CASE: what's the Dx?
A 25-y.o. female w/ 6 months of intermittent bilateral retro-orbital pain associated with blurred vision and wavy lines OU.
Numbness of her hands and legs.
BMI 35
Visual acuity was 20/20 OU,
Briskly reactive pupils OU and no relative afferent pupillary defect Intraocular pressure was 17 mm Hg OU.
Ishihara color plates were 13/13 OU.
EOMI and Full.
Ophthalmoscopic examination-see image
(blurring and elevation of the nasal margins of the optic disc consistent with grade 1 optic disc edema in both eyes (Figure)).
Exam-->

CASE:

Adult female w/ Controlled T2DM presented with
a 6-mo arthralgias in her hands, feet, elbows, and knees;
3 weeks of a purpuric rash and foot paresthesias;
and 2 weeks of bilateral eye pain and redness.

no response to Prednisone.
No fevers, epistaxis, rhinorrhea, cough Shortness of breath, or hematuria.
No history of recent travel or illicit drug use and was not taking any medications.

On examination, vital signs were normal.
She had bilateral scleral injection and swelling and tenderness over the proximal interphalangeal joints bilaterally.

I just heard about the Damar Hamlin collapse during MNF. I understand a defibrillator was needed and used with CPR on the field.

Blunt chest trauma during early (30mSecond) part of ventricular repolarization (T-wave upstroke) can illicit an "R-on-T" equivelant and cause V-Fib. This is what we call 'Commotio Cordis' which refers to the sudden arrhythmic death caused by a blunt specifically-timed chest wall impact. Commotio Cordis is seen mostly in athletes in their teens and early 20's

I don't have all the facts, but I just found out and need more info

The rates of arterial and venous thrombotic complications in COVID-19 are low in non-hospitalised individuals with asymptomatic or mild disease.

Thrombotic risk increases with severity of COVID-19 illness, with those on intensive care being at greatest risk.
@ACEPNow @EricTopol Thrombotic disease includes PE, DVT, arterial emboli, CVA, OMI, end-organ infarcts, and generalized microthrombi.

The two common end results of severe & citical #COVID19 disease leading to ICU stays, vents, and death are Cytokine Release Syndrome (CRS, inflammation) & thrombosis

I get asked why do I post that cases and hopsitalizations will be so drastically reduced by late September?

Our immunity with three key elements:

1. Vaccine induced circulating immunity (cnAbs-blood)
2. Mucosal alveolar imm. (lungs)/PI
3. Cellular imm.

https://twitter.com/MdFacep/status/1551639898897035264

Based on our mucosal alveolar immunity from prior infection, and the circulating immunity gained from vaccination, supported by our humoral immunity, and having an estimated 60-70% of the US previously infected, I hope for a reduction of 50-75% in hospitalization before late Sept

Let's discuss boosters. 🧵

How many are there?
What are they?
When do we expect them?
Which one would do the most good in the big picture?

That means the one that reduces infection, transmission, and reduce hospitalization so you may make an informed decision.

1/12 How maqy are there?
Moderna will have 3 options. Pfizer 2-TBA
1. The current 1273 S-protein targeting vaccine(first gen. monvalent vaccine against the ancestral VOC)

2. A 1273-214 bivalent vaccine (ancestral + BA.1)

3. A 1273-222 bivalent 'upgraded' (ancest + BA.4/5 VOC)

2/12

Here I go again:
ER visits for #CovidIsNotOver are declining.

That is usually followed by a decline in hospitalization.

I know it is unpopular to talk of declining numbers, but that is what I am seeing.

We should see a 50-75%+ decline in hospitalization over the next 8 weeks. COVID is not mild.

ER visits are going down and hospitalization may peak between 45K-55K-I posted this before

It was similarly unpopular in January when I said hospitalization will go down in February '22 down by 80%

Others were calling for end of time

https://twitter.com/MdFacep/status/1487637506472361992

SARS-CoV-2 and Lyphocytopenia

CV-19 enters cells with ACE2 receptors

Llymphocytes express the main receptor for SARS-CoV-2, called angiotensin-converting enzyme 2.

SARS-CoV-2 can also use ACE2-independent pathways to enter lymphocytes.

CV-19 enters other ACE2 expressing cells In addition to type 2 alveolar cells, the ACE2 expression has been indicated in various organs such as intestine, heart, liver, bladder, kidney, brain, thyroid and testis.

These are areas of SARS-CoV-2 insult when we get infected

webofscience.com/wos/woscc/full…

BA.5 key observations. We need data!
🧵

Even in the extremely advance aged patient, regardless of vaccination status, presenting with BA.4/5 infection, diffuse bilateral ground-glass opacity airway disease is RARE.

Despite seeing some pts. w/ evidence of heme injury Lymphopenia (LPA) with total lymphocyte count below 20% (normal range is 20%-40%), and absolute LPA below 1.0 (normal is 1.0 - 4.0) is seen to much lesser degree and severity than with Delta.

Even in those patients, diffuse bilateral multifocal pneumonia is NOT often seen!

WHY?

Not long ago, I proposed the possibility of progression of SARS-CoV-2 , through recombination with other Human Corona Viruses (HCoVs) which would expand target organ of infection to include Liver, pancreas, and GI system organ.

Collecting data now-

https://twitter.com/MdFacep/status/1475866514859315204

I have been urging forward thinking and grasping that Omicron's mutation (insertions and through recombination) will most likely evolve and we must consider an OSV-Omicron Specific Vaccine.

See my posts on Multivalent vaccines- a Vaccine combining a SARS-CoV-2 ancestral + OSV

My Omicron Up To Date Review:

Based on my comprehensive literature search and extracted data within PubMed, Scopus, Web of Science, bioRxiv, ScienceDirect, medRxiv, NEJM and JAMA COVID resources, I can make these statements:

Omicron is well studied and has the following- 1. Omicron spreads faster than any other previous variants.

2. It has higher transmissibility which can be ascribed to its advanced ability to evade immunity developed by both vaccinations and previous infections.

3. It is less severe than Other VOCs

If yet another mutation or variant of concern surges that more completely evades the antibodies people have built up, “we start all over,” ---Dr. Gregory Poland, head of the Mayo Clinic's Vaccine Research Group 1/4/2022

I stress that mutations happen during rampant surge Omicron has an enhanced and focused affinity for the upper airways, replicating 70X more than delta and not invading the lower airway.
The resultant edema, inflammation, increased secretions are presenting as bronchiolitis, RAD, bronchospasms, and croup depending on the age group

A week of attending duties and monitoring the trends across The US- Here is what I observed:

US has 93-97% Omicron now
Some states went this week from 10% to 66%
All should be at 97% by next week.
Hospitalizations rising.. For and with about 55% & 45% The Booster raises your protection of reinfection & hospitalization close to 90% in > older than 65.

The problem is anything less than 3 dose (boosted) reinfection is very likely & hospitalization is about 5-10% of infected depends on risk status

US has only 36% boosted people

Stop calling Omicron "mild".
It is NOT. In fact it is a major public threat and here is why: Allow me please,

Omicron is more infectious than Delta by a factor of 2.7-3.7.

If you are recovered from previous infection, chance of reinfection w/ Omicron is 5.4 times that of Delta Researchers at UKHSA and NHS estimate the growth and immune escape of the Omicron variant in England.

They used data from for all PCR-confirmed SARS-CoV-2 cases in England who had taken a COVID test between November 29th and December 11th 2021.

They tested for Omicron..

Omicron is genetically far removed from its ancestral variants like Delta and even farther away from Beta.

That is why the BOOSTER will not be effective against Omicron-The current mRNA vaccine version is meant for the Wuhan virus, not Omicron!!!!!!!!!!
osf.io/f7txy/ Substitution & deletion mutations have appeared in previous SARS-CoV-2 lineages, the insertion mutation (ins214EPE) has not been previously observed in any SARS-CoV-2 lineage other than Omicron.
More in common with the common cold
@AlbertBourla @WHCOVIDResponse

#Immunology General concepts:
1. A virus rampantly spreading will tend to mutate, and
2. 'natural selection' principles select the most transmissible strains that'll predominate.
3. Under a vaccinated population environment, the selection is towards a vaccine resistant strains! The predominate strain will then be more transmissible, and develop vaccine resistance properties.
@pfizer and other vaccine scientists need to continue to sequence and test for the evolution of SARS-CoV-2 against transmissibility and vaccine resistance properties
@CDCDirector

1/The absolute key to beating this pandemic is testing to identify any and all positive patients, isolating them until they test negative. This will temporize the pandemic allowing us time to develop therapeutic drugs, study therapeutics in clinical trials, and develop a vaccine 2/Lessons from Singapore and Wuhan,China should serve as lessons for us here. Containment is always the primary objective. Let us not give up on containment.
Mitigation is not appropriate for #coronavirus. That maybe okay for the flu, but not #COVIDー19