Assessing the impact of the COVID-19 pandemic on inpatient admissions and management of patients with anorexia nervosa within a single tertiary paediatric gastroenterology department

N3 Figure 1New inpatient admissions and average length of stay by quarters from June 2018 - May 2021[Figure omitted. See PDF] N3 Figure 2Average daily bed occupancy with anorexia nervosa patients per month from May 2018 - June 2021[Figure omitted. See PDF]Summary and ConclusionThis study has demonstrated an increase in number of inpatient admissions for patients with Anorexia Nervosa at a single centre over the past year. A national shortage in specialised Tier 4 ED beds has also likely contributed to increase in patient volume, length of stay and requirement for more intensive management, placing a greater demand on hospital resources.It is recognised that there is an increasing number of patients presenting with Anorexia Nervosa. The observed trend of patients with increased complexity and severity, delay in presentation and prolonged hospital stay is likely to have been influenced by COVID-19 pandemic.

Patient experience of attend anywhere virtual consultations in a tertiary paediatric gastroenterology centre

IntroductionVideo consultations using the Attend Anywhere web platform were introduced into clinical practice in our tertiary paediatric gastroenterology centre during the COVID-19 pandemic as an alternative to face-to-face consultations. We analysed online feedback received from these consultations to understand our patients’ experience of virtual consultations and to identify areas of improvement.MethodsAll patients scheduled for a paediatric gastroenterology video consultation were invited by the hospital Patient Experience Team to complete an online Survey monkey questionnaire at the end of the consultation. We retrospectively analysed feedback received from 01 February 2021 to 30 September 2021.ResultsOver an eight-month period, 83 responses were received. In terms of accessibility, most patients (n=82, 99%) were able to access the virtual consultation without additional help. Most patients (n=81, 98%) saved at least 30 minutes in travel time and of these, 20 patients (24%) saved more than 3 hours of travel. 81 parents (98%) reported financial savings from not travelling to hospital, with 25 patients (30%) saving over £21.29 patients (35%) found the virtual consultation experience to be significantly better or better than a previous face-to-face consultation. 51 patients (61%) reported it to be about the same, and only three (4%) reported it to be worse or significantly worse.46 patients (56.1%) found video consultations less stressful compared to face-to-face consultations, while 29 (35%) reported no difference, and 5 (6%) found it more stressful.77 patients (93%) were happy to have further follow-up appointments virtually, one patient was unhappy for further virtual appointments, and five (6%) did not know.There was an opportunity for parents to enter free-text comments on their experience. In this, parents commented on how video consultations were convenient, timesaving and less disruptive to family life compared to face-to-face consultations. In addition, they saved the trouble of worrying about traffic, being late, parking delays and navigating in an unfamiliar city. Three parents also commented that having virtual consultations reduced the risk of contracting Covid-19.Several suggestions were made to improve the experience. This included providing an option for a face-to-face appointment at the point the appointment was made, an indicator to inform patients of expected waiting times in the virtual waiting room and making it clearer who to contact for help if no health professional joined the call.Compared to telephone consultations, parents/patients found video consultations more interactive especially for the child, as they could see the clinician and participate throughout the consultation instead of just listening in.ConclusionOur study highlights the benefits of virtual consultations, including significant time and financial savings to families. Most families found virtual consultations a satisfactory alternative to face-to-face consultations. Inherent limitations to video consultations- the inability to physically examine patients, and challenges in building rapport with families through video- mean that not all patients will be suitable for video consultation. Overall, video consultations are a useful tool to deliver outpatient services during the pandemic and beyond. The option should be given to families and potential improvements to the service should be investigated.

Evidence supporting safe diagnosis of coeliac disease in children with antitissue transglutaminase titre ≥5 times upper limit of normal.

OBJECTIVE: European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) guidelines on coeliac disease (CD) recommend that children who have IgA-based antitissue transglutaminase (TGA-IgA) titre ≥10× upper limit of normal (ULN) and positive antiendomysial antibody, can be reliably diagnosed with CD via the no-biopsy pathway. The aim of this study was to examine the relationship between TGA-IgA ≥5×ULN and histologically confirmed diagnosis of CD. METHODS: Data including TGA-IgA levels at upper gastrointestinal endoscopy and histological findings from children diagnosed with CD following endoscopy from 2006 to 2021 were analysed. CD was confirmed by Marsh-Oberhuber histological grading 2 to 3 c. Statistical analysis was performed using χ² analysis (p<0.05= significant). RESULTS: 722 of 758 children had histological confirmation of CD. 457 children had TGA-IgA ≥5×ULN and 455 (99.5%) of these had histological confirmation for CD; the two that did not had eventual diagnosis of CD based on clinicopathological features. 114 of 457 had between TGA-IgA ≥5×ULN and <10×ULN, all had confirmed CD. The likelihood of a positive biopsy with TGA-IgA ≥5×ULN (455/457) compared with TGA-IgA <5×ULN (267/301) has strong statistical significance (p<0.00001). The optimal TGA-IgA cut-off from receiver operating characteristic curve analysis was determined to be below 5×ULN for the two assays used. CONCLUSION: 99.5% of children with TGA-IgA ≥5×ULN had histological confirmation of CD, suggesting that CD diagnosis can be made securely in children with TGA-IgA ≥5×ULN. If other studies confirm this finding, there is a case to be made to modify the ESPGHAN guidelines to a lower threshold of TGA-IgA for serological diagnosis of CD.

Adaptations to the current ECCO/ESPGHAN guidelines on the management of paediatric acute severe colitis in the context of the COVID-19 pandemic: a RAND appropriateness panel.

OBJECTIVE: Paediatric acute severe colitis (ASC) management during the novel SARS-CoV-2/COVID-19 pandemic is challenging due to reliance on immunosuppression and the potential for surgery. We aimed to provide COVID-19-specific guidance using the European Crohn's and Colitis Organisation/European Society for Paediatric Gastroenterology, Hepatology and Nutrition guidelines for comparison. DESIGN: We convened a RAND appropriateness panel comprising 14 paediatric gastroenterologists and paediatric experts in surgery, rheumatology, respiratory and infectious diseases. Panellists rated the appropriateness of interventions for ASC in the context of the COVID-19 pandemic. Results were discussed at a moderated meeting prior to a second survey. RESULTS: Panellists recommended patients with ASC have a SARS-CoV-2 swab and expedited biological screening on admission and should be isolated. A positive swab should trigger discussion with a COVID-19 specialist. Sigmoidoscopy was recommended prior to escalation to second-line therapy or colectomy. Methylprednisolone was considered appropriate first-line management in all, including those with symptomatic COVID-19. Thromboprophylaxis was also recommended in all. In patients requiring second-line therapy, infliximab was considered appropriate irrespective of SARS-CoV-2 status. Delaying colectomy due to SARS-CoV-2 infection was considered inappropriate. Corticosteroid tapering over 8-10 weeks was deemed appropriate for all. After successful corticosteroid rescue, thiopurine maintenance was rated appropriate in patients with negative SARS-CoV-2 swab and asymptomatic patients with positive swab but uncertain in symptomatic COVID-19. CONCLUSION: Our COVID-19-specific adaptations to paediatric ASC guidelines using a RAND panel generally support existing recommendations, particularly the use of corticosteroids and escalation to infliximab, irrespective of SARS-CoV-2 status. Consideration of routine prophylactic anticoagulation was recommended.

Impact of COVID-19 on diagnosis and management of paediatric inflammatory bowel disease during lockdown: a UK nationwide study.

BACKGROUND: COVID-19 has impacted on healthcare provision. Anecdotally, investigations for children with inflammatory bowel disease (IBD) have been restricted, resulting in diagnosis with no histological confirmation and potential secondary morbidity. In this study, we detail practice across the UK to assess impact on services and document the impact of the pandemic. METHODS: For the month of April 2020, 20 tertiary paediatric IBD centres were invited to contribute data detailing: (1) diagnosis/management of suspected new patients with IBD; (2) facilities available; (3) ongoing management of IBD; and (4) direct impact of COVID-19 on patients with IBD. RESULTS: All centres contributed. Two centres retained routine endoscopy, with three unable to perform even urgent IBD endoscopy. 122 patients were diagnosed with IBD, and 53.3% (n=65) were presumed diagnoses and had not undergone endoscopy with histological confirmation. The most common induction was exclusive enteral nutrition (44.6%). No patients with a presumed rather than confirmed diagnosis were started on anti-tumour necrosis factor (TNF) therapy.Most IBD follow-up appointments were able to occur using phone/webcam or face to face. No biologics/immunomodulators were stopped. All centres were able to continue IBD surgery if required, with 14 procedures occurring across seven centres. CONCLUSIONS: Diagnostic IBD practice has been hugely impacted by COVID-19, with >50% of new diagnoses not having endoscopy. To date, therapy and review of known paediatric patients with IBD has continued. Planning and resourcing for recovery is crucial to minimise continued secondary morbidity.