologists (59%). Prior to COVID-19, the most commonly provided teleconsultation service was advice and guidance (A+G) to general practitioners (GPs;55% responses). The majority of responders (63%) conducted no teleconsultations. Teleconsultations accounted for < 25% of all consultations in 98% responses. Since the pandemic there has been a marked shift in practice. Forty-nine per cent of responders now conduct > 25% of consultations as teleconsultations. Only 8% provide no teleconsultations. Teleconsultations are now being offered for new consultations [n = 62 (80%)], followup consultations [n = 101 (84%)] and A+G for GPs [n = 96 (80%)]. The most common format is telephone consultations with photographs (72%). For follow-up of paediatric eczema, the most effective format was felt to be telephone consultations with photographs [n = 52 (43%)], followed by video consultations with photographs [n = 32 (27%)]. Over half of responders (54%) felt that teleconsultations were less effective than face-to-face appointments for follow-up of paediatric eczema. Seventeen (21%) responders felt they could accurately assess eczema severity using a video vs. 27 (34%) using photographs. Reported barriers to teleconsultations included poorquality images, technical problems, reduced diagnostic accuracy and impaired communication. Importantly, the issue of safeguarding children was a concern. The majority of clinicians felt that teleconsultations were beneficial for reducing footfall in hospitals and minimizing time missed from school. Our results demonstrate variation in clinician opinion on the effectiveness of teleconsultations and the optimal format for paediatric eczema follow-up appointments. As part of a UK DCTN-themed research call award, we plan to conduct a patient survey, qualitative patient interviews and a health economics analysis of teleconsultations for paediatric eczema. This feasibility work will help to inform a future clinical trial.

Risk for SARS-CoV-2 infection in patients with breast cancer treated with chemotherapy, biologic therapy or active surveillance: Patient outcomes from multicenter institution in New York

Background: In high-risk estrogen-receptor positive, HER2 positive, or triple negative breast cancer (BC), chemotherapy can increase cure rates in early-stage disease and prolong survival in setting of advanced disease. Real world data specific to BC is needed to counsel patients (pts) with BC on their risk for SARS-CoV-2 infection and mortality in the context of the SARS-CoV-2 pandemic. Methods: In this retrospective study, we abstracted clinical data including demographics, tumor histology, cancer treatment, and COVID-19 testing results status from the electronic medical record of 3778 BC patients who received cancer care from 02/01/2020 - 05/01/2020 in New York City at our cancer center. The primary endpoint of the study was incidence of SARS-CoV-2 infection by treatment type (cytotoxic chemotherapy (CT) vs non-cytotoxic therapies (endocrine and/or HER2 directed therapy (E/H)) diagnosed by either serology, RT-PCR, or documented clinical diagnosis. Probability of Treatment Weighting (IPTW) and Mann-Whitney Test were used to assess risk of SARS-CoV-2 infection by treatment and assess outcomes based on oncologic and non-oncologic risk factors respectively. Results: 3062 patients met inclusion criteria with 379 pts in CT, 2343 pts in E/H and 340 in NT groups. During study period 641 patients (20.9%) were tested by either PCR or serology with 64 patients (2.1%) diagnosed with COVID-19. All pts who tested positive by PCR and subsequently had serology testing were positive for IgG. The weighted risk of SARS-COV-2 infection was 3.5% in CT vs. 2.7% in E/H (p=0.523). 27 patients (0.9%) expired over follow up, with 10 deaths attributed to SARS-CoV-2 infection. The weighted risk for death was 0.7% with CT vs. 0.1% with E/H, p=0.24 (Table A). Age, BMI,CCI and advanced cancer stage were associated with increased mortality following SARS-CoV-2 infection (Table). Conclusions: CT was not associated with increased risk of infection with SARS-CoV-2 infection or death following infection. BC cancer treatment, including CT, can be safely administered with enhanced infectious precautions and should not be withheld particularly when given for curative intent.

Clinical frailty scale (CFS) for risk stratification in younger patients hospitalised with covid-19

Background and aim: The importance of frailty is recognised in clinical guidelines for the therapeutic management of diabetes in older people. NICE guidelines recommend that therapeutic decisions should be based on CFS in inpatients with covid-19 aged over 65 years though this has not been validated in people <65 years. We assessed CFS in predicting outcomes in people <65 years with and without diabetes hospitalised with covid-19. Methods: Retrospective analysis of 142 patients, hospitalised with covid-19, aged 35 to 65 years, including 44 patients with diabetes (type 1, n = 5;type 2, n = 39) was undertaken. Results: Thirty-two patients developed severe respiratory failure requiring ventilation, while 9/14 (64.3 %) of those without prior end-stage renal disease required renal replacement therapy (RRT). There were 7 (7.1%) deaths in individuals without and 3 (6.8%) with diabetes. In univariate analysis, CFS was associated with mortality [OR 1.92 (1.27-2.89;p = 0.002)], RRT [OR 1.92 (1.27-2.89;p = 0.002)], length of stay (LOS) [OR 6.2 (3.8-8.58;p < 0.001)] in the whole cohort. In people with diabetes, CFS was associated with increased LOS [OR 6.6 (2.1-11.1;p = 0.005)] and need for RRT [OR 1.66 (0.98-2.81;p = 0.058)]. We observed an interaction with BMI whereby the effect of CFS on LOS was greater at higher BMI [β = 0.35 (0.05-0.64, p = 0.021)]. Conclusion: CFS predicts severe covid-19 in people <65 years with and without diabetes. Patients <65 years of age should be assessed for frailty as they may be candidates for early intervention and enhanced monitoring.