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.

Flexible portfolio training: a novel approach to future physician training.

Flexible portfolio training (FPT) is a novel Royal College of Physicians' training scheme developed in 2019 to tackle issues of burnout, retention and recruitment among medical registrars. Awareness of the FPT scheme may be lacking and this article intends to inform potential future FPT trainees and their supervisors. Open to applicants at the time of appointment to higher specialty training, the FPT scheme protects up to 20% of total training time for trainees to pursue an area of interest in one of four pathways (medical education, quality improvement, clinical informatics and research) without extending time to achieve their certificate of completion of training (CCT). Training numbers remain limited and are only available in certain areas across England and Wales. This article explores the benefits of FPT including medical scholarship, flexibility of time and flexible development of personal learning outcomes and objectives and, crucially, improved wellbeing. The experience of FPT trainees and example projects from those on the medical education pathway in the East Midlands suggest that the scheme can address some of the concerns identified in the future doctor report, potentially sustaining trainees through specialty training, preventing stress and burnout as well as propelling individuals towards lifelong and rewarding careers.