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Omicron, Vaccination & Way Forward!

Dec 08 | 3:30 PM

On 26 November 2021, WHO designated the variant B.1.1.529 a variant of concern, named Omicron, on the advice of WHO’s Technical Advisory Group on SARS-CoV-2 Virus Evolution. What exactly do we know about it? Let's find out more about it's Transmissibility, Severity of disease, Effectiveness of prior SARS-CoV-2 infection, Effectiveness of vaccines & current tests and Required changes in current treatment protocol. This session is aimed at covering all that you need to know about omicron.

[Music] so good evening everyone i am doctor yash kedia and i am a third year md resident in pulmonary medicine at scion hospital mumbai we have been we have been in this covet 19 pandemic for almost two years now and with the rapid research which has been going on we have been able to crack some answers but not all answers about covet 19. we have been able to know what kind of virus it is some few effective methods which we can use to prevent it as few properties of the virus but not exactly everything has been cracked right now so the last two years various variants of the virus have been uh have evolved like the alpha beta gamma delta and now the o micron variant so what is this new variant and a lot of questions remains remains unanswered around this variant like will the current treatment modality will be effective against it will the current vaccination policy be effective against it and the most important question of all when will all this end so to answer some of these questions we have amongst us dr vishwa swaran subramanyam is a lead consultant pulmonologist at yashoda hospital hyderabad sir has been credited with a number of publications more than 25 publications both nationally as well as internationally and he is an expert in sleep medicine and interventional pulmonology sir also holds a fellowship in interventional pulmonology at yeshua hospital hyderabad so to some to answer some of the questions about the omicron variant the current vaccination policy will it be effective and what the future holds for us we have sir here with us to answer some of these questions so without further further delay i would like uh sir to please join on the stage and enlighten us with your knowledge good evening friends uh myself dr vishwa sharon bala subramanian i'm currently working as a lead consultant culinary medicine and sleep medicine attention hospitals molecule in hyderabad so we all know that this new variant which is the b 1.1.529 which is otherwise referred to as the omicron so this was first isolated on 24th november 2021 in a province in south africa but it was on 26th november two days later that the who declared it as a variant of concern so before we go into this variant of consent there is a body which is referred to as the technical advisory group on virus evolution so this body consists of independent group of experts who period or periodically monitor and evaluate the evolution of the sar scovi virus and they assess whether these virus have got specific mutations or a combination of mutations that would alter the behavior so it's only based upon the guy opinion of this tag v group the who takes a notice whether it is a variant of uh concern or it is variant of investigation so as i said to you not all variants are variants of concern we have few which are referred to as a variant of investigation so these are the viruses which have their genetic changes that are predicted to or known to affect the virus characteristic like transmissibility or capability to cause severe diseases or ability to invade escape the immune mechanism or they can have some effect on the existing diagnostic and therapeutic usages and these viruses should be capable of causing significant community transmission or covid19 occurring in clusters when these two criteria are fit this tag v group represents that mutation of virus as a variant of investigation but to be labeled as a variant of concern as we are seeing this omicron various in addition to being labeled as a variant of investigation it should have an increase in transmissibility or a detrimental change in the kovid19 epidermology or it should have an increase in the virulence or changes in the clinical disease presentation or it should decrease in the effectiveness of public health and social measures like available diagnostics vaccines and therapeutics so when we take this omicron virus this fits into all of these criteria of the variant of investigation plus the criterias that are required for variant of console because it has got almost 45 to 52 mutations across the whole genome with almost 26 to 32 mutations occurring in the spike protein through which the virus attaches to the host cell so these some of these mutations also overlap with those mutations of alpha beta gamma and delta but however there are specific mutations which are exclusive for this omicron virus so these mutations can result in impact on one specific pcr test by s gene target failure which i will be dealing it in detail so it can have an effect on your existing diagnostic algorithm it can have an effect on increasing the transmission of infection and it can have an increase in the adherence therefore improved binding affinity and it can also escape the antibody response by the body or that is antibodies that are given passively so that is why this o micron has been considered as a variant of concern by the tag v group so the first case so so you're not audible i guess you got muted for a second uh not early sorry for the technical glitch and since then since the 24th november there have been consistent increase in the number of cases throughout the world and right now we are also having it in india in multiple states so the one important thing why it became all of a craze that omicron is because if you see the graph the way the beta started the way the delta started and where the omicron started it is capable of higher risk of transmission so there is a clusters of population getting affected that is why it became such a serious concern because it may prove all your covet containment measures ineffective if it spreads at this fast and especially for a country like india where the population is so huge such high risk of transmission can result in large number of patients getting affected so it is found to be more than 500 percent more competitively infectious and it is more than two times the number of bad spike mutations which is found in delta and with which we had the worst experience of the kovid 19 pandemic and this is a genome analysis of various alpha beta and delta if you see there are a few of the mutations that are shared by all of these strains but if you see the pink color structure in your left most corner of the screen there are 26 to 30 mutations which are exclusively for this o micron variant that is what makes it very interesting as a variant of concern so now let's move on to understanding what is the existing data that we have so with respect to the transmissibility yes the omicron is likely to have an increased risk of transmission in comparison to the original covid19 pandemic string that is because it has got multiple gene mutations namely the n phi zero y mutation which increases its affinity to bind to the ace2 receptor which causes increased transmission in addition to this there are also n501y mutation and q498r combination mutations which increases affinity further in addition to this there are other mutations like h655y or n679k and p681h and so on all this increases the risk of transmission so one point is very clear that this virus is capable of getting transmitted at a much faster rate and therefore it is capable of causing clusters of covid19 active infections the other important thing is severity so initially there was a scare that is it going to behave like a delta virus but luckily the severity of the virus that has been observed in the world has been found to be lesser in comparison to even delta virus but however it is very too early to say that this virus does not cause serious infections because when it spreads at such a rapid rate then there will be a certain amount of a vulnerable population who may be exposed to this virus and can still have a serious infection so only with time we will know whether these viruses are capable of causing a serious infection or not but as of now we do not have any understanding about the severity of the diseases but existing coming reports are reassuring saying that most of these infections are mild and they present with sore throat fever myalgia and the loss of smell and taste that was characteristically found in other covid19 virus strains are not characteristic of this virus next important question which we all have is it going to affect our already existing vaccine-induced immunity or if i already got a covet-19 infection is the strain going to cause a reinfection so as we all know that this virus has been around us only for almost 15 days by now so it is very too early to say about all these things but one important thing is most of these mutations occur in the spike protein of the virus so when such mutations occur in the spike protein of the virus then there are chances that this virus may evade the immune response which you have attained either through vaccination or through prior infection so that is why there are chances of reinfection and reinfection in vulnerable population can even result in serious infections and laboratory and epidemiological studies are needed to assess the impact of the omicron variant which will eventually have the data with time though we know that this virus is capable of evading the immune response by vaccination or by prior infection the who and all the world health bodies clearly mentioned that the vaccination should be taken because the vaccination will not help you in protecting yourself from getting reinfected but it will protect you from getting severe forms of infection and hospitalization and death which is what we are really concerned about so for all practical purposes even now even in presence of omicron variant you should get your at least two doses of vaccination and one another thing is whether the monoclonal antibodies that are commercially available in market these days are they really effective against this omicron variant initial few data that was taken suggested that this pipe protein mutation can have an effect on the antibody response induced by this monoclonal antibody that means despite getting this monoclonal antibodies few patients may continue to worsen so as of now we have three antibody cocktail regimens that are we are having one is the straw sort of vimer which is currently not available in india bamla view member and atcb mob which is also not available what we have is the region kovi which is nothing but casio review map plus immediately map that is currently available in india and initially when they saw through all the gene mutations whatever black things what you are seeing here are those are those pro or those mutations in the virus which can be targeted by your monoclonal antibody but whatever you are seeing in the grade are those proteins in your virus which cannot be targeted by your antibody which means that most few of these antibody cocktails may become ineffective especially when you administer to a patient with a omicron variant but however having said that the company has issued a statement saying that though the in-vitro analysis and structural modeling suggests that the omicron variant may have a reduced effectiveness with the monoclonal antibody now they are saying that there are data evolving that even your monoclonal antibody might be effective against these omicron variants there is a newer antibody which is coming which is a gsk antibody and they found out that the sort ravi map decreases the risk of hospitalization and fatality in patients with mild to moderate covet infection by 79 percentage in clinical trials and they say that this antibody is also effective against your omicron variant so having known about the monoclonal antibody and the immune mechanism is the omicron variant going to have an effect on your diagnostic modality luckily the most important point to notice our pcr typically detects three genes of your virus one is the n-gene one is the nd one is the rdrp gene and the third one is called as a s gene one characteristic feature of this omegran variant is that when you test these patients with these rtpcr your s gene will not be detected so that is what we refer to as a s gene dropout or the s gene target failure so when it is present it may indicate probably you are dealing with a case of a omicron variant but however it is not conformatory so the presence of s gene dropout detection pattern when it is seen so that is the point that we need to send all these samples for omicron analysis omicron variant genomic analysis in specialized labs so another important point we all have doubt is is there any change in the way management when we are dealing with this case of omicron variant the answer is we still do not know but what has been very clear is in case of severe infections with covid19 you can still give steroids and il6 receptor blockers but however with respect to the other treatment as we have seen earlier the monoclonal antibodies may or may not be effective and the other medic medications still remain the same even though you are dealing with a new strain of covet 19 pandemic virus so one another drug which is recently coming into market in india we will be having it very soon is called as the mall loop river this morning is a drug which causes deletions in the genomic sequence of the virus thereby prevents the replication of this virus so what they found was when this modern power is given at a dose of 800 milligram twice daily for mild to moderate cases of covet with one of the risk factors within five days of onset of symptoms then this was found to decrease the risk of mortality but however the after the european union even the fda has approved but definitely the fda has approved with a word of caution so what is the word of caution is that initially the makers of this molecule that is the model stated that they had a 52 percent reduction in admissions for when malnutrition was given but however when it was projected to the fda the number was brought down to 30 percentage so probably there is some amount of discrepancy in the data presented to the fda in addition to this the another important theoretical concept is we are altering the genetic mutation of this virus so using such drugs which alter the genetic mutation of the genetic makeup of the virus can also result in production of certain amount of new variants which may be resistant to these drugs or even new variants which may have more severity so this drug is being just introduced by the fda as a backup until and unless the another drug which is produced by the pfizer which is called as the pack slow bit is expected by the end of december this pack slow wit drug has been found to be quoted as having 89 effectiveness in reducing the risk of hospitalization but for all practical purposes as of now our existing treatment for covet along with steroids and il6 treatment remains the cornerstone of treatment for all cases of covit and maldiveria is about to be launched in indian market very soon and it may find its place in few cases of early mild to moderate infection with risk factors but however this small nipper ever has to be looked into once it is entered once it has entered into the clinical phase because it can still result in production of some resistant variants of covet 19. another important thing that is being always spoken about is does booster dose really provide an effect in india as of now we do not have an access to the boosted dose of vaccine to the population at large but however there are multiple studies on various factions which has found that once booster doses are given it enhances your immunity and these booster doses are generally given after six to eight months of your second dose of vaccination and there are also few trials which clearly say that when you mix match this vaccine that is for example if you have taken one vaccine of a particular type for your first two doses you can change the vaccine type for the next booster dose and that is found to enhance your immunity in comparison to taking the same vaccine manufacturer however these are still not available in india but however in western countries and in u.s the pfizer by biontech and the johnson and johnson all have approved their booster doses of vaccine especially during this pandemic of omicron variant so few of them just to sum it up like we need to have a very good surveillance and monitoring we need to have research we need to generate evidence we need to assess and we need to make informed decisions and policies so these are the few important points which really makes sense once you look at the omicron they have some amount of resistance to the neutralizing antibodies they are associated with an increased transmissibility and they can evade your innate immunity which can also further enhance the transmissibility they do share few mutations which are associated with alpha gamma lambda and delta but however they also have more than 26 to 32 unique mutations in the spike protein of the virus which makes them a different variant of concern and with respect to the severity research is still going on and though initially there was a lot of hype about the omicron what we have noticed right now is it is capable of higher risk of transmission and reinfection but luckily the severity has been on the lower side and as respect to the monoclonal antibodies yes we still need more evidence but as of date your monoclonal antibodies may fail in treatment with omicron variant except for few of the brands of monoclonal antibody and few of the six variants with spike protein mutations are found to be resistant to monoclonal antibodies including currently what is available in india that is castlevania map and immediate map and this is again what we have seen transmissibility yes it has got a higher transmission severity we still do not know effectiveness of vaccine yes you need to get yourself vaccinated and your existing rt pcr can give you some clue about the omicron variant but however you need a genomic sequencing to confirm that particular variant and you need to have enhanced surveillance you need to share the genomic sequence data and you need to report these initial cases and there should be an effective public health measures to analyze the risk and take appropriate measures and just before i conclude this is something which is very important like the indian government has particularly given some guideline advisories for people who are traveling from a foreign country and as per that all foreign nationals should have a self declaration form and they should undergo an rt pcr and if they are coming from a high risk country then they may be subjected to an rtpcr even at once on arrival and they need at least 7 days of home quarantine before they step out into the general public this can be accessed through our guidelines of health and family welfare and i would like to end my talk here and if there are any questions we can take it so if anyone have any question they can post their questions here okay so i have one question so uh recently i read in an article that dr jacob john the senior viral logistics cmc vendor he had said that we can expect a third wave but at the same time he had also said that we as indians have have a good natural immunity so what is your take on the third wave like uh will india be facing the third wave in fps how severe will it be see them it's all speculation because they predicted the third wave in the month of september then they predicted the third wave in the month of december now we are predicting the third wave in the month of february so it's all just predictions but having said that with new variants coming yes you may see a wave but what the most of the data suggests is it will not be as severe as that delta wave because we have most of the population getting vaccinated with at least one or most of them even have got two doses of copper 19 vaccination so some amount of natural immunity is existing in the community and at least the severe and those who require hospitalization might be low though we may see a lot of mild cases coming with existing variants okay and dr sanketh here has asked can you please say about the opportunistic infections related to omicron so like are there any other risk factors which we should look into see it's a very very new variant like 15 days we know about all this variant so i think only with the epidemiological data coming we will be able to clarify whether it has got any specific affinity for for patients with diabetes or patients with underlying heart problems but having said that almost all virus irrespective of what sort of virus be it flu or be it covet all have had severe manifestations in patients with underlying diabetes or immunocompromised or patients who are having underlying heart disease so that subset of population will always be vulnerable to any sort of viral infection and maybe even for omicron they will be the most severe targets doctor aristotle is asking what is your experience with rendezvous and will you advise it in the further course of management during micron and to be very honest remnants will also don't have a very strong scientific backup data when it comes to treating with kovite 19 even before the previous springs but unfortunately we do not have anything else to offer so when a patient has a saturation less than 94 and patient is progressing to pneumonia then ideally at that point of time it we still give reminders where we still give steroids and anticoagulation so the treatment whatever variant it is it's still going to remain the same because we do not have an alternative proven therapy for 19 except for the monoclonal antibody which we had with uh for mild or a mild illness so one drug that is coming into the market right now is the malnutrition as i said to you before that is somewhat looks like a promising drug but it has its own set of side effects like since it is altering the genomics of the virus you can see a more resistant strain which is resistant to the monopoly as well or even some deadly strains occurring during the treatment that is very early to say it is just a hypothesis so so i think existing treatment doesn't hardly change it still remains the same okay uh so dr mona here is asking so when should uh if a patient comes positive for covert 19 or should all patients do genomic testing or is there any certain particular guidelines or some particular indications to do the general testing see right now um genomic testing will is not something which is readily accessible for all that you get a viral swab immediately you send for genomic that is not possible so what you have to look is when you do this rt pcr your microbiologist will look for whether there is a s gene drop up as i said to you while i was discussing or the loss of this yes target gene if this loss of s target gene is there then probably it gives a hint that you are not dealing with the existing variance that is found in india so such samples has to be triaged and sent to genomic analysis the another thing that can be done for genomic analysis patients coming from high-risk countries for example patient coming from south africa patient coming from uh other countries where this train is there like botswana and other things then probably on arrival you can send these swamp samples and send for genomic analysis but doing genomic analysis for each and every sample is practically impossible and there are very limited labs and it requires a lot of expertise so so another question that is asked by dr k you is uh like in second wave due to use of steroids in an inappropriate way we have got much microsis what shall we learn from the second wave regarding steroid use to be very honest we would have treated more than 5000 patients in our own hospital which is one of the three hospitals of yeshuda so we never had even a single in-house muppet microsoft all our muker micro system came to us that those which are referred from other hospitals so that effectively means like one important thing that is being missed in most of the reference centers are that they lack proper monitoring of blood sugars and abuse of steroids steroids are not indicated for any patient on opd basis that is absolutely not right to put any patient of copay on steroids when they come to your opt steroids are indicated only when they have progression of the disease as evidenced by pneumonia or if they have a fall in saturation less than 94 then only we put these patients on steroids so i think if you monitor your sugar levels properly then i don't think there is there would be a higher incidence of mucour microsis in this way another question which is being asked over here is uh by dr nc she's asking whether uh what about deoxy glu 2d oxy glucose will it work against your micro what is that have you used your dioxide what is your experience with it so we have used 2 dg in few cases and the recommended indications are like patients who are progressing on oxygen but not on ventilator and patients should not have any other end organ involvement like chronic cld or ckd or mi so we really don't know whether it really made a difference or not because when once you treat a patient of covet there are multiple things you are doing with the same patient you are giving steroids you are giving anticoagulation you are giving 2 dg so it it can never be a randomized trial to say that this is the only drug that is making the benefit so it is being tried on experimental basis but we do not have any robust data to support that it really made a difference another question for dr deep is do you believe that co-vaccine being a whole virus vaccine will prove to be better than other vaccines that are mrna or spiked protein vaccine against a microbial yeah that is the advantage any time the advantage of a whole genome vaccine because it it it covers all the genes rather than looking into one particular mechanism of action of the virus but will will it really make a difference that only time can say but theoretically yes a whole genome virus should be much more potent when new variants are coming because most of these variants attack the spiked protein against which all our vaccines are made so your whole genome vaccine should be theoretically better than your spike in vaccines but we don't have scientific data to say yes that is the true okay so dr shikha is asking what about pediatric population in the third wave like it has been predicted that always been saying that pediatric population is not getting the vaccines in foreign yes pediatric even children more than five years of age are eligible for vaccination somehow in india we still do not have the advisories for the pediatric vaccinations but having said that there was a trial by the icmr i think i'm not very sure they have done the zero positivity testing for uh the pediatric population and they found out that even without infection most of these children tend to have protective or at least the antibodies against copper that means they could have had a clinical infection and they could have developed this antibody response uh so definitely most of these patients have some sort of immunity against this covet virus but vaccinating would be the ideal way because this antibody levels tend to rain off with time so and you you may you may need to adequately vaccinate them at least before a third wave starts but that is being considered at a national level even by the advisory committee though we do not have any specific guideline recommendations okay so what is your take on the booster booster usb available in india anytime having a boosted dose is a better option because because it has been clearly found that your immunity with vaccine tends to rain off with time and most of the boosted doses are given at an interval of six to eight months following your second dose of it has started coming and they are even mismatching the boosted doses so maybe in future with the evolving evidence even our government may move booster dosing because we are going to see more and more variants so i think it's nicer to have a boost and like you have mentioned that there are some studies which have said that mix matching of the vaccines can uh can prove beneficial so what is your take on that is it could it be beneficial or could it just worsen uh immunity so initial preliminary data suggests that it is found to have enhanced immunogenicity in comparison to using the vaccine of the same type but all these are like very early preliminary studies but i think given even there are no side effects i think there should not be any harm in mix matching of when it is done understood uh so do you think it is time to develop a multi-variant vaccine like all of these new variants are coming so like we have numerous variant vaccine and so on so uh covered maybe if uh do you think it is a time to develop multivariate vaccine i am not a scientist to answer that but yes it has something like that yes it would be good yeah okay thank you so much and uh what do you think is the r0 value of the micron variant sir are you aware of that data also i really don't have ideas and [Music] doctor asking what systems of the human body are more vulnerable for getting infected with uh uh which will prove it uh fetal complications so apart from the lungs like we have seen that most commonly involve the pulmonary system do you think there are other system which can get involved yeah it does it it is not only the pulmonary system it involves every other system you have got vascular manifestations and almost all the systems in the body we have seen patients developing stroke we have seen patients developing myocardial infarction we have seen patients developing thrombosis in unusual sites like inferior vena cava patient presented to us with gangrene we have seen multiple ways covet can manifest so the pathophysiological mechanisms are very clear one it causes a pro coordinate state second it causes a immune dysregulation so we can have all the side effects related to immune dysregulation and third it can cause a hyper inflammatory state so you can have an immune exhaustion like the system also so you you you can have all the spectrums and it is not limited okay uh so another question is uh so uh like we have seen that during this overtime the speed of research which has been happening is very high that the research is going on very fast so how reliable is the data do you feel there were many drugs which came with so much of promise they went off even without now those are considered to be absolutely useless so it's it's like so we learn with science and we evolve with science so it will keep changing what was considered as a standard of care may not be a standard of care now so so it is like you have to take it because there is no other way you are living in an age of evidence medicine so you need to have evidence to support your decisions so and your evidence keeps changing so your decisions also should should keep changing you can't have one protocol for every time when kobit started i still remember the first case of kovit we treated with anti-hiv medications low benevolent may move from monoclonal to more advanced medicine so it keeps changing so you have to accept it so one of the questions asked by dr virendra is incubation period of covet 19 on the grounds of variance over 19 is how many days like is there a difference in the incubation period between the different variants of the vaccine of the virus there is a difference in presentation i have seen like for example when we had the first train of kovit it was very classical first week you will have fever and one to two days of fever from maya then you are totally all right second week you start developing all the inflammatory phase you start developing pneumonia and other things but when the delta variant came there was nothing like that patient procedure on day one or day two in respiratory failure so the pattern of presentation keeps changing with every variant that is why it is considered to be a variant of concern like it can have different characteristics from the existing variant so this omicron i think should have less incubation time because it has got a very high risk of transmission that means it keeps moving from one patient one person to another person at a faster rate so i'm not very sure about the incubation time but yes i think it should be much shorter than the existing rate okay and [Music] one more question asked by dr moon is can we expect a micron variant to act as a natural booster since the clinical fatality is low so like we have seen that infectious uh it is more infectious but the severity is they're saying let's see where it is one of the there are multiple if you go through web you can see lot of articles that it is also considered as a silver language because delta variant was much severe so with the omicron taking over the delta with the lesser quality yes this may be a better option than the delta variant but all these are like speculations we still do not know anything about omega 20 days you don't know what this virus is going to have for a long term and how it is going to evolve further so but uh if a less virulent strain becomes the majority of strain a than a more virulent strain that is what happened even with h1n1 like when it all came uh h1n1 was the most serious strain but right now adrenaline is still there in the community but it's not possible so your variants change and sometimes it may be for a good reason

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Dr. Murtuza Zozwala & 1837 others

SPEAKERS

dr. Yash Kedia

Dr. Yash Kedia

Learner | Pulmonologist | Youtuber

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dr. Viswesvaran Balasubramanian

Dr. Viswesvaran Balasubramanian

Renowned Interventional Pulmonology and Sleep medicine specialist | Consultant - Yashoda hospitals Hyderabad | Credits more than 25 publications in indexed national and international journals

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dr. Yash Kedia

Dr. Yash Kedia

Learner | Pulmonologist | Youtuber

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dr. Rohan Desai

Dr. Rohan Desai

MBBS | MBA, IIM-A | Founder & CEO, PlexusMD

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dr. Yash Kedia

Dr. Yash Kedia

Learner | Pulmonologist | Youtuber

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dr. Viswesvaran Balasubramanian

Dr. Viswesvaran Balasubramanian

Renowned Interventional Pulmonology and Sleep...

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dr. Yash Kedia

Dr. Yash Kedia

Learner | Pulmonologist | Youtuber

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dr. Rohan Desai

Dr. Rohan Desai

MBBS | MBA, IIM-A | Founder & CEO, PlexusMD

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