Pneumomediastinum in COVID-19: a phenotype of severe COVID-19 pneumonitis? The results of the United Kingdom (POETIC) survey.

BACKGROUND: There is an emerging understanding that coronavirus disease 2019 (COVID-19) is associated with increased incidence of pneumomediastinum. We aimed to determine its incidence among patients hospitalised with COVID-19 in the United Kingdom and describe factors associated with outcome. METHODS: A structured survey of pneumomediastinum and its incidence was conducted from September 2020 to February 2021. United Kingdom-wide participation was solicited via respiratory research networks. Identified patients had SARS-CoV-2 infection and radiologically proven pneumomediastinum. The primary outcomes were to determine incidence of pneumomediastinum in COVID-19 and to investigate risk factors associated with patient mortality. RESULTS: 377 cases of pneumomediastinum in COVID-19 were identified from 58 484 inpatients with COVID-19 at 53 hospitals during the study period, giving an incidence of 0.64%. Overall 120-day mortality in COVID-19 pneumomediastinum was 195/377 (51.7%). Pneumomediastinum in COVID-19 was associated with high rates of mechanical ventilation. 172/377 patients (45.6%) were mechanically ventilated at the point of diagnosis. Mechanical ventilation was the most important predictor of mortality in COVID-19 pneumomediastinum at the time of diagnosis and thereafter (p<0.001) along with increasing age (p<0.01) and diabetes mellitus (p=0.08). Switching patients from continuous positive airways pressure support to oxygen or high flow nasal oxygen after the diagnosis of pneumomediastinum was not associated with difference in mortality. CONCLUSIONS: Pneumomediastinum appears to be a marker of severe COVID-19 pneumonitis. The majority of patients in whom pneumomediastinum was identified had not been mechanically ventilated at the point of diagnosis.

Stroke risk stratification scores in atrial fibrillation: current recommendations for clinical practice and future perspectives.

Atrial fibrillation (AF) increases the risk of stroke. This additional risk varies depending on the presence of various clinical risk factors. The contribution of some risk factors, for example vascular disease and female gender, has been disputed. Stroke risk stratification scores (RSS) incorporate these risk factors to identify patients at different levels of stroke risk. These RSS enable the targeting of oral anticoagulants (OAC) at high-risk patients, who stand to gain the most in terms of stroke risk reduction, and avoidance of their use in low-risk patients, in whom the harms of OAC (increased risk of bleeding) may outweigh their stroke prevention capabilities. Guidelines on the management of AF have used and adapted various RSS for this purpose, and have tailored their therapeutic recommendations around the different risk categories. Current guidelines advocate the use of the CHA2DS2-VASc RSS to assess stroke risk in AF patients, to identify truly low-risk patients (men and women aged <65 years with no risk factors) who may not require antithrombotic therapy, with consideration of OAC for all other patients. The recent development of novel OACs is changing the risk threshold at which it is acceptable to treat AF patients. However, consideration of OAC therapy for stroke prevention also requires assessment of the associated bleeding risk and incorporation of patients' preferences when making treatment decisions.

Prognosis and outcome predictors in psychogenic nonepileptic seizures.

It is estimated that one in five patients referred to specialist epilepsy clinics for refractory seizures have psychogenic nonepileptic seizures (PNES). Despite the high prevalence, little is known about the prognosis of patients with PNES. In this paper we set out to systematically assess published original studies on the prognosis and outcome predictors of patients with PNES. Our literature search across the databases Medline, PsycINFO, and EMBASE generated 18 original studies meeting the search criteria. Prognosis was found to be poor in adults, but good in children. Predictors of poor outcome included the presence of coexisting epilepsy or psychiatric comorbidities, violent seizure phenomenology, dependent lifestyle, and poor relationships. Overall, too much reliance is placed on seizure remission as an outcome measurement for patients with PNES, and the impact of many of the outcome predictors requires evaluation using larger studies with longer followup.