The identification of coronavirus disease 2019 (COVID-19) patients with oxygen saturations between 90-94% who can be safely discharged from the emergency department (ED) is challenging due to the difficulty of community monitoring. A pathway consisting of home pulse oximetry with telephone follow-up was devised and implemented at a London District General Hospital to facilitate the safe discharge of these patients from the ED. Twenty patients with confirmed or suspected COVID-19 with oxygen saturations between 90%-94% were discharged on this novel ambulatory care pathway. Eighty-five percent of patients successfully avoided hospitalisation, whilst 15% were re-assessed and subsequently admitted to hospital. Home pulse oximetry monitoring was utilised to aid discharge from the ED and therefore prevent hospital admission. Telephone follow-up identified patients requiring further assessment. This study demonstrates the potential for safe ambulation of a subgroup of patients with COVID-19.

Vomiting-induced pneumomediastinum can be a result of barotrauma causing alveolar rupture or Boerhaave’s syndrome. Although a rare cause of secondary pneumomediastinum, Boerhaave’s syndrome allows extravasation of air and fluid due to oesophageal perforation. We report a case of a 20-year-old female who presented with prolonged vomiting during a panic attack. Extensive surgical emphysema and pneumomediastinum were visualised radiologically. A source of oesophageal rupture was not visualised on cross-sectional computed tomography imaging following contrast ingestion. A complication of mediastinitis provided the evidence that this was a case of Boerhaave’s syndrome whereby microscopic perforation of the oesophagus led to secondary pneumomediastinum, rather than vomiting-induced spontaneous pneumomediastinum caused by barotrauma. Recurrent Boerhaave’s syndrome in this case is owed to the patient having previously experienced identical symptoms which spontaneously resolved.

comorbidities. Hypertension was more common in the cohort of patients who required reassessment, which supports previous studies showing that cardiovascular comorbidities are associated with increased mortality in COVID-19. 2 Pulmonary infiltrates on chest X-ray were more common in the cohort of patients who required reassessment, mirroring the importance of radiological findings in the outcomes of COVID-19 patients. 3 ConclusionsHome pulse oximetry with telephone follow-up was used to prevent hospital admission in a considerable proportion of patients who would have otherwise been admitted in the absence of this pathway. Telephone follow-up effectively identified patients who required further clinical assessment.This study demonstrates the potential for safe ambulation of a subgroup of patients with COVID-19, while identifying practical inclusion criteria that could be replicated in ambulatory units across the UK. Future research should focus on the inclusion of various prognostic markers, due to their potential power in determining disease trajectory. n Conflicts of interestNone declared.

Summary: An aberrant right subclavian artery (ARSA) is a rare anatomical variation of the aortic arch. Although an incidental finding and asymptomatic in the majority of individuals, an ARSA can cause troubling symptoms during both childhood and in later life. In adulthood, the most common symptom is dysphagia, where the condition is named dysphagia lusoria. In other rare cases it can cause shortness of breath, chronic cough and hoarseness of voice amongst others. We present a case of a 65-year-old female patient who was diagnosed with dysphagia lusoria following a barium swallow examination to investigate a 10-year history of dysphagia. She was further investigated with other imaging modalities to establish her diagnosis. The dysphagia was not progressive, nor did it result in malnutrition, and hence the patient was managed conservatively. There is currently no established guideline to classify the severity of symptoms or radiological findings of this anatomical anomaly. Our case reiterates the importance of such protocols, in order to be able to avoid the risks of an unnecessary surgical procedure, whilst being sure to prevent the undertreatment of affected individuals.