Wearing surgical face mask has no significant impact on auscultation assessment.

Objective: During the COVID-19 pandemic, universal mask-wearing became one of the main public health interventions. Because of this, most physical examinations, including lung auscultation, were done while patients were wearing surgical face masks. The aim of this study was to investigate whether mask wearing has an impact on pulmonologist assessment during auscultation of the lungs. Methods: This was a repeated measures crossover design study. Three pulmonologists were instructed to auscultate patients with previously verified prolonged expiration, wheezing, or crackles while patients were wearing or not wearing masks (physician and patients were separated by an opaque barrier). As a measure of pulmonologists' agreement in the assessment of lung sounds, we used Fleiss kappa (K). Results: There was no significant difference in agreement on physician assessment of lung sounds in all three categories (normal lung sound, duration of expiration, and adventitious lung sound) whether the patient was wearing a mask or not, but there were significant differences among pulmonologists when it came to agreement of lung sound assessment. Conclusion: Clinicians and health professionals are safer from respiratory infections when they are wearing masks, and patients should be encouraged to wear masks because our research proved no significant difference in agreement on pulmonologists' assessment of auscultated lung sounds whether or not patients wore masks.

Corrigendum to: Post-treatment neutrophil to lymphocyte ratio as a prognostic tool in patients treated with tocilizumab for severe COVID-19 pneumonia - a single center experience.

[This corrects the article DOI: 10.11613/BM.2023.020704.].

Post-treatment neutrophil to lymphocyte ratio as a prognostic tool in patients treated with tocilizumab for severe COVID-19 pneumonia - a single center experience.

Introduction: Tocilizumab is used in patients with severe COVID-19 pneumonia and high concentration of IL-6. We studied potential prognostic role of neutrophil and lymphocyte count regarding tocilizumab treatment. Materials and methods: We enrolled 31 patients with severe COVID-19 pneumonia and higher serum IL-6 concentration. The samples were taken on the day of tocilizumab administration and five days later. We used ROC analysis to investigate the association between the analysed parameters and 30-day mortality in order to determine the best pre-treatment and post-treatment prognostic factor. Kaplan-Meier curves and log-rank test were used to present and to analyse the difference in survival. Results: Patients had a median age of 63 (55-67) years and were treated with a median tocilizumab dose of 800 mg. During the 30-day follow-up period, 17 patients died (30-day mortality 54%). Among pre-treatment variables, neutrophil count had the best prognostic accuracy (AUC 0.81, 95%CI: 0.65-0.96, P = 0.004), while neutrophil to lymphocyte ratio (NLR) had the highest accuracy among post-treatment variables in predicting 30-day mortality (AUC 0.94, 95%CI: 0.86-1.00, P < 0.001). Among post-treatment parameters, neutrophil count and NLR were equally good prognostic factors. Post-treatment NLR cut-off of 9.8 had the sensitivity of 81% and specificity of 93%. Patients with NLR ≥ 9.8 had the median survival of 7.0 (3-10) days vs. median survival not reached in patients with NLR < 9.8 (P < 0.001). Conclusion: Pre-treatment and post-treatment neutrophil count with post-treatment NLR may represent prognostic tools for patients with higher IL-6 concentration in severe COVID-19 pneumonia treated with tocilizumab.

Acupuncture as a Complementary Method of Traditional Psoriasis Treatment: Myth or Reality?

Dear Editor, the practitioners of traditional Chinese medicine described psoriasis some 2000 years ago (1). Psoriasis vulgaris is a common, chronic inflammatory skin disease whose worldwide prevalence ranges from 0.1-3% (2,3). Understanding the role of the immune system in psoriasis and the interplay between the innate and adaptive immune system has helped to manage this complex disease, which affects patients far beyond the skin changes themselves (2). In addition to the usual and widely accepted methods of treatment of psoriasis, including topical therapies, phototherapy, and conventional and biological systemic therapies, data can be found in the literature that suggest a favorable effect of acupuncture on the course of psoriasis (4,5). Despite that, this complementary method of traditional treatment of various diseases is not yet widely accepted worldwide. According to the World Health Organization (WHO), acupuncture has been an officially recognized method of treatment for more than 50 diseases from 1979 (5). At the Department of Neurology at the University Hospital Center Zagreb, acupuncture has been used since 2011 for the treatment of various types of headaches, trigeminal neuralgia, and spinal pain syndromes. We report the case of a patient with a known history of psoriasis who was treated for chronic migraines with acupuncture. The 49-year-old female patient was examined for headache of a pulsating character that she had had for 16 years. The headache was mainly located on the left side of head and accompanied by nausea, vomiting, and both photophobia and phonophobia, and there was a worsening of symptoms upon exertion. The headaches were occurring once a week with an average duration of 2-3 continuous days. The patient also had frequent mild headaches. Additionally, the patient was diagnosed with psoriasis at the age of 29 and was occasionally treated with phototherapy. Systemic therapy for psoriasis had not been given to the patient thus far. After the clinical evaluation and considering the medical history and clinical findings, the diagnosis of chronic migraine was established and prophylactic therapy with dual antidepressant was introduced. On follow-up examinations, a reduction in the frequency and intensity of migraine headaches was observed. After one year there was a progression of symptoms, and treatments with acupuncture were started. Stainless steel filiform needles of 25 mm in length were inserted perpendicularly into points on the head, arm, and legs and retained for 30 minutes. The treatment was administered once a day for 10 days with an interval of 2-3 days between treatments. The patient showed significant improvement for a period of 6 months after the acupuncture treatment, which is why the treatment with acupuncture was repeated. The patient stated that very soon after the beginning of each acupuncture treatment, she had noticed a significant improvement regarding psoriatic lesions as a "side effect". On the first day of acupuncture, extensive erythematosquamous plaques were noticed on the skin of the dorsum of the feet (Figure 1), palms, and elbows. It is important to emphasize that the patient did not use any specific topical antipsoriatic therapies during the acupuncture treatment, but only bland emollients. During the third week of treatment, a significant improvement was observed, or according to the patient, "she has not had such a good skin for a long time" (Figure 2). The improvement of the clinical status can be explained by overlapping acupuncture points used in the treatment of pain syndromes and psoriasis or to the holistic effect of acupuncture. In recent years, several high-quality evidence-based Western medicine guidelines have been developed for the treatment of psoriasis (6,7). In addition to that modern approach, several studies confirmed the effectiveness of acupuncture in the treatment of psoriasis. The recent review by Coyle et al. (4) indicates promising evidence of the efficacy of acupuncture for psoriasis treatment with an increasing number of people achieving clinical and statistical improvements. Furthermore, Wang et al. (8) have recently published the protocol for a systematic review which aims to assess the effectiveness and safety of acupuncture for patients with psoriasis. In acupuncture, hair-thin needles are inserted into the skin, releasing natural pain killers such as adenosine, endorphins, and serotonin into the body. It is known that patients with psoriatic arthritis can benefit from the treatment. Some patients may be concerned that acupuncture needles could worsen a skin flare-up but an acupuncturist uses sterile needles to prevent any risk to flaring skin. The advantage of acupuncture is that it is a very safe alternative medicine treatment and is not likely to interfere with any existing psoriasis treatment. It is important to note that acupuncture is a 5000-year-old alternative medicine treatment and that it has been officially recognized by the WHO for more than three decades (5). After achieving clinical improvement and regression of psoriatic plaques during the acupuncture for headache, the authors reviewed the literature and found reports about possible benefits of treating psoriasis with acupuncture. Therefore, the purpose of this letter and case study is to raise awareness and inform dermatologists about the different and until now under-explored possibilities of acupuncture in treating psoriasis.