Title: A nanobody recognizes a unique conserved epitope and potently neutralizes against the SARS-CoV-2 omicron variants.

The SARS-CoV2 Omicron variant sub-lineages spread rapidly worldwide, mostly due to their immune-evasive properties. This has put a significant part of the population at risk for severe disease and underscores the need for effective anti-SARS-CoV-2 agents against emergent strains in vulnerable patients. Camelid nanobodies are attractive therapeutic candidates due to their high stability, ease of large-scale production and potential for delivery via inhalation. Here, we characterize the RBD-specific nanobody W25 and show superior neutralization activity towards Omicron sub-lineages in comparison to all other SARS-CoV2 variants. Structure analysis of W25 in complex with the SARS-CoV2 spike glycoprotein shows that W25 engages an RBD epitope not covered by any of the antibodies previously approved for emergency use. In vivo evaluation of W25 prophylactic and therapeutic treatments across multiple SARS-CoV-2 variant infection models, together with W25 biodistribution analysis in mice, demonstrates favorable pre-clinical properties. Together, these data endorse W25 for further clinical development.

Chronic skin ulcers in hemodialysis patient: A fatal case of calciphylaxis.

Calciphylaxis is a rare and deadly vascular disease with poorly understood pathophysiology and without definitive treatment. Early presentations include skin ulcers with risk factors including end stage renal disease on hemodialysis, hypertension, hyperlipidemia, and diabetes mellitus. In our case, we present an 80-year-old female with multiple risk factors including hemodialysis and clinical features of necrotic and gangrenous skin lesions diagnostic of calciphylaxis who became hemodynamically unstable and ultimately expired secondary to toxic sequelae. We illustrate this case to explore early clinical presentation, limitations of current disease management and treatments, and the role for further studies to improve diagnosis and reduce mortality.

Delayed doxorubicin induced cardiomyopathy in a breast cancer patient: A case report.

Heart failure (HF) is a clinical syndrome with a wide spectrum of presentations and an even wider array of etiologies. Anthracyclines such as Doxorubicin, Daunorubicin, Idarubicin, and Epirubicin have demonstrated increased risk of HF with significant morbidity and mortality. We present an interesting case report of a patient with a history of breast cancer treated with Doxorubicin who presented with symptoms of HF who had a comprehensive evaluation that excluded the most common etiologies, narrowing our diagnosis to late onset doxorubicin induced HF with on-going recovery after initiation of guideline-directed medical therapy.

Symptomatology, prognosis and clinical findings of myocarditis as an adverse event of COVID-19 mRNA vaccine: a systematic review

Funding Acknowledgements Type of funding sources: None. Background Myocarditis, an inflammation of the myocardium in the absence of ischemic injury, may be caused by viruses, drugs, and vaccines. The Myocarditis following COVID-19 vaccinations is most commonly seen in young adult males and commonly after the second dose of the mRNA vaccine. It usually presents with chest pain, dyspnoea, palpitations but has a diverse clinical presentation and varied therapeutic response. We aim to systematically collate the symptomatology, prognosis, and clinical findings of COVID-19 vaccine adverse events causing Myocarditis. Method Following the PRISMA statement 2020, a systematic search was conducted to isolate confirmed cases of COVID-19 vaccine-induced Myocarditis. By applying the BOOLEAN logic, the following keywords were used: COVID-19, SARS-CoV-2, Myocarditis, Mortality. Four databases were searched from January 2021 through August 2021: PubMed, Science Direct, Google Scholar, and Cochrane Library;the reference lists of screened studies were searched as well (umbrella methodology). Results In total, 12 case reports, 10 case series and 1 cohort study with a total of 107 patients were included in the final analysis. A total of 101 male patients were recorded, and 6 were female showing male dominance. The mean age of all participants was 24.73 years(SD = 13.18), ranging from 14 to 70. The most common presenting symptoms were chest pain (47.66%), fever (35.51%), and myalgia (25.23%). Lab findings showed elevated Troponin I, CRP, and ESR levels in the majority of patients. ECG was abnormal in most of the patients, which include sinus rhythm (24%), ST-elevation (42.05%) and T wave inversion (13.08%). Echo findings include decreased Ejection fraction in 19.62% of patients while 13.08% of patients having a hypokinetic left ventricular wall. Further, CMR finding suggestive of confirmed myocarditis cases in 36% patients while rest are suspected one. Overall mortality(1.86%) was low among patients. Conclusion There is increasing evidence for Myocarditis as a rare adverse event of COVID-19 mRNA vaccination in young adults. This evidence is strongest amongst young male patients. The majority of the patients complain of chest pain and fever. In lab findings Troponin I, CRP and ESR are usually increased and ST elevation is common in the ECG. This entity is mainly treated with nonsteroidal anti-inflammatory drugs, Colchicine, Beta-blockers, ACE inhibitors, Steroids. However, prognosis and outcomes are favourable with a very low mortality rate.

Cerebral Venous Sinus Thrombosis Following COVID-19 Vaccination: A Systematic Review.

INTRODUCTION: COVID-19 vaccines became available after being carefully monitored in clinical trials with safety and efficacy on the human body. However, a few recipients developed unusual side effects, including cerebral venous sinus thrombosis (CVST). We aim to systematically review the baseline features, clinical characteristics, treatment, and outcomes in patients developing CVST post-COVID-19 vaccination. METHODS: This study was conducted according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) 2020 guideline. Investigators independently searched PubMed, Embase, and Google Scholar for English language articles published from inception up until September 10, 2021, reporting the incidence of CVST post-COVID-19 vaccines. We analyzed CVST patients' baseline data, type of vaccines, clinical findings, treatment, and outcomes. Our systematic review process yielded patient-level data. RESULT: The final analysis included 25 studies that identified 80 patients who developed CVST after the COVID-19 vaccination. Of the 80 CVST cases, 31 (39.24%) patients died. There was no significant relationship between mortality and age (P = .733), sex (P = .095), vaccine type (P = .798), platelet count (P = .93), and comorbidities such as hypertension (P = .734) and diabetes mellitus (P = .758). However, mortality was associated with the duration of onset of CVST symptoms after vaccination (P = .022). Patients with CVST post-COVID-19 vaccination were more likely to survive if treated with an anticoagulant (P = .039). Patients who developed intracranial hemorrhage (P = .012) or thrombosis in the cortical vein (P = .021) were more likely to die. CONCLUSION: COVID-19 vaccine-associated CVST is associated with high mortality rate. Timely diagnosis and management can be lifesaving for patients.

Transformation of acute cholecystitis to acute choledocholithiasis in COVID-19 patient.

The global pandemic of Coronavirus 2019 (COVID-19) or SARS-CoV-2 has numerous manifestations in different organ systems. It is known that SARS-CoV-2 infects the hepatobiliary system leading to presentations such as acute cholecystitis, choledocholithiasis and hepatitis. Although the exact mechanism of the underlying pathology is unknown, it is likely attributed by the tropism of the virus to the ACE2 receptors in the hepatocytes and bile duct cells resulting in a cytokine storm that precipitates as systemic symptoms from acute COVID-19 infection. In this case report we present a case of a 47-year-old male who presented with signs consistent with acute cholecystitis. It was confirmed on ultrasound and he was incidentally found to be positive for COVID-19 on routine surveillance testing. He was asymptomatic and was being prepped for cholecystectomy, but developed an acute elevation of liver enzymes suggesting choledocholithiasis. After endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy the patient experienced a rapid normalization of liver enzymes and improvement of his abdominal symptoms.

Chilaiditi syndrome: A structural displacement in a heart failure patient.

BACKGROUND: Chilaiditi's sign is often found incidentally on chest or abdominal radiograph and can be accompanied by clinical symptoms such as abdominal pain, gastrointestinal complications, and less commonly associated with dyspnea. CASE PRESENTATION: In this interesting case, we discover lingering dyspnea in our 79 year old male with a past medical history of asthma and heart failure with preserved ejection fraction admitted for acute heart failure exacerbation with reduced ejection fraction along with a new incidental finding of Chilaiditi's sign on chest radiograph. Patient received optimal diuretics and guideline-directed medical treatment for heart failure exacerbation, but mild dyspnea with pleuritic chest pain persisted. Dyspnea with pleurisy was likely attributed to a structural anatomical defect (Chilaiditi's sign) that can be picked up on imaging. CONCLUSION: Chilaiditi syndrome can be an incidental cause of ongoing persistent dyspnea, and if symptoms are severe, intervention can be warranted for symptomatic resolution. LEARNING OBJECTIVE: Chilaiditi syndrome should be considered as a possible diagnosis among patients with a history of heart failure and incidental Chilaiditi's sign on chest radiographic imaging who suffer from persistent dyspnea and pleurisy despite optimal diuretics and guideline-directed medical treatment.

Complete heart block in patients infected with SARS-CoV-2: A case series from a developing country.

Coronavirus Disease 19 (COVID-19) has led to a global pandemic and has been the center of attention across the entire medical community. This novel virus was initially thought to affect primarily the respiratory system, but now it is evident that it has a multitude of effects on the human body. Our point of interest is to establish the effect of COVID-19 infection on the conducting system of the heart. We present a case series of four patients who developed complete heart block (CHB) shortly after being infected with COVID-19 without any previous known risk factors of complete heart block. There have only been a few previous case reports on the occurrence of CHB in COVID-19 patients highlighting the importance and the need of our case series to the literature of cardiovascular outcomes in COVID-19 patients. Our case series highlight that COVID-19 can indeed affect the conduction system of the heart and cause CHB in patients who then recovered spontaneously further elucidating the transient nature of cardiovascular effects caused by the novel virus.

Coronavirus disease 2019 (COVID-19): Multisystem review of pathophysiology.

Coronavirus disease-19 (COVID-19) pandemic is associated with high morbidity and mortality. COVID-19, which is caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS CoV-2), affects multiple organ systems through a myriad of mechanisms. Afflicted patients present with a vast constellation of symptoms, from asymptomatic disease to life-threatening complications. The most common manifestations pertain to mild pulmonary symptoms, which can progress to respiratory distress syndrome and venous thromboembolism. However, in patients with renal failure, life-threatening cardiac abnormalities can ensue. Various mechanisms such as viral entry through Angiotensin receptor (ACE) affecting multiple organs and thus releasing pro-inflammatory markers have been postulated. Nevertheless, the predictors of various presentations in the affected population remain elusive. An ameliorated understanding of the pathology and pathogenesis of the viral infection has led to the development of variable treatment options, with many more that are presently under trial. This review article discusses the pathogenesis of multiple organ involvement secondary to COVID-19 infection in infected patients.

Telemedicine in the Wake of the COVID-19 Pandemic: Increasing Access to Surgical Care.

The COVID-19 pandemic has brought seismic shifts in healthcare delivery. The objective of this study was to examine the impact of telemedicine in the disadvantaged population. METHODS: All consecutive patients with outpatient appointments amongst 5 providers in the Plastic and Reconstructive Surgery Department between March 2, 2020, and April 10, 2020, were retrospectively reviewed. Appointment and patient characteristics collected include visit modality, reason for visit, new or established patient, history of recorded procedure, age, sex, race, insurance provider, urban/rural designation of residence, Social Vulnerability Index, and income. The primary outcome of interest was whether or not a patient missed their appointment (show versus no-show). RESULTS: During the study period, there were a total of 784 patient appointments. Before the COVID-19 pandemic, patients with a higher Social Vulnerability Index were more likely to have a no-show appointment (0.49 versus 0.39, P = 0.007). Multivariate regression modeling showed that every 0.1 increase in Social Vulnerability Index results in 1.32 greater odds of loss to follow-up (P = 0.045). These associations no longer held true after the lockdown. CONCLUSIONS: This study indicates a reduction in disparity and an increase in access following the dramatically increased use of telemedicine in the wake of the COVID-19 pandemic. Although drawbacks to telemedicine exist and remain to be addressed, the vast majority of literature points to an overwhelming benefit-both for patient experience and outcomes-of utilizing telemedicine. Future studies should focus on improving access, reducing technological barriers, and policy reform to improve the spread of telemedicine.