Delivering outpatient virtual clinics during the COVID-19 pandemic: early evaluation of clinicians’ experiences

BackgroundThe COVID-19 pandemic has put health systems across the world under significant pressure. In March 2020, a national directive was issued by the National Health Service (NHS) England instructing trusts to scale back face-to-face outpatient appointments, and rapidly implement virtual clinics.MethodsA multidisciplinary team of change managers, analysts and clinicians were assembled to evaluate initial implementation of virtual clinics at Guy’s and St Thomas’ NHS Foundation Trust. In-depth interviews were conducted with clinicians who have delivered virtual clinics during the pandemic. An inductive thematic approach was used to analyse clinicians’ early experiences and identify enablers for longer term sustainability.ResultsNinety-five clinicians from specialist services across the trust were interviewed between April and May 2020 to reflect on their experiences of delivering virtual clinics during Wave I COVID-19. Key reflections include the perceived benefits of virtual consultations to patients and clinicians; the limitations of virtual consultations compared with face-to-face consultations; and the key enablers that would optimise and sustain the delivery of virtual pathways longer term.ConclusionsIn response to the pandemic, outpatient services across the trust were rapidly redesigned and virtual clinics implemented. As a result, services have been able to sustain some level of service delivery. However, clinicians have identified challenges in delivering this model of care and highlighted enablers needed to sustaining the delivery of virtual clinics longer term, such as patient access to diagnostic tests and investigations closer to home.

Interactions Between Experience, Genotype and Sex in the Development of Individual Coping Strategies

Coping strategies, the first line of defense against adversities, develop through experience. There is consistent evidence that both genotype and sex contribute to the development of dysfunctional coping, leading to maladaptive outcomes of adverse experiences or to adaptive coping that fosters rapid recovery even from severe stress. However, how these factors interact to influence the development of individual coping strategies is just starting to be investigated. In the following review, we will consider evidence that experience, sex, and genotype influence the brain circuits and neurobiological processes involved in coping with adversities and discuss recent results pointing to the specific effects of the interaction between early experiences, genotype, and stress in the development of functional and dysfunctional coping styles.

The Children

The children’s early experiences provide a context for assessing subsequent outcomes. Data collected from case files and records presented to the courts show that before separation from birth parents, almost all 210 adoptees had experienced serious and often multiple forms of maltreatment; this was the primary reason for removal. Before entering their adoptive homes, 69% of the adoptees had had four or more adverse childhood experiences (ACEs), 32% had experienced failed reunifications and 48% had had three or more foster placements. Adverse childhood experiences before entry to care, harmful experiences in care and repeated exposure to grief and loss are likely to have contributed to the high prevalence of emotional and behavioural difficulties, displayed by 49% of the adoptees. According to our classification, 57% were at high risk of experiencing adverse outcomes in adulthood.

The Role of Social and Emotional Adjustment in Mediating the Relationship Between Early Experiences and Different Language Outcomes

Background: Studies have highlighted the relationship between early childhood experiences and later language and communication skills on the one hand and social and emotional adjustment on the other. Less is known about this relationship between different types of early experiences and their relationship to different communication skills over time. Equally important is the extent to which the child's behaviour is related to later outcomes affecting the relationship between the child's environment and aspects of their communication development.Method: Drawing on data from 5,000 children in Growing Up in Scotland, a representative sample of children born in 2003. This paper looks are the differential relationships between home learning environment (HLE) (reads books/storeys, engages in painting or drawing, reads nursery rhymes and teaches letter/shapes and parental mental health (PMH) (Depression, Anxiety and Stress Scale (DASS) in the first year of life and both structural language skills (“Listening Comprehension” and “Expressive Vocabulary” subtests of The Wechsler Individual Achievement Tests) and pragmatic competence (The Children's Communication Checklist) at 11 years and explores the extent to which they are mediated by social and emotional adjustment at school entry.Results: PMH was associated with pragmatics but not listening comprehension or vocabulary. By contrast HLE was associated with all three measures of communication. In the final mediated model social and emotional adjustment mediated the relationship between PMH and all three measures of communication. The mediation was statistically significant for the relationship between HLE and both pragmatics and listening comprehension but not for expressive vocabulary. The results are discussed in terms of the relationships concerned and what they tell us about the potential for targeted early interventions.Conclusions: The mediating role of socio-emotional adjustment at school entry points to the need for careful monitoring of children's social and emotional development in primary and middle childhood. Services and policy aimed at improving child outcomes through improving home learning environments must work hand in hand with those responsible for offering support for the mental health, social-emotional adjustment and wellbeing of parents and children from birth and into the school years.

Early Experiences in Switching between Monoclonal Antibodies in Patients with Nonresponsive Migraine in Spain: A Case Series

Monoclonal antibodies targeting the calcitonin gene-related peptide have been introduced into the therapeutic arsenal of migraine prophylaxis. Clinical trials report similar efficacy between them, and there is no evidence of switching to another one after failure. We aim to describe our experience in switching from erenumab to galcanezumab after therapeutic failure. We retrospectively reviewed 30 migraine patients who received monoclonal antibodies, with 15 of them switched after failure to achieve reduction in migraine days per month ≥30%. A ≥30% reduction in migraine days per month compared to baseline was observed in 8/15 (4/15 ≥ 50%) patients after switch. Some nonresponsive patients may benefit from switching between monoclonal antibodies with different therapeutic targets.