Educational opportunities for postgraduate medical trainees during the COVID-19 pandemic: deriving value from old, new and emerging ways of learning.

The COVID-19 pandemic has had a significant impact on postgraduate medical training across all specialties. Although some traditional learning opportunities have been curtailed, there have been numerous examples of highly valuable educational experiences that have arisen during this time. Here, from a trainee perspective, we consider the educational merits of the re-emergence of 'firm-based' teams, new online learning opportunities, use of digital technologies and the rise of telephone clinics and new COVID-19 clinical services. As health services continue to recover from surges in COVID-19 cases, it is important to reflect on and recognise the value of these educational experiences so that helpful elements can be retained and embedded into training programmes for the benefit of both trainees and patients.

Homeless healthcare: raising the standards.

Over the past 3 years the number of homeless people in the UK has increased by 34%. Most will die young, largely due to treatable conditions. Secondary care can, and must, do more for the silent killer that homelessness is.

The destructive combination of Scediosporium apiosperum lung disease and exuberant inflammation in cystic fibrosis.

This paper describes a patient whose decline over two years was precipitous, from an active independent life with lung function (FEV1) above 50% to requiring transplantation. The main pathogen on sputum culture throughout that period was Scediosporium apiosperum. The epidemiology pathogenicity and treatment of this fungal pathogen are discussed.

Chest CT features and functional correlates of COVID-19 at 3 months and 12 months follow-up.

Long-term pulmonary sequelae of Coronavirus 2019 (COVID-19) remain unclear. Thus, we aimed to establish post-COVID-19 temporal changes in chest computed tomography (CT) features of pulmonary fibrosis and to investigate associations with respiratory symptoms and physiological parameters at 3 and 12 months' follow-up. Adult patients who attended our initial COVID-19 follow-up service and developed chest CT features of interstitial lung disease, in addition to cases identified using British Society of Thoracic Imaging codes, were evaluated retrospectively. Clinical data were gathered on respiratory symptoms and physiological parameters at baseline, 3 months, and 12 months. Corresponding chest CT scans were reviewed by two thoracic radiologists. Associations between CT features and functional correlates were estimated using random effects logistic or linear regression adjusted for age, sex and body mass index. In total, 58 patients were assessed. No changes in reticular pattern, honeycombing, traction bronchiectasis/bronchiolectasis index or pulmonary distortion were observed. Subpleural curvilinear lines were associated with lower odds of breathlessness over time. Parenchymal bands were not associated with breathlessness or impaired lung function overall. Based on our results, we conclude that post-COVID-19 chest CT features of irreversible pulmonary fibrosis remain static over time; other features either resolve or remain unchanged. Subpleural curvilinear lines do not correlate with breathlessness. Parenchymal bands are not functionally significant. An awareness of the different potential functional implications of post-COVID-19 chest CT changes is important in the assessment of patients who present with multi-systemic sequelae of COVID-19 infection.

Intestinal perforation due to miliary tuberculosis in a patient with myasthenia gravis.

A man in his early 70s presented to the emergency department with a fall, following a history of fatigue and malodorous urine. On presentation, he was feverish, tachycardic and confused and was treated for presumed urinary sepsis. A chest radiograph showed increased opacification in the left upper lobe with calcification. CT imaging and bronchoalveolar lavage demonstrated miliary tuberculosis infection. His background included myasthenia gravis, which led to challenges in selecting appropriate antituberculosis treatment. During his stay, he developed sudden-onset abdominal pain due to intestinal perforation. He subsequently deteriorated and underwent multiple interventions, including a Hartmann's procedure and ileocaecal resection. Histological examination of his sigmoid colon revealed abundant acid-fast bacilli. Unfortunately, the patient died due to multiorgan failure in the context of several complications. This case highlights intestinal perforation as a rare complication of miliary tuberculosis and emphasises the importance of being vigilant for this potential complication.

Recovering from COVID-19: lessons learnt from an intensive secondary care follow-up service.

In response to the first COVID-19 surge in 2020, secondary care outpatient services were rapidly reconfigured to provide specialist review for disease sequelae. At our institution, comprising hospitals across three sites in London, we initially implemented a COVID-19 follow-up pathway that was in line with expert opinion at the time but more intensive than initial clinical guidelines suggested. We retrospectively evaluated the resource requirements for this service, which supported 526 patients from April 2020 to October 2020. At the 6-week review, 193/403 (47.9%) patients reported persistent breathlessness, 46/336 (13.7%) desaturated on exercise testing, 167/403 (41.4%) were discharged from COVID-19-related secondary care services and 190/403 (47.1%) needed 12-week follow-up. At the 12-week review, 113/309 (36.6%) patients reported persistent breathlessness, 30/266 (11.3%) desaturated on exercise testing and 150/309 (48.5%) were discharged from COVID-19-related secondary care services. Referrals were generated to multiple medical specialties, particularly respiratory subspecialties. Our analysis allowed us to justify rationalising and streamlining provisions for subsequent COVID-19 waves while reassured that opportunities for early intervention were not being missed.

When to consider tuberculosis: bronchiectasis in the elderly population.

In England patients aged 65 years and over experience a delay of more than 4 months between onset of symptoms and diagnosis of pulmonary TB. This report examines three cases of patients experiencing significant delays in both diagnosis and treatment. Each case had a background of bronchiectasis. Symptoms were initially believed to be secondary to their pre-existing lung disease. Immunosenescence, atypical presentation and pre-existing lung disease mean there is often a significant delay in diagnosis in this population at both a primary care and specialist level.

Secondary syphilis presenting with acute unilateral vision loss and a widespread maculopapular rash.

Syphilis infection has shown a marked resurgence over the past several years. Ocular involvement is a rare complication of syphilis, occurring in approximately 1% of cases. We present the case of a man in his 50s who presented to hospital with acute unilateral vision loss and a widespread maculopapular rash. Ophthalmological examination showed unilateral optic disc swelling and bilateral vitritis. Intracranial imaging revealed no acute pathology. Initial blood tests were normal apart from mildly elevated inflammatory markers. A comprehensive autoimmune and infection screen revealed positive syphilis serology. The patient was subsequently treated for syphilis with ocular involvement with a course of intravenous benzylpenicillin, resulting in rapid symptomatic improvement. This case highlighted the importance of considering syphilis infection as part of the differential diagnosis for unexplained multisystemic symptoms, such as loss of vision in combination with dermatological involvement.

The future hospital: a rewarding place to train and work? A perspective from the shop floor.

The provision of medical care for the next 40 years lies in the hands of the trainees of today. In order to deliver the care our patients deserve in the way in which they wish to receive it, this future workforce needs to be trained appropriately and to be supported and encouraged to develop into the doctors needed to fulfil this mission. This personal view authored by a trainee of today discusses some of the likely demands placed upon the physician of tomorrow, placed in the context of the Shape of Training report commissioned by the GMC, and the report of the Future Hospital Commission of the Royal College of Physicians, to which the author contributed. To achieve the visions set out in those reviews and maximal satisfaction for the patients served the enthusiasm, experience and innovation of trainees will be of fundamental importance.