Patients with coronavirus disease 2019 characterized by dysregulated levels of membrane and soluble cluster of differentiation 48.

BACKGROUND: Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can progress into a severe form of acute lung injury. The cosignaling receptor cluster of differentiation 48 (CD48) exists in membrane-bound (mCD48) and soluble (sCD48) forms and has been reported to be implicated in antiviral immunity and dysregulated in several inflammatory conditions. Therefore, CD48 dysregulation may be a putative feature in COVID-19-associated inflammation that deserves consideration. OBJECTIVE: To analyze CD48 expression in lung autopsies and peripheral blood leukocytes and sera of patients with COVID-19. The expression of the CD48 ligand 2B4 on the membrane of peripheral blood leukocytes was also assessed. METHODS: Twenty-eight lung tissue samples obtained from COVID-19 autopsies were assessed for CD48 expression using gene expression profiling immunohistochemistry (HTG autoimmune panel). Peripheral whole blood was collected from 111 patients with COVID-19, and the expression of mCD48 and of membrane-bound 2B4 was analyzed by flow cytometry. Serum levels of sCD48 were assessed by enzyme-linked immunosorbent assay. RESULTS: Lung tissue of patients with COVID-19 showed increased CD48 messenger RNA expression and infiltration of CD48+ lymphocytes. In the peripheral blood, mCD48 was considerably increased on all evaluated cell types. In addition, sCD48 levels were significantly higher in patients with COVID-19, independently of disease severity. CONCLUSION: Considering the changes of mCD48 and sCD48, a role for CD48 in COVID-19 can be assumed and needs to be further investigated.

Homeopathic Treatment for COVID-19-Related Symptoms: A Case Series.

BACKGROUND: Severe acute respiratory syndrome due to coronavirus 2 (SARS CoV-2) is a novel infectious disease, which has quickly developed into a pandemic. The spectrum of COVID-19 symptoms is broad, ranging from a mild, self-limiting respiratory tract illness to severe progressive pneumonia, multi-organ failure and possible death. Despite much effort and multiple clinical trials, there are, to date, no specific therapeutic agents to treat or cure the coronavirus infection. CASE REPORTS: The present paper presents 5 cases of patients with moderate to severe COVID-19 infections, 2 of them hospitalized in the intensive care unit, who were successfully treated with homeopathy. RESULTS: All 5 patients responded to homeopathic treatment in an unexpectedly short time span, improving both physically and mentally. CONCLUSION: The present case series emphasizes the rapidity of response among moderate to severely ill patients to homeopathic treatment, when conventional medical options have been unable to relieve or shorten the disease. The observations described should encourage use of homeopathy in treating patients with COVID-19 during the acute phase of the disease.

Influence of language skills on the choice of terms used to describe lung sounds in a language other than English: a cross-sectional survey of staff physicians, residents and medical students.

INTRODUCTION: The value of chest auscultation would be enhanced by the use of a standardised terminology. To that end, the recommended English terminology must be transferred to a language other than English (LOTE) without distortion. OBJECTIVE: To examine the transfer to Hebrew-taken as a model of LOTE-of the recommended terminology in English. DESIGN/SETTING: Cross-sectional study; university-based hospital. PARTICIPANTS: 143 caregivers, including 31 staff physicians, 65 residents and 47 medical students. METHODS: Observers provided uninstructed descriptions in Hebrew and English of audio recordings of five common sounds, namely, normal breath sound (NBS), wheezes, crackles, stridor and pleural friction rub (PFR). OUTCOMES: (a) Rates of correct/incorrect classification; (b) correspondence between Hebrew and recommended English terms; c) language and auscultation skills, assessed by crossing the responses in the two languages with each other and with the classification of the audio recordings validated by computer analysis. RESULTS: Range (%) of correct rating was as follows: NBS=11.3-20, wheezes=79.7-87.2, crackles=58.6-69.8, stridor=67.4-96.3 and PFR=2.7-28.6. Of 60 Hebrew terms, 11 were correct, and 5 matched the recommended English terms. Many Hebrew terms were adaptations or transliterations of inadequate English terms. Of 687 evaluations, good dual-language and single-language skills were found in 586 (85.3%) and 41 (6%), respectively. However, in 325 (47.3%) evaluations, good language skills were associated with poor auscultation skills. CONCLUSION: Poor auscultation skills surpassed poor language skills as a factor hampering the transfer to Hebrew (LOTE) of the recommended English terminology. Improved education in auscultation emerged as the main factor to promote the use of standardised lung sound terminology. Using our data, a strategy was devised to encourage the use of standardised terminology in non-native English-speaking countries.

[DIAPHRAGMATIC PARALYSIS].

INTRODUCTION: One-sided diaphragmatic paralysis is a common phenomenon which is usually a-symptomatic. In case of acute onset or if there is an underlying lung disease, the phenomenon may be symptomatic and even limiting. In this article, we present a patient who arrived with subacute shortness of breath when lying down. She underwent thorough investigations but, as happens in most cases, the cause of the paralysis was not identified and it remains idiopathic. The authors present an overview of the etiology, differential diagnosis and treatment of diaphragmatic paralysis.

Influence of observer preferences and auscultatory skill on the choice of terms to describe lung sounds: a survey of staff physicians, residents and medical students.

BACKGROUND: In contrast with the technical progress of the stethoscope, lung sound terminology has remained confused, weakening the usefulness of auscultation. We examined how observer preferences regarding terminology and auscultatory skill influenced the choice of terms used to describe lung sounds. METHODS: Thirty-one staff physicians (SP), 65 residents (R) and 47 medical students (MS) spontaneously described the audio recordings of 5 lung sounds classified acoustically as: (1) normal breath sound; (2) wheezes; (3) crackles; (4) stridor and (5) pleural friction rub. A rating was considered correct if a correct term or synonym was used to describe it (term use ascribed to preference). The use of any incorrect terms was ascribed to deficient auscultatory skill. RESULTS: Rates of correct sound identification were: (i) normal breath sound: SP=21.4%; R=11.6%; MS=17.1%; (ii) wheezes: SP=82.8%; R=85.2%; MS=86.4%; (iii) crackles: SP=63%; R=68.5%; MS=70.7%; (iv) stridor: SP=92.8%; R=90%; MS=72.1% and (v) pleural friction rub: SP=35.7%; R=6.2%; MS=3.2%. The 3 groups used 66 descriptive terms: 17 were ascribed to preferences regarding terminology, and 49 to deficient auscultatory skill. Three-group agreement on use of a term occurred on 107 occasions: 70 involved correct terms (65.4%) and 37 (34.6%) incorrect ones. Rate of use of recommended terms, rather than accepted synonyms, was 100% for the wheezes and the stridor, 55% for the normal breath sound, 22% for the crackles and 14% for the pleural friction rub. CONCLUSIONS: The observers' ability to describe lung sounds was high for the wheezes and the stridor, fair for the crackles and poor for the normal breath sound and the pleural friction rub. Lack of auscultatory skill largely surpassed observer preference as a factor determining the choice of terminology. Wide dissemination of educational programs on lung auscultation (eg, self-learning via computer-assisted learning tools) is urgently needed to promote use of standardised lung sound terminology.

Mechanical ventilation in medical departments: a necessary evil, or a blessing in bad disguise?

In most countries there is a mismatch between demand for intensive care unit (ICU) beds and ICU bed availability. Because of a policy of low ICU-bed reimbursement this mismatch is much more profound in Israel, which arguably has the lowest number of ICU beds/1000 population of OECD countries. Increasing demand for mechanical ventilation has led to an ever-rising presence of ventilated patients in medical departments, which may reach up to 15% or more of medical beds, especially during winter months, posing serious challenges such as: delivery of adequate treatment, guaranteeing patient safety, nosocomial infections, emergence and spread of resistant organisms, dissatisfaction among family members and medical and nursing staff, as well as enormous direct and indirect expenses.This paper assumes that no change in ICU reimbursement will occur in the near future. We, therefore, describe a number of policy issues that should ideally be addressed together in order to cope realistically with the increase in mechanically ventilated patients in medical departments. First, all medical departments should operate a 5-bed augmented care room with one dedicated nurse per shift. Medical residents should receive a mandatory 3-month ICU rotation in their first year of residency, and attending physicians should receive adequate training in mechanical ventilation and vasopressor support, point-of-care ultrasound and central venous catheterization. Second, family physicians should be required to discuss and fill relevant forms with advance directives for elderly and/or chronically ill patients. Third, rules for terminal extubation should be established, even if only applied infrequently. Finally, co-payment should be considered for families of patients demanding all possible medical treatment in spite of contrary medical advice, considering these patients' terminal status.Implementation of these recommendations will require policy decision making in the Ministry of Health, Scientific Council of the Israeli Medical Association, the professional societies (for internal medicine and family practice) and finally by the leadership of individual hospitals.