The search continues...

 

Sometimes dimensions interlace, like moving between dream and reality, it's time to get a little real. To those of you who actually read this sometimes my 'stories' cross-over, some are random, and some are me pouring my heart into art.

 

My online friend is missing guys, *chokes up a little typing this*.

 

For weeks I've been silently hoping I'd see ONLINE, or a reply to my messages, or... well, any tiny lead that would indicate that they are ok. I hope they are ghosting me... never thought I'd say that out loud. However, I became concerned as others came asking if I had heard from her.

 

Here's the thing friends, we need some kinda buddy system on here. Make your bestfriend an admin to your group, An emergency contact... or something to keep people in the loop, so we don't...

you know, go mad.

 

Stay safe out there. <3

 

♩ ♪ ♫ ♬ ♫ ♪ ♩

  

Photo taken @ Skrunda 3

(New Sim / Dirt datestamp: Oct26/2021)

Builder: Megan Prumier

maps.secondlife.com/secondlife/Reynolds%20Hollow/150/124/23

 

--

 

CREDITS

*Bolson / Tattoo - Hort

-[CL]- Eye Scar #004 (BOM)

DeeTaleZ Addon *SPORTY TUMMY*

DRD - geekmania - keyboard

DRD - geekmania - neckwrap

duckie . faint blood // bom

[ kunst ] - Anuket Septum Ring

[ kunst ] - Chronos Watch V2 / Leather

[ kunst ] - Emma signet rings

[ kunst ] - Knox boot / Leather

[ kunst ] - Razor blade earring

[monso] Jinx Hair @ Collabor88

NEO: Nasal Cannula

RichB. CyberSound Earring

:::SOLE::: GRPE - Headset (Black) (Unrigged)

:::SOLE::: SA - BT Armor MIKI (Black) (M.Lara)

*Star-Crossed* - Nose Bleed

*Tentacio* Let me breathe. Oxygen mask RARE

[theSkinnery] Huntress Markings - Eye Wound

[theSkinnery] Huntress Markings - Tired of Fighting

TF: Machinist

TURB - Neo Tech Pants Chonk @ Warehouse Sale

-[TWC]- Pissed off -Scars-

''If you love life, life will love you back.''

( Arthur Rubinstein)

 

To those of you cooped up in a bedroom or a tent somewhere protecting your loved ones, You're a superhero. 😉

 

(I miss you more than you'll ever know) 💕

 

♩ ♪ ♫ ♬ ♫ ♪ ♩ 3Breezy - Isolation

 

CREDITS

//Ascend// Willie Baseball Cap @ MAN CAVE

AsteroidBox. Zara T-Shirt - Maitreya - Black

*Bolson / Tattoo - Hort

duckie . faint blood // evo x

Izzie's - Body & Face Beach Sand

[ kunst ] - Navigator watch

[ kunst ] - Phoenix Tag necklace

[LINKRAVE] LinkHack Glove (mod to show only left)

NEO: Nasal Cannula

RichB. CyberSound Earring

Semller Worn Canvas Hi Tops Festival Edt.

:::SOLE::: TIME RIFTER Armtech

*Star-Crossed* Nose Bleed ExoX

.:villena:. - Destroyed Mom Jeans

[ west end ] Bento Poses - Vice - Pose Collection

 

[My 'new' arm mod is composed of 3 different arms]

(and I'm not telling! *hints in the tags)

 

SCENE COMPONENTS

Botanical - T2C Campfire

Botanical - T2C Log Seating

Botanical - T2C Mesh Fir Trees

DECO - MESH Survivalist Backpack

DRD- Camping- popup tent single

Heart - Trees - WILDWOOD Giant Oak Tree Forest

JIAN Goat :: Static (Baaah)

[ kunst ] - Cold-cola carrier RARE

10Thousand&co. Nuka Beer Cooler

..::THOR::.. Boho Guitar

..::THOR::.. Chill Out Chair w/blanket

Token&Tribe- Smore' Set

View On Black

and larger

Featuring |

 

Genus Project : Eliot Skin BOM 2K SLUV @ ALPHA

 

Genus Project : Medical Cannula ETHEREAL BREATH @ ALPHA

 

Full credits here.

 

Sponsored:

 

Air Tank x Nose Tube: Breathe Buddy OMY x Puddles., available at Anthem, and afterwards at the OMY Mainstore.

 

Other Deets:

Head: Lelutka - Kris

Body: Legacy - Male

Hospital gown: Somnium - Subject Zero

__________________________________

Follow me on Primefeed!

║ ❝ Feel like a princess. ❞

 

|| SONG THEME

Olivia Rodrigo - good 4 u

 

✕✕✕

 

♡ SPONSOR SPACE ♡

 

HAIR: Moon. Hair // Bunny

EYES: LOTUS. Lullaby Eyes 17

TATTOO: !SIDIKA SAKA! Cyber Sonic Tattoo Bom

 

✕✕✕

 

BACKGROUND: Cian City Muerte Backdrop - The Bearded Guy @ COMING SOON ON ACCESS - 30TH SEPT

 

✕✕✕

♡ BIGGIRL EVENT ♡

 

DRESS: Normandy-Lotus

POSE: 6. OG. Blackrose

 

BIGGIRL TAXI HERE

 

✕✕✕

 

FADES: Dazed. Weird Faded Body

FACE TATTOO: polar<3bunny. rachel face paint.

LIPS: TOP1SALON - HD PEPA P2 LIPSTICK

EYELINER: [BEEZ] KIMMY EYELINER

NOSE: NEO: Nasal Cannula

 

✕✕✕

Credit:

hair: RAMA SALON/tram

tattoes: chaos/DAPPA

tops: lunar/MIWAS

skirt: seul

nasal cannula: Harakiri

nose, neck band: Harakiri

pose: versuta

 

Ugggh, Who has time to be sick?! Not this lady

 

Cannula- Random. Things

 

Sleepy Eddy- Classic Glasses

 

Stealthic- Jealousy (B&W)

 

:LG: Cute Frozen Cheeks

 

Queen of Ink- 2 souls

 

IDK bout chall but I'm totes excited to see the new Dune. If you live under a rock and ain't seen what's all bout, Ima hook choo up right neow. youtu.be/qu1bFHe0Y40

 

CREDITS:

 

HAIR:

.Shi Hair : Chokmah

 

HAIRBASE:

TretaVarietyStore TVS - Angel Hairbase Black

 

EYELASHES:

Malina - Monya eyelashes / Lelutka EVO & EVO X

 

CLOAK:

PFC~Elven Cloak v2

 

OUTFIT:

[NC] - Thunder Suit - Kilt White - Maitreya

[NC] - Thunder Suit - Pants White - Maitreya

[NC] - Thunder Suit RARE - Top White - Maitreya

[NC] - Thunder Suit - Shoes White - Maitreya

[NC] - Thunder Suit - Knee Armor White - Maitreya

[NC] - Thunder Suit - Gloves White - Maitreya

[NC] - Thunder Suit - Gloves White - Maitreya

 

ON FACE:

NEO: Nasal Cannula

 

EYES:

RELENTLESS Blue Eyes [LEL EVO] [LEL EVO X]

*an extra blue glow is added to the eyes

 

/ HEAD / lel EvoX BRIANNON 3.0

 

BACKDROP:

ProjectBlank DUNE - sim surround terrain

marketplace.secondlife.com/p/DUNE-sim-surround-terrain/18...

*Dust particles are brushed in.

 

POSE:

*PosESioN* Choupie 10

Zwei moderne Injektionspens (für die Selbstadministration von Insulin) waren jagen und haben beide eine Beute von hochkonzentrierten Kohlehydraten erlegt.

---

Two modern injection pens (for self-administration of insulin) have been hunting and have both shot a prey of highly concentrated carbohydrates.

   We travelling so far to find who we are…

   

  

Join us at Cyber Fair for our new Fremens Suit from Altered State! The outfit is sold separately or as a fatpack, The White color option is fatpack only. Rigging for Legacy M & F, Jake and Maitreya. There may be a Freya update soon.

 

The mega fatpack includes boots, mask, nose cannula, gloves, mesh eyes, and all suit color options.

 

The fatpack includes all suit colors.

 

Chest strap tubing is animated.

 

Please demo before purchase ty!

 

9/365

 

After many attempts at weaning himself off of his oxygen by pulling the cannula out of his nose, the doctors decided today that he no longer needed it. Ben still had to have his saturation monitored, to make sure he was tolerating the transition to room air, but we were happy to see him shed one more piece of equipment, and get one step closer to coming home.

From Lilithé, available at Warehouse Sale

Apr 23 - May 18

 

Nabia Tattoos

- Brand New 2K textures!

- BoM ONLY

- UNISEX: Fitted for Most Bodies [Mainly, Legacy F/M | eBODY Reborn] .

- 2K Essentials: Simplistic Finger Tattoos .

- 4 Options .

- [ + Aii's Demonic Touch Fingers Fit ]

- Fresh, Faded, Worn and Faint Versions Included .

- Mod/Copy

 

Lilithé Mainstore

 

From AVEC TOI available at the Mainstore

 

KIT SHOES WITH SOCKS - His & Hers

Fitted for:

- FEMALE: Legacy Female / Maitreya LaraX / eBody Reborn

- MALE: Legacy Male / Signature Gianni / Belleza Jake

 

- Shoe, sock, laces and metal accents are customisable by HUD.

- Socks included and can be turned on and off by HUD.

- Female and male sizes sold separately.

- PBR ONLY

 

Available in:

- PATENT MINI PACKS: 6 patent leather colours + 6 socks designs.

- PATENT FATPACK: 24 patent leather colours + 12 exclusive patent leather colours + 24 sock designs + 19 sock patent fatpack exclusives.

- LEATHER MINI PACKS: 7 sleek leather colours + 20 socks designs.

- LEATHER FATPACK: 14 sleek leather colours+ 20 socks designs + 8 sock leather fatpack exclusives.

- PLATINUM PACK: Includes the shoes in patent and sleek leathers. A Pack for those who want it all!

 

AVEC TOI is celebrating 5 years together with a massive 50% off for Group Members at the mainstore - DON'T MISS OUT!

 

AVEC TOI Mainstore

 

Other stuff:-

Volkstone Klaus BELLY Light V1

Volkstone Klaus PUBIC Light V1

TF: Body Hair V2 (M) :: Arm - Black (BoM)

TF: Body Hair V2 (M) :: Leg 0 - Black (BoM)

TF: Body Hair V2 (M) :: Leg 2 - Black (BoM)

TF: Body Hair V2 (M) :: Chest 0 - Tintable (BoM)

TF: Body Hair :: Pit (BoM)

Pretty Liars - Pec Enhancer [LEVEL 2] + Push up [LEVEL 3]

Pretty Liars - Butt Lift + Enhancer [LEVEL 3]

Pretty Liars - Back Augmentation [LEVEL 2]

Pretty Liars - Pelvis Enhancer [LEVEL 2]

Mea Tenebra - The Bouncy

Obsidian. x Quirky - FU Nails Legacy M (Claw - MIX)

2AM - 126-PANTS-MALE[LEGACY]-MINI

GENUS - ELIOT - Scream - Brows - 2K BOM

GENUS MORPH - ETHEREAL BREATH - Cannula - Stretched Male

GENUS MORPH - Head Base Rectangle - v1.1.1 M

GENUS MORPH - Eyes - v1.1 - Default Rigged

GENUS MORPH - NoseMorph Aqualine - v1.1 M

GENUS MORPH - EyeMorph Almond - v1.1.1 M

GENUS MORPH - LipMorph Natural - v1.1 M

GENUS MORPH - Ears Human - Male - v1.1

WINGS - EF0705-HAIR Short

MESHBODY - Legacy (m) Athletic (1.7.1)

VELOUR - PICASSO HOMME Skin for Legacy (FIT/SCREAM) Picasso Neck

LOTUS - Immortal Eyes 01 (BOM)

Injected into the living city, this is an intubation of humanity.

Coils of plastic nasal cannula tubing, lighted with red light from above and blue light from below.

Seven coils of tubing were used. The exterior of the tubing is smooth, but the interior has small ridges and channels to minimize collapse if kinked. These channels create additional lines and texture due to light refraction through the tubing. Shot with Laowa 65mm 2:1 macro lens on Sony a6000, aperture f/11. Image width 40mm. No post-processing other than adjustments in raw conversion and removal of fibers and dust specks. HMM!

I took a cheeky shot of Tim this morning, just after his cannula was inserted for his CT scan! I didn't take a photo, even though the ladies let me watch them apply the mask, but you can see what the masks look like as there are two in the background in this photo! They told us we can have Tim's as a souvenir when his treatment is over!! He now has a permanent tattoo (looks like a blackhead, lol!) on his chest, that they will use to line the mask up with when they do the radiotherapy.

 

This was all done fairly quickly, so we went to the hospital cafe for a late breakfast. It was lucky we hadn't started our journey home, as Tim had a phone call there from a nurse (A MacMillan one, I believe) who he had done a survey for online. She didn't realise he had an appointment today, but managed to grab him and give him some time to talk through any concerns he had. She said he should make sure the people he works for knows about his treatment, etc, and to big it up, reminding him it is Cancer and they should be kind to him and be aware he could be tired for a while after the radiotherapy. They are very kind people that work in Oncology.

The saddest thing that I'd ever seen

Were smokers outside the hospital doors

 

Weird as it may sound, the title is really appropiate for this picture: I took it a few months ago, when I had to spent a few days in hospital due to a kidney infection. The hospital room has this cosy patio with lavenders which came quite handy to me to relief my habit (I know, it's bad). And there I was, with a cannula in one arm and my camera in the other, dressed in a gown, killing time taking pictures.

} Part 7 of 7. This is the last installment of what has been the Flickrverse’s backstory of Clayface. For the complete final arc, start at “Reprise”. I want to express a thank you (that can’t even begin to be big enough) to Duncan Young, Lord Allo, and though they are inactive, Brute Eatin and FeelOkayInc as well, for that first invitation to be canon in the universe they started. And also, to anyone that’s stuck through even one of these stories, or left a kind comment: This really has been a blast, because of you. {

 

The charge is fleeting. Morgan immediately butts heads with Bonecrusher and comes to a standstill. Ivy vaults out the way of several gunshots, with the aid of a stalk erupting through the pavement. Electro uses the plant as cover to retaliate with his own blaster. I head straight for Flannegan, still standing over my son, but Diablo throws up a funnel of fire in my way.

 

Zodiac: To hell with this. I’m a lover, not a fighter.

 

He releases smoke pellets from a cancer symbol on his suit, and just as the King of Cats lunges for him, he vanishes.

 

Electro: Recreant deserter!

 

Sims still stands out of range, surveying the pandemonium. He shakes his head at me.

 

Myself (glowering): You’ll beg for death, Sims. For me.

 

Sims (ignoring me, his words finally having tired): The big man sends his regards. He couldn’t make it, but he wanted you to know he’s thinking of you.

 

At that, I begin to realize several faces in the sea of challengers before me are painted. Pastel cheeks. Bright hair. Clowns. HE was still there, in the background, taunting me. I barrel through three of the henchmen, slicing one across the chest. Sims only smiles.

 

***

 

Garfield Lynns clambers out of the rubble. His hand is still tight around his tool’s trigger, but little more than a spark spurts forth in response. Fuel is leaking from his tanks fast. And three of Sims’ lackeys are approaching: Planet Master, some hulking devil… thing, and that green creep that was sucking up to Sims.

 

Gar (only half-kidding): … Batman?

 

Bulb: He’s taking a swim.

 

Burke: Any less-pathetic last words?

 

Gar: Gosh, uh, how does Sims taste?

 

Burke (lowering his palms): I don’t get it.

 

Bulb: I do. Let’s haul him back there so the boss can take this chump’s ‘headshot of death’. I didn’t develop my greatest handiwork for it to be used ONCE.

 

NKVDemon: I kill him here. Camera doesn’t need them all for himself.

 

Burke: But I wanna try the suit out on-

 

Bulb: NEVER MIND, someone just off him!

 

NKVDemon: до свида́ния, little bug.

 

Gar: Okay, what I really meant was…

 

He discreetly taps his flamethrower’s muzzle to the fuel puddle.

 

Gar: Burn.

 

The trail ignites and flows into Gar’s wrecked pack. It detonates, propelling Gar straight into Burke, too fast for NKVDemon to take aim, and back towards Karlo and the others. The blast also catches Bulb, flinging him, alight and screeching wildly, into the water.

 

***

 

I’ve gained next to no ground on Diablo, continuously swarmed by underlings and nobody-villains. In my peripheral vision, Morgan has thoroughly taken Harbinger’s Bonecrusher body out of the fight, but is being menaced by Swagman, Pyg and Karl. Ivy is still on the defense, and Electro is running headlong into a billowing ash cloud for a kill. I try to tear away and assist even one of them, only to be assaulted with the sensation of railroad spikes easing into my brain, and a nauseating, distinctive tune being hummed. Tetch had gotten within range. I thrash about blindly, but couldn’t land a single blow, even on the odd minion. Then it ceases, and I’m greeted by Gar holding his flamethrower like a mallet; Tetch, with a bruised jaw, dazed at his feet.

 

Gar (already dashing away from a hail of gunfire): Don’t take on Sims yet! His secret weapon… I think it’s in his h-

 

That’s all I can make out before Burke floats down and a gravitational surge tosses car-sized chunks of cement at me from every direction. I briefly make contact with my son’s stare before I’m entombed by the avalanche.

 

***

 

Ivy endures her plants' cries as they choke on the flames that are now spreading everywhere. A few Joker goons are wrenched into the ground by enraged roots. She spies Anarky, on the heels of Gar, and scoops him up easily in a tangle of wicked-looking briar thorns. He howls, until he realizes it’s only heightening the agony. Ivy draws him closer.

 

Ivy (venomously): My son is going learn you and your friends are not the most terrifying force in Gotham. I am.

 

Ulysses (excruciatingly collecting himself in his final breath): There’ll be more h-… after me. Ngh… I AM Gotham.

 

His thumb pulls taut a cord under his jacket; his vest is rigged. Ivy narrowly grows a mass of branches in front of herself as the explosion shakes the entire yard.

 

***

 

The shockwave helps clear the debris suffocating me, but I make it no more than a step outside my crater before Burke has attacked again, icing me over to a Plutonian temperature. I’m helpless as I see NKVDemon approaching Gar’s hideaway; Diablo, readying to torch a pile of lumber Ivy may or may not be alive under. Electro springs out of a recently-formed ditch and zaps Dorian with his firearm. Before my eyes, the mad doctor shrinks to the size of a tangerine, and Electro gleefully crushes the pitiful thing. I would have gladly turned away, if not for my cocoon. What have I wrought?

 

Electro’s celebration is cut off by shrapnel ripping into his shoulder. He trips. I hear a muffled decree of revenge before he hits a button on his belt and warps into nothingness, just as Swagman fires at him again. Morgan bolts at him from behind, with Pyg’s cleaver wedged in his collarbone. Swagman draws his own blade and the pair tussles up and over a trench carved in the concrete, out of sight. Burke hasn’t let up on my prison for one moment. Sims… I see Sims looking hideously pleased. He’s about to call it a wrap.

 

?: A bloodbath, and I reccceived no invitation? I ssshould be insssulted.

 

A second, deeper rasp, piercing the battleground: Bad call, Camera. Word travels fast in our line of work… I didn’t even ask the coin for this one.

 

A Thompson submachine gun being cocked finally betrays the location of the echoing voices. Sims’ forces turn as one to see Two-Face and his gang, Dr. Hellfern, The Mad Monk and even Magan, marching in behind me. Some of my oldest comrades. I hadn’t even asked them.

 

Magan: Hhnngm FNGND.

 

Sims: … What?

 

Hellfern (injecting something into his forearm): Er sagte, … ”you’re fucked.”

 

Diablo acts faster than anyone, lobbing two quick fireballs at the group. Magan unpacks his sandblaster and turns it on the projectiles. The collision fuses the sand to glass, and multitudes of shards fly into Diablo’s eyes, as well as a few larger ones into Burke’s suit. They aren’t dead, but their successive moans tell me that prospect wouldn’t be entirely disagreeable to them. The Mad Monk darts forward, displacing clowns like water, hurling a few straight up. Hellfern is now metamorphosing into a gangling monster, protrusions of unnatural bone all along his back.

 

Hellfern: Now I haff become... Death.

 

Pyg (the first in Hellfern’s path): Oh my… you *snort* are ALREADY perfect…

 

Hellfern backhands Pyg, joining in The Monk’s carnage. Gar and I are freed now, back to back with Dent, as everyone Sims has left rallies. I can’t see Ivy; the rain has increased, and the entire area is a smoldering maze.

 

***

 

Ivy stirs under the wood pile, feeling a cold hand on her arm. It’s… The Mad Monk? When did…

 

Tepes: Ssstay out of sssight; I can sssmell internal bleeding.

 

She ignores him, standing with some travail. An atrocious creature with Doctor Death’s unmistakable facial hair teeters after the vampire, dragging a body like a doll.

 

Tepes: The boy, Hellfern! Ssspare only the one that appearsss as Clayfaccce!

 

Ivy sees they’re making a beeline for Sims and Flannegan; the two, along with her son, are almost backed up to the water’s edge. All their defenses are occupied by Basil. She meets Sims’ eyes from a distance. There’s worry in them. And she savors it.

 

Sims (pushing along his feeble captive and directing Flannegan with a nod): That’d be your department.

 

Tepes is upon him first. With his staff, Flannegan counters three swipes from the hooked, undead fingers, and with a fourth move, drives the blunt end into Tepes’ neck. The Monk gurgles and bellows, as Flannegan snaps his own weapon in half, bashing Tepes in the forehead with the lantern, and finally thrusting the remaining section of the rod into his heart. Ivy hasn’t managed more than a few yards, in her condition.

 

Flannegan: And the next…

 

Hellfern wails like a phantom, slashing at his much shorter foe. Flannegan lures his attacks towards a stack of tires, rolling out of way for Hellfern to stab into the rubber and negate their lethality. The swings are still powerful though, and just one nicking Flannegan’s calf slings him upside down into a brick wall. Hellfern fails to finish the job, however, downed by two potshots in the skull, courtesy of NKVDemon. The Russian himself receives several stray bullets seconds later, from Two-Face’s gun.

 

Ivy sees her opportunity, but falters as she nears Flannegan. He wipes a glove on his leg, and bends down to her. He removes his mask.

 

Flannegan (hovering close enough to feel her breath): Go ahead, plant one on me.

 

Her fist flies up, but not to his face. A sizable, lush tree with green fruits pushes through the ground, but no vines or barbs reach out at Flannegan. She slumps.

 

Flannegan: Cute. Yeah, not really my type anyway.

 

He stretches, looking up at the rain trickling through the leaves and onto his eyes.

 

Flannegan: You know, I would’ve helped you and Basil if you’d come to me first. Just the luck of the draw. You both could’ve stood to be mor- agh… gAAH… HAUUG-

 

The sap of the manchineel tree behind Flannegan has already begun exhibiting its blistering effects, only spurred on by the rain carrying it. Ocular and respiratory damages, Ivy knows, will soon follow. She and Flannegan both crumple.

 

***

 

Magan, Gar and Two-Face are all pinned down, but there doesn’t appear to be any more heavy-hitters to have a chance at slowing me. Sims must still be trapped along the shore. I start to transform into a Joker thug, but I’m blindsided by someone we’ve all overlooked: Hagen. Still taking cheap shots. We trade punches and attempts to draw in the others’ mind, ending in a stalemate just far enough from Sims, and my son, to be seen through the haze.

 

Myself (to Hagen, via our current telepathic link): I’m sure you’d like to think you’re my arch-enemy, Hagen, but I’m killing you quickly. Not even for Cassie will I give you the satisfaction…

 

Hagen (also through the link, barely warding off my onslaught): Cassie… alive. Please… make it seem… I’m dead… or Sims will… my friends…

 

Sims cannot see from his position that Hagen’s hand is stretched out to a manhole, a portion of himself preparing to sever.

 

Hagen (pleading): I failed his plan… Please Basil… I have… other life.

 

Any longer and Sims will know something is wrong. I steel myself, hardly believing it as I allow just enough of Hagen to wriggle out of sight. The faintest “Thank-“ reverberates through what I still have left of him in my clutches. Then I lay it on hard, for Sims’ enjoyment.

 

Myself (with the Hagen decoy): This… is what I promised you… for stealing from me!

 

Sims sees me consume what he thinks is the last of Hagen, and he fidgets slightly as I turn to him. My sons eyes are so, so empty now.

 

Myself: Release him. You can’t do anything else.

 

Sims (hoisting the boy to his feet): Y’know how I know you’re wrong? Because what I’m going to kill you with, I already tried out. On Sloane. Yeah, he DID remember you. I had Hagen replace him because that imbecile, after you burned his face off, FORGAVE you, in his last moments. So I put the sap out of his delusional misery.

 

I’m at a loss. What could I say, “How could you”? After what I had done?

 

Sims: Gotham’s underworld is stagnating, with the likes of you at the helm. I’ll be giving back to the lifestyle you claimed to care about… once you’re a lifeless mound.

 

Can my son hold himself together if he should fall in the water? Don’t let this happen…

 

Myself: I sent you down the wrong path… Harry. I never would have let you take this road if I knew-

 

Sims (through his teeth): That I would be better than you at it! You. STILL. Can’t say it!

 

Myself: Let me be a better father to him than I was to you. I can’t fix anything here, only move past.

 

Sims (ready to shove the boy): Save it!

 

A sudden splash startles us both, and a cord fired from the bay a few meters out snags Sims’ pant leg. He hollers as The Batman, still grappling with the yellow scuba diver, succeeds in toppling him. I react just in time to catch my son, who made no movement to stop from falling in himself. And like that, at long last, my child is there, in my arms. He looks like me, but I can’t feel me at all when I hold him; he’s really himself. His own.

 

Myself: Do you know me?

 

He finally overcomes his trance. His hand tries to point at me.

 

Myself: Do you know… your mother?

 

My son (now extending a hand to the ground): Cold… below…

 

More violent breaches of the water’s surface ring out, and I’m reminded of our need to flee. Gar is a distance away, just now making it through a stilled battlefield.

 

Gar (checking his back): Basil? You got him, let’s go!

 

Myself (to my son, as I begin to lead him away to cover): I understand. I’ll take you back to the sewer. You’ll never have to see any of this again.

 

His grip now equals my own, and I know he comprehends. I would make good on what I said to her all that time ago. He would be my one wise choice. Not a repeat. Not a mistake. She could heal him again. Knowing that, I could rest.

 

***

 

Sims flounders and sputters. Tiger Shark still hasn’t done away with The Bat. And now, Basil is going to get away… The thought flows through his veins, and gives him new strength. He kicks and claws his way out of the mess of cable and cape, overflowing with loathing. He rockets straight onto land on his stomach, letting loose a bloodcurdling shriek, flicking the new mechanism behind his mask. The helmet is waterlogged, but he hears Gar’s concerned cry to Basil; he’s in range. Sims takes the shot.

 

***

 

Gar sees Basil and the kid rounding a barrier from Sims’ attack, as he falls back himself, behind a container, shutting his eyes. There’s still a white puff that penetrates his lids, and for an instant, he thinks he’s done for. But he still feels the gravel under his head. The newly acquired burns. He cracks one eye, then crawls back to the open.

 

There’s Basil… or his son?.. Standing over… dust. Already the pile is being carried away in the runoff.

 

Gar: Jesus… Basil?

 

They don’t say anything, just stand like a statue, save for trembling hands. Sims, folded over the dock, rips off his helmet. He too witnesses the scene, and begins half-choking, half falling over himself in hysterics.

 

Sims (in stitches): It… it doesn’t matter! Ha ha… It’s even more perfect in a way… It…

 

A spray of bullets scares Sims into submerging. Two-Face hikes up into the scene.

 

Two-Face: Which of them..?

 

Gar: I don’t know.

 

Ivy is has found it in herself to rise again. She sees the last of the unknown victim slide away, in addition to the survivor standing over it. He looks at her with such departure and a quality of lostness. It’s her turn as a statue when the Clayface still living descends into a grate. Gar sprints to it, calling out, but they’re gone.

 

***

 

Sims regains his head as Tiger Shark throws him down.

 

Sims: We’re on… ground…

 

Tiger Shark: My sub. Bats is shish kebab-ed, good as dead. Now cough up.

 

Sims (breaking into a laugh again): Good as dead. Aheh. GOOD, as dead. As most things ar-

 

Tiger Shark (punching him): You full of it? I want my payment, asshat.

 

Sims (composing momentarily): You’ll get your fortune. The previous holder… won’t miss it. He hasn’t for a while. H-ha…

 

Tiger Shark (dropping him again): I plan to wear a REAL suit before my career is up, you get me? I’m done with this dress-up crap. You try to get funny, I’ll feed you your hands.

 

Sims pets the photo in his pocket. Damaged, but distinguishable. Basil Karlo’s last moment alive. It will need a frame.

 

***

 

Ivy turns as The Mad Monk, singed and impaled, joins the rest.

 

Tepes (removing the skewer): Amateursss, ssstill consssulting fairytalesss to ssslay me…

 

Two-Face: If that putz didn’t drown, he and I are having words… Where are you headed, Lynns?

 

Gar: … Drink.

 

Ivy cradles Morgan’s massive head. He now carries Swagman’s machete in his chest too. The blood has pooled as high as his heels.

 

Morgan: Did Basil… get…

 

Ivy: Yes.

 

Morgan (every syllable arduous): He told me… your son. Back when he was better… he liked Creighton. For a name. Had he said…

 

The bestial man’s muscles stop being ridged. Ivy’s head bows.

 

Tepes (walking with Hellfern’s broken form): He mussst be returned to hisss lab, with hassste.

 

He pauses only briefly, before soaring away.

 

Tepes: My… condolensssesss.

 

Magan punts a rock.

 

Two-Face: One of them was still there! Go after him, before-

 

Ivy: He won’t come back. Neither of them. Whichever one it was.

 

***

 

Cassie sits up. Not the first time she had done so, greeted by broken ribs and a nasal cannula. God she hated those. Alfred is standing by, alerted by the same thing that roused her: The Batmobile returning to base. She goes to hop up before Alfred gives her a sad, stern look.

 

Bruce (bounding out of the car’s cockpit, the engine running): Some of them got away. Kyle. Zodiac. Tetch. I need footage from the entire district.

 

Alfred: The computer is still irreparable. Sir… the harpoon in your arm-

 

Bruce (already having located gauze and forceps): Is the reason I’m not telling you this over comms. Find another way. Gordon’s officers can’t round them all up in time; a new one got away aboard a submarine.

 

Cassie: Basil?

 

Bruce: You’re in that bed because of him. Worry about recovering.

 

Cassie: He had to have known I’d survive the fall. Maybe he was forced to. They had his son…

 

Bruce is already patched up, Alfred trailing and scolding him all the way back down to the Batmobile.

 

Cassie (laying back): I know it wasn’t you Basil. It had to have been something…

 

***

 

News gets around before dawn. Claims to the bodies in the street, most of them false boasts. Money traded from a few macabre bets on the outcome. And Gotham would see no shortage of villains even now. The lowest of the low were emboldened. The mainstay masterminds and gangsters’ trigger fingers were faster than ever. Seeds of rivalry now planted would ensure for the city’s unrest and a hundred more wars to be fought in the night.

 

In a rundown carnival, a pair of red lips arches with glee, while a battered henchman tells the whole story again. The Clown Prince of Crime kicks up his spatterdashes and toys with an old VHS of the original “Dread Castle” in one hand, and a root beer float in the other.

 

“Here’s mud in your eye, Karlo. I’ll thank the academy for you.”

 

***

 

Ext. A farmers’ market - The next day

 

Matt Hagen: Carrots, two-forty a bundle? You keep trying to rob us, and I’ll give you your own supervillain name.

 

The lady grocer across from him: You are perfectly within your rights to take your business elsewhere, pal.

 

They both laugh.

 

Matt (paying): My cat likes them; please, show some mercy.

 

Grocer (still acting): I only make exceptions for friends.

 

Matt glances around while she’s opening the cash register. No cameras. No stalkers.

 

Matt: Ouch… say listen, if it’s not indelicate, I haven’t asked… why are you here? In Gotham, not the market, I mean.

 

Grocer: It’s my hometown, I’ve alway loved it here, especially summer.

 

Matt rolls his eyes.

 

Grocer: Yeah, well, what’d you think? I’m stuck here for now. Who isn’t?

 

Matt: You know, I could leave anytime. I’m kind of over this place. Most of it, anyway. I might even ask a friend to tag along.

 

Grocer (smirking): Sounds adventurous for the person that always gets carrots, two bags.

 

Matt: It’s just… someone I knew, who I thought wouldn’t have given me the time of day, did something really amazing for me recently. I think it’s time I let some people in myself. Shed my layer.

 

***

 

Int. “My Alibi” - 2:47 AM, right after the dust had settled

 

Drury Walker: … Just like that? Where’d Sims, and Batman, and that… other guy go?

 

Gar: Underwater. I don’t know Dru.

 

Drury: I can’t believe… Sewer King too.

 

Two-Face: Maybe it wouldn’t be so unbelievable if you’d BEEN there, Moth.

 

Gar (downing a shot): Piss off Dent, s’nothing he could’ve done.

 

Drury opens his mouth but says nothing.

 

Two-Face: Well it turned out there was nothing ANY of us could’ve done. What this stripy oaf failed to acknowledge, same as Sims, Flannegan, all those others, is that Basil was a founder. Of everything that IS, now, for Gotham’s criminals. And if you respected the ounce of credibility YOU have, you’d have SHOWED.

 

Len (without looking up, with fingers laced on his counter): You can rant out there.

 

Two-Face: Another softy. That goes double for you, Eraser, you greasy…

 

He kicks over a stool and points at Drury as he goes.

 

Two-Face: Don’t let me see your face until you can say you protect the likes of us. That you’ll risk something. I won’t hold my breath.

 

Magan passes Len Basil’s knife, recovered from the scene, before stepping out.

 

Len: And Ivy. She’s long gone by now?

 

Gar: Get me another one of these.

 

Drury: I swear I would’ve gone, but I’ve, eh, met someone. Being there, on Clayface’s side… it’s that new Tiger guy. If he’d seen me, there’s no way he’d let me near… what I mean to say is, I need his approval with…

 

Gar: Hey, am I blaming you? And am I asking?

 

Drury: … Do you love anyone?

 

Gar: God I need to be more drunk than this.

 

Len: Lay low for a while. You’ve got a gimmick, you’ve got heart. You’ll make it big one day.

 

Drury: I’d be there, for either of you guys. One day, I swear it. What other family am I ever going to have?

 

} The End {

Today it was either a pic of these photo passes or a close up of the technicolour cannula bruise on my arm.

This was done for Amy Spanos, and the project that she is doing as described a little further down.

 

However I wanted to give you my explanation first for the shot.

 

I wanted to participate in this project because we all are beautiful in lots of different ways and beautiful is really what you want it to be.

 

I spent many many years hiding from my disease and not telling anyone, but as I have grown older I have come to terms with it, infact I have embraced it! I was diagnosed with an incurable bowel disease when I was 14. It took nearly 2 years to diagnose and lots of ridiculous and incorrect diagnosis along the way such as anorexia! I have Crohns Disease but I don't let it rule my life. I don't wake up each morning and say to myself 'Good morning, I have Crohns Disease'! I have a motto which is 'I have it - it doesn't have me'

 

I have had many abdominal surgeries for my disease and have scars not only on my stomach as you see here but scars on my neck from central lines from the many times in intensive care and many scars all over my hands and arms from cannulas particulary where they haven't been able to gain access to the vein because I have very small veins that are well hidden!

 

I've spent lots of my life in pain and in toilets! and I also have a lot of health problems as a result of my disease and the medications and operations that I have had to have. But inspite of all of this I have a lot to thank my disease for. If it wasn't for my disease I wouldn't make myself exercise, I wouldn't watch what I eat, I wouldn't make sure that I appreciate that health is such a gift! I haven't had surgery for 4 years now and this in itself is AMAZING! Long may this remission period last!!

 

Do I get stares in changing rooms - yes! Does it bother me - No! These scars that I bear are the a reminder of why I am alive today! I'll never have a flat tummy - no matter how many sit ups I do the muscles won't flatten as they have been cut so much they don't work now - infact I always joke that I have a 'front bum' because of the way the muscles now lie - hehe!!

 

The saddest thing though through all of this and the one thing I can't control is the suffering that I put my loved ones through when I have to have surgery. I wish I could take away the pain that they suffer when they have to see me that way - it breaks my heart.

 

Ok - enough from me about me - please read below from Amy:

 

"Whoever reads this, you're beautiful and someone out there is crazy about you. So smile. Life is too short to be unhappy.

 

Hello my name is Amy Spanos. I was asked to make a video for self-harm awareness day on the 1st of march, and I thought about what to do, and then decided where better to do it then here on flickr with the most creative, beautiful, inspiring minds out there. One in ten people have harmed by the age of sixteen and approximately three teenagers self injure every hour in the UK, mainly because they don’t feel like they’re enough. I want you to all know you are, you are all beautiful as you are, and you have something no one else ever can, and that’s you.

 

But instead of boring you all with more statistics I will tell you about the project. I started a project last year called The Around The World Project, where I found out loads of fun facts about your countries. But in this project I want to find out more about you, the people of flickr. I want your photos to represent you as people, if you’re silly wear a funny wig or glasses, if you’re crazy cover yourself in paint, if you love cats let your pets join you in your photo. I want it to represent your personality completely, be as crazy and imaginative as you like. Like the Around the world project, I would like written in the photo (on paper or on your body or wherever) the words ‘I am Beautiful’ because you all are so damn beautiful! :p Please try and get the photo added to the group by the 1st of March, which is when I will be making the video to bring people out there a little more confidence and hope for self harm awareness day, if you want to take part in the project but won’t be able to get a photo done by then you are still invited to add your photo in the group later on as I will leave it open! I guess all that is left to say now is have fun and i hope to find out more about you all!"

Attended the hospital for a colonoscopy as part of the bowel cancer screening programme (Everything was all clear and I'm OK) The nurse couldn't get the cannula to take on the back of my right hand, and struggled to get it in place on my left hand, but got there eventually...this was before I put less cumbersome plasters on.

Jonathan

Many children in the Philippines do not have the luxuries we enjoy here in Australia. For instance, they don't have a computer so cannot play games; they don't have the hand-held games that so many have here.

 

What they do have though is a sense of having fun doing whatever happens to be at the time and this is no exception!!

 

This tricycle would be used for carrying provisions, or work materials or for having fun as these children are proving.

 

This is a road away which runs parallel to the main highway in Ibabao, Cuenca, Batangas, where Rosey and I used to live in the Philippines. These roads are safe for children to play on. The only vehicles that use these would be motor cycles or the occasional vehicle. Maybe a man on his horse is going coconut gathering and he would walk along this road, sometimes breaking into a canter when the going was clear!!

 

These children are having a ball as you can see. What joy it is to see them co-operating in this way. I am not sure if the little boy in the front is telling his "driver" to put on a burst of speed. The others are happy there is a camera handy to record this vision. Also they are happy that this guy is white!!!

 

Thanks for your prayers and thoughts while I was in Griffith Base Hospital - the Lady of Smiles visited me most days and stayed either back here in Leeton or with a friend in Griffith - her garden needed to be watered so it fell to her to carry on that detail when she came home.

 

I visited Griffith Base Hospital last week for a week. Because I am on warfarin I need to come off warfarin and onto a drip containing heparin so I have a little "mate" on wheels I walk around with. The procedure lasted for around a 1/2 hour. Then warfarin is re-introduced into my system via tablets while the heparin keeps maintaining a dose via a cannula that is equal to warfarin while the warfarin level returns to normal, then I am dis-connected and can go home. I will wait now for another 6 weeks before my next treatment of radium therapy takes place.

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).[8] The disease was first identified in December 2019 in Wuhan, the capital of China's Hubei province, and has since spread globally, resulting in the ongoing 2019–20 coronavirus pandemic.[9][10] As of 26 April 2020, more than 2.89 million cases have been reported across 185 countries and territories, resulting in more than 203,000 deaths. More than 822,000 people have recovered.[7]

 

Common symptoms include fever, cough, fatigue, shortness of breath and loss of smell.[5][11][12] While the majority of cases result in mild symptoms, some progress to viral pneumonia, multi-organ failure, or cytokine storm.[13][9][14] More concerning symptoms include difficulty breathing, persistent chest pain, confusion, difficulty waking, and bluish skin.[5] The time from exposure to onset of symptoms is typically around five days but may range from two to fourteen days.[5][15]

 

The virus is primarily spread between people during close contact,[a] often via small droplets produced by coughing,[b] sneezing, or talking.[6][16][18] The droplets usually fall to the ground or onto surfaces rather than remaining in the air over long distances.[6][19][20] People may also become infected by touching a contaminated surface and then touching their face.[6][16] In experimental settings, the virus may survive on surfaces for up to 72 hours.[21][22][23] It is most contagious during the first three days after the onset of symptoms, although spread may be possible before symptoms appear and in later stages of the disease.[24] The standard method of diagnosis is by real-time reverse transcription polymerase chain reaction (rRT-PCR) from a nasopharyngeal swab.[25] Chest CT imaging may also be helpful for diagnosis in individuals where there is a high suspicion of infection based on symptoms and risk factors; however, guidelines do not recommend using it for routine screening.[26][27]

 

Recommended measures to prevent infection include frequent hand washing, maintaining physical distance from others (especially from those with symptoms), covering coughs, and keeping unwashed hands away from the face.[28][29] In addition, the use of a face covering is recommended for those who suspect they have the virus and their caregivers.[30][31] Recommendations for face covering use by the general public vary, with some authorities recommending against their use, some recommending their use, and others requiring their use.[32][31][33] Currently, there is not enough evidence for or against the use of masks (medical or other) in healthy individuals in the wider community.[6] Also masks purchased by the public may impact availability for health care providers.

 

Currently, there is no vaccine or specific antiviral treatment for COVID-19.[6] Management involves the treatment of symptoms, supportive care, isolation, and experimental measures.[34] The World Health Organization (WHO) declared the 2019–20 coronavirus outbreak a Public Health Emergency of International Concern (PHEIC)[35][36] on 30 January 2020 and a pandemic on 11 March 2020.[10] Local transmission of the disease has occurred in most countries across all six WHO regions.[37]

 

File:En.Wikipedia-VideoWiki-Coronavirus disease 2019.webm

Video summary (script)

 

Contents

1Signs and symptoms

2Cause

2.1Transmission

2.2Virology

3Pathophysiology

3.1Immunopathology

4Diagnosis

4.1Pathology

5Prevention

6Management

6.1Medications

6.2Protective equipment

6.3Mechanical ventilation

6.4Acute respiratory distress syndrome

6.5Experimental treatment

6.6Information technology

6.7Psychological support

7Prognosis

7.1Reinfection

8History

9Epidemiology

9.1Infection fatality rate

9.2Sex differences

10Society and culture

10.1Name

10.2Misinformation

10.3Protests

11Other animals

12Research

12.1Vaccine

12.2Medications

12.3Anti-cytokine storm

12.4Passive antibodies

13See also

14Notes

15References

16External links

16.1Health agencies

16.2Directories

16.3Medical journals

Signs and symptoms

Symptom[4]Range

Fever83–99%

Cough59–82%

Loss of Appetite40–84%

Fatigue44–70%

Shortness of breath31–40%

Coughing up sputum28–33%

Loss of smell15[38] to 30%[12][39]

Muscle aches and pains11–35%

Fever is the most common symptom, although some older people and those with other health problems experience fever later in the disease.[4][40] In one study, 44% of people had fever when they presented to the hospital, while 89% went on to develop fever at some point during their hospitalization.[4][41]

 

Other common symptoms include cough, loss of appetite, fatigue, shortness of breath, sputum production, and muscle and joint pains.[4][5][42][43] Symptoms such as nausea, vomiting and diarrhoea have been observed in varying percentages.[44][45][46] Less common symptoms include sneezing, runny nose, or sore throat.[47]

 

More serious symptoms include difficulty breathing, persistent chest pain or pressure, confusion, difficulty waking, and bluish face or lips. Immediate medical attention is advised if these symptoms are present.[5][48]

 

In some, the disease may progress to pneumonia, multi-organ failure, and death.[9][14] In those who develop severe symptoms, time from symptom onset to needing mechanical ventilation is typically eight days.[4] Some cases in China initially presented with only chest tightness and palpitations.[49]

 

Loss of smell was identified as a common symptom of COVID‑19 in March 2020,[12][39] although perhaps not as common as initially reported.[38] A decreased sense of smell and/or disturbances in taste have also been reported.[50] Estimates for loss of smell range from 15%[38] to 30%.[12][39]

 

As is common with infections, there is a delay between the moment a person is first infected and the time he or she develops symptoms. This is called the incubation period. The incubation period for COVID‑19 is typically five to six days but may range from two to 14 days,[51][52] although 97.5% of people who develop symptoms will do so within 11.5 days of infection.[53]

 

A minority of cases do not develop noticeable symptoms at any point in time.[54][55] These asymptomatic carriers tend not to get tested, and their role in transmission is not yet fully known.[56][57] However, preliminary evidence suggests they may contribute to the spread of the disease.[58][59] In March 2020, the Korea Centers for Disease Control and Prevention (KCDC) reported that 20% of confirmed cases remained asymptomatic during their hospital stay.[59][60]

 

A number of neurological symptoms has been reported including seizures, stroke, encephalitis and Guillain-Barre syndrome.[61] Cardiovascular related complications may include heart failure, irregular electrical activity, blood clots, and heart inflammation.[62]

 

Cause

See also: Severe acute respiratory syndrome coronavirus 2

Transmission

Cough/sneeze droplets visualised in dark background using Tyndall scattering

Respiratory droplets produced when a man is sneezing visualised using Tyndall scattering

File:COVID19 in numbers- R0, the case fatality rate and why we need to flatten the curve.webm

A video discussing the basic reproduction number and case fatality rate in the context of the pandemic

Some details about how the disease is spread are still being determined.[16][18] The WHO and the U.S. Centers for Disease Control and Prevention (CDC) say it is primarily spread during close contact and by small droplets produced when people cough, sneeze or talk;[6][16] with close contact being within approximately 1–2 m (3–7 ft).[6][63] Both sputum and saliva can carry large viral loads.[64] Loud talking releases more droplets than normal talking.[65] A study in Singapore found that an uncovered cough can lead to droplets travelling up to 4.5 metres (15 feet).[66] An article published in March 2020 argued that advice on droplet distance might be based on 1930s research which ignored the effects of warm moist exhaled air surrounding the droplets and that an uncovered cough or sneeze can travel up to 8.2 metres (27 feet).[17]

  

Respiratory droplets may also be produced while breathing out, including when talking. Though the virus is not generally airborne,[6][67] the National Academy of Sciences has suggested that bioaerosol transmission may be possible.[68] In one study cited, air collectors positioned in the hallway outside of people's rooms yielded samples positive for viral RNA but finding infectious virus has proven elusive.[68] The droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs.[16] Some medical procedures such as intubation and cardiopulmonary resuscitation (CPR) may cause respiratory secretions to be aerosolised and thus result in an airborne spread.[67] Initial studies suggested a doubling time of the number of infected persons of 6–7 days and a basic reproduction number (R0 ) of 2.2–2.7, but a study published on April 7, 2020, calculated a much higher median R0 value of 5.7 in Wuhan.[69]

 

It may also spread when one touches a contaminated surface, known as fomite transmission, and then touches one's eyes, nose or mouth.[6] While there are concerns it may spread via faeces, this risk is believed to be low.[6][16]

 

The virus is most contagious when people are symptomatic; though spread is may be possible before symptoms emerge and from those who never develop symptoms.[6][70] A portion of individuals with coronavirus lack symptoms.[71] The European Centre for Disease Prevention and Control (ECDC) says while it is not entirely clear how easily the disease spreads, one person generally infects two or three others.[18]

 

The virus survives for hours to days on surfaces.[6][18] Specifically, the virus was found to be detectable for one day on cardboard, for up to three days on plastic (polypropylene) and stainless steel (AISI 304), and for up to four hours on 99% copper.[21][23] This, however, varies depending on the humidity and temperature.[72][73] Surfaces may be decontaminated with many solutions (with one minute of exposure to the product achieving a 4 or more log reduction (99.99% reduction)), including 78–95% ethanol (alcohol used in spirits), 70–100% 2-propanol (isopropyl alcohol), the combination of 45% 2-propanol with 30% 1-propanol, 0.21% sodium hypochlorite (bleach), 0.5% hydrogen peroxide, or 0.23–7.5% povidone-iodine. Soap and detergent are also effective if correctly used; soap products degrade the virus' fatty protective layer, deactivating it, as well as freeing them from the skin and other surfaces.[74] Other solutions, such as benzalkonium chloride and chlorhexidine gluconate (a surgical disinfectant), are less effective.[75]

 

In a Hong Kong study, saliva samples were taken a median of two days after the start of hospitalization. In five of six patients, the first sample showed the highest viral load, and the sixth patient showed the highest viral load on the second day tested.[64]

 

Virology

Main article: Severe acute respiratory syndrome coronavirus 2

 

Illustration of SARSr-CoV virion

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel severe acute respiratory syndrome coronavirus, first isolated from three people with pneumonia connected to the cluster of acute respiratory illness cases in Wuhan.[76] All features of the novel SARS-CoV-2 virus occur in related coronaviruses in nature.[77] Outside the human body, the virus is killed by household soap, which bursts its protective bubble.[26]

 

SARS-CoV-2 is closely related to the original SARS-CoV.[78] It is thought to have a zoonotic origin. Genetic analysis has revealed that the coronavirus genetically clusters with the genus Betacoronavirus, in subgenus Sarbecovirus (lineage B) together with two bat-derived strains. It is 96% identical at the whole genome level to other bat coronavirus samples (BatCov RaTG13).[47] In February 2020, Chinese researchers found that there is only one amino acid difference in the binding domain of the S protein between the coronaviruses from pangolins and those from humans; however, whole-genome comparison to date found that at most 92% of genetic material was shared between pangolin coronavirus and SARS-CoV-2, which is insufficient to prove pangolins to be the intermediate host.[79]

 

Pathophysiology

The lungs are the organs most affected by COVID‑19 because the virus accesses host cells via the enzyme angiotensin-converting enzyme 2 (ACE2), which is most abundant in type II alveolar cells of the lungs. The virus uses a special surface glycoprotein called a "spike" (peplomer) to connect to ACE2 and enter the host cell.[80] The density of ACE2 in each tissue correlates with the severity of the disease in that tissue and some have suggested that decreasing ACE2 activity might be protective,[81][82] though another view is that increasing ACE2 using angiotensin II receptor blocker medications could be protective and these hypotheses need to be tested.[83] As the alveolar disease progresses, respiratory failure might develop and death may follow.[82]

 

The virus also affects gastrointestinal organs as ACE2 is abundantly expressed in the glandular cells of gastric, duodenal and rectal epithelium[84] as well as endothelial cells and enterocytes of the small intestine.[85]

 

ACE2 is present in the brain, and there is growing evidence of neurological manifestations in people with COVID‑19. It is not certain if the virus can directly infect the brain by crossing the barriers that separate the circulation of the brain and the general circulation. Other coronaviruses are able to infect the brain via a synaptic route to the respiratory centre in the medulla, through mechanoreceptors like pulmonary stretch receptors and chemoreceptors (primarily central chemoreceptors) within the lungs.[medical citation needed] It is possible that dysfunction within the respiratory centre further worsens the ARDS seen in COVID‑19 patients. Common neurological presentations include a loss of smell, headaches, nausea, and vomiting. Encephalopathy has been noted to occur in some patients (and confirmed with imaging), with some reports of detection of the virus after cerebrospinal fluid assays although the presence of oligoclonal bands seems to be a common denominator in these patients.[86]

 

The virus can cause acute myocardial injury and chronic damage to the cardiovascular system.[87] An acute cardiac injury was found in 12% of infected people admitted to the hospital in Wuhan, China,[88] and is more frequent in severe disease.[89] Rates of cardiovascular symptoms are high, owing to the systemic inflammatory response and immune system disorders during disease progression, but acute myocardial injuries may also be related to ACE2 receptors in the heart.[87] ACE2 receptors are highly expressed in the heart and are involved in heart function.[87][90] A high incidence of thrombosis (31%) and venous thromboembolism (25%) have been found in ICU patients with COVID‑19 infections and may be related to poor prognosis.[91][92] Blood vessel dysfunction and clot formation (as suggested by high D-dimer levels) are thought to play a significant role in mortality, incidences of clots leading to pulmonary embolisms, and ischaemic events within the brain have been noted as complications leading to death in patients infected with SARS-CoV-2. Infection appears to set off a chain of vasoconstrictive responses within the body, constriction of blood vessels within the pulmonary circulation has also been posited as a mechanism in which oxygenation decreases alongside with the presentation of viral pneumonia.[93]

 

Another common cause of death is complications related to the kidneys[93]—SARS-CoV-2 directly infects kidney cells, as confirmed in post-mortem studies. Acute kidney injury is a common complication and cause of death; this is more significant in patients with already compromised kidney function, especially in people with pre-existing chronic conditions such as hypertension and diabetes which specifically cause nephropathy in the long run.[94]

 

Autopsies of people who died of COVID‑19 have found diffuse alveolar damage (DAD), and lymphocyte-containing inflammatory infiltrates within the lung.[95]

 

Immunopathology

Although SARS-COV-2 has a tropism for ACE2-expressing epithelial cells of the respiratory tract, patients with severe COVID‑19 have symptoms of systemic hyperinflammation. Clinical laboratory findings of elevated IL-2, IL-7, IL-6, granulocyte-macrophage colony-stimulating factor (GM-CSF), interferon-γ inducible protein 10 (IP-10), monocyte chemoattractant protein 1 (MCP-1), macrophage inflammatory protein 1-α (MIP-1α), and tumour necrosis factor-α (TNF-α) indicative of cytokine release syndrome (CRS) suggest an underlying immunopathology.[96]

 

Additionally, people with COVID‑19 and acute respiratory distress syndrome (ARDS) have classical serum biomarkers of CRS, including elevated C-reactive protein (CRP), lactate dehydrogenase (LDH), D-dimer, and ferritin.[97]

 

Systemic inflammation results in vasodilation, allowing inflammatory lymphocytic and monocytic infiltration of the lung and the heart. In particular, pathogenic GM-CSF-secreting T-cells were shown to correlate with the recruitment of inflammatory IL-6-secreting monocytes and severe lung pathology in COVID‑19 patients.[98] Lymphocytic infiltrates have also been reported at autopsy.[95]

 

Diagnosis

Main article: COVID-19 testing

 

Demonstration of a nasopharyngeal swab for COVID-19 testing

 

CDC rRT-PCR test kit for COVID-19[99]

The WHO has published several testing protocols for the disease.[100] The standard method of testing is real-time reverse transcription polymerase chain reaction (rRT-PCR).[101] The test is typically done on respiratory samples obtained by a nasopharyngeal swab; however, a nasal swab or sputum sample may also be used.[25][102] Results are generally available within a few hours to two days.[103][104] Blood tests can be used, but these require two blood samples taken two weeks apart, and the results have little immediate value.[105] Chinese scientists were able to isolate a strain of the coronavirus and publish the genetic sequence so laboratories across the world could independently develop polymerase chain reaction (PCR) tests to detect infection by the virus.[9][106][107] As of 4 April 2020, antibody tests (which may detect active infections and whether a person had been infected in the past) were in development, but not yet widely used.[108][109][110] The Chinese experience with testing has shown the accuracy is only 60 to 70%.[111] The FDA in the United States approved the first point-of-care test on 21 March 2020 for use at the end of that month.[112]

 

Diagnostic guidelines released by Zhongnan Hospital of Wuhan University suggested methods for detecting infections based upon clinical features and epidemiological risk. These involved identifying people who had at least two of the following symptoms in addition to a history of travel to Wuhan or contact with other infected people: fever, imaging features of pneumonia, normal or reduced white blood cell count, or reduced lymphocyte count.[113]

 

A study asked hospitalised COVID‑19 patients to cough into a sterile container, thus producing a saliva sample, and detected the virus in eleven of twelve patients using RT-PCR. This technique has the potential of being quicker than a swab and involving less risk to health care workers (collection at home or in the car).[64]

 

Along with laboratory testing, chest CT scans may be helpful to diagnose COVID-19 in individuals with a high clinical suspicion of infection but are not recommended for routine screening.[26][27] Bilateral multilobar ground-glass opacities with a peripheral, asymmetric, and posterior distribution are common in early infection.[26] Subpleural dominance, crazy paving (lobular septal thickening with variable alveolar filling), and consolidation may appear as the disease progresses.[26][114]

 

In late 2019, WHO assigned the emergency ICD-10 disease codes U07.1 for deaths from lab-confirmed SARS-CoV-2 infection and U07.2 for deaths from clinically or epidemiologically diagnosed COVID‑19 without lab-confirmed SARS-CoV-2 infection.[115]

  

Typical CT imaging findings

 

CT imaging of rapid progression stage

Pathology

Few data are available about microscopic lesions and the pathophysiology of COVID‑19.[116][117] The main pathological findings at autopsy are:

 

Macroscopy: pleurisy, pericarditis, lung consolidation and pulmonary oedema

Four types of severity of viral pneumonia can be observed:

minor pneumonia: minor serous exudation, minor fibrin exudation

mild pneumonia: pulmonary oedema, pneumocyte hyperplasia, large atypical pneumocytes, interstitial inflammation with lymphocytic infiltration and multinucleated giant cell formation

severe pneumonia: diffuse alveolar damage (DAD) with diffuse alveolar exudates. DAD is the cause of acute respiratory distress syndrome (ARDS) and severe hypoxemia.

healing pneumonia: organisation of exudates in alveolar cavities and pulmonary interstitial fibrosis

plasmocytosis in BAL[118]

Blood: disseminated intravascular coagulation (DIC);[119] leukoerythroblastic reaction[120]

Liver: microvesicular steatosis

Prevention

See also: 2019–20 coronavirus pandemic § Prevention, flatten the curve, and workplace hazard controls for COVID-19

 

Progressively stronger mitigation efforts to reduce the number of active cases at any given time—known as "flattening the curve"—allows healthcare services to better manage the same volume of patients.[121][122][123] Likewise, progressively greater increases in healthcare capacity—called raising the line—such as by increasing bed count, personnel, and equipment, helps to meet increased demand.[124]

 

Mitigation attempts that are inadequate in strictness or duration—such as premature relaxation of distancing rules or stay-at-home orders—can allow a resurgence after the initial surge and mitigation.[122][125]

Preventive measures to reduce the chances of infection include staying at home, avoiding crowded places, keeping distance from others, washing hands with soap and water often and for at least 20 seconds, practising good respiratory hygiene, and avoiding touching the eyes, nose, or mouth with unwashed hands.[126][127][128] The CDC recommends covering the mouth and nose with a tissue when coughing or sneezing and recommends using the inside of the elbow if no tissue is available.[126] Proper hand hygiene after any cough or sneeze is encouraged.[126] The CDC has recommended the use of cloth face coverings in public settings where other social distancing measures are difficult to maintain, in part to limit transmission by asymptomatic individuals.[129] The U.S. National Institutes of Health guidelines do not recommend any medication for prevention of COVID‑19, before or after exposure to the SARS-CoV-2 virus, outside of the setting of a clinical trial.[130]

 

Social distancing strategies aim to reduce contact of infected persons with large groups by closing schools and workplaces, restricting travel, and cancelling large public gatherings.[131] Distancing guidelines also include that people stay at least 6 feet (1.8 m) apart.[132] There is no medication known to be effective at preventing COVID‑19.[133] After the implementation of social distancing and stay-at-home orders, many regions have been able to sustain an effective transmission rate ("Rt") of less than one, meaning the disease is in remission in those areas.[134]

 

As a vaccine is not expected until 2021 at the earliest,[135] a key part of managing COVID‑19 is trying to decrease the epidemic peak, known as "flattening the curve".[122] This is done by slowing the infection rate to decrease the risk of health services being overwhelmed, allowing for better treatment of current cases, and delaying additional cases until effective treatments or a vaccine become available.[122][125]

 

According to the WHO, the use of masks is recommended only if a person is coughing or sneezing or when one is taking care of someone with a suspected infection.[136] For the European Centre for Disease Prevention and Control (ECDC) face masks "... could be considered especially when visiting busy closed spaces ..." but "... only as a complementary measure ..."[137] Several countries have recommended that healthy individuals wear face masks or cloth face coverings (like scarves or bandanas) at least in certain public settings, including China,[138] Hong Kong,[139] Spain,[140] Italy (Lombardy region),[141] and the United States.[129]

 

Those diagnosed with COVID‑19 or who believe they may be infected are advised by the CDC to stay home except to get medical care, call ahead before visiting a healthcare provider, wear a face mask before entering the healthcare provider's office and when in any room or vehicle with another person, cover coughs and sneezes with a tissue, regularly wash hands with soap and water and avoid sharing personal household items.[30][142] The CDC also recommends that individuals wash hands often with soap and water for at least 20 seconds, especially after going to the toilet or when hands are visibly dirty, before eating and after blowing one's nose, coughing or sneezing. It further recommends using an alcohol-based hand sanitiser with at least 60% alcohol, but only when soap and water are not readily available.[126]

 

For areas where commercial hand sanitisers are not readily available, the WHO provides two formulations for local production. In these formulations, the antimicrobial activity arises from ethanol or isopropanol. Hydrogen peroxide is used to help eliminate bacterial spores in the alcohol; it is "not an active substance for hand antisepsis". Glycerol is added as a humectant.[143]

  

Prevention efforts are multiplicative, with effects far beyond that of a single spread. Each avoided case leads to more avoided cases down the line, which in turn can stop the outbreak in its tracks.

 

File:COVID19 W ENG.ogv

Handwashing instructions

Management

People are managed with supportive care, which may include fluid therapy, oxygen support, and supporting other affected vital organs.[144][145][146] The CDC recommends that those who suspect they carry the virus wear a simple face mask.[30] Extracorporeal membrane oxygenation (ECMO) has been used to address the issue of respiratory failure, but its benefits are still under consideration.[41][147] Personal hygiene and a healthy lifestyle and diet have been recommended to improve immunity.[148] Supportive treatments may be useful in those with mild symptoms at the early stage of infection.[149]

 

The WHO, the Chinese National Health Commission, and the United States' National Institutes of Health have published recommendations for taking care of people who are hospitalised with COVID‑19.[130][150][151] Intensivists and pulmonologists in the U.S. have compiled treatment recommendations from various agencies into a free resource, the IBCC.[152][153]

 

Medications

See also: Coronavirus disease 2019 § Research

As of April 2020, there is no specific treatment for COVID‑19.[6][133] Research is, however, ongoing. For symptoms, some medical professionals recommend paracetamol (acetaminophen) over ibuprofen for first-line use.[154][155][156] The WHO and NIH do not oppose the use of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen for symptoms,[130][157] and the FDA says currently there is no evidence that NSAIDs worsen COVID‑19 symptoms.[158]

 

While theoretical concerns have been raised about ACE inhibitors and angiotensin receptor blockers, as of 19 March 2020, these are not sufficient to justify stopping these medications.[130][159][160][161] Steroids, such as methylprednisolone, are not recommended unless the disease is complicated by acute respiratory distress syndrome.[162][163]

 

Medications to prevent blood clotting have been suggested for treatment,[91] and anticoagulant therapy with low molecular weight heparin appears to be associated with better outcomes in severe COVID‐19 showing signs of coagulopathy (elevated D-dimer).[164]

 

Protective equipment

See also: COVID-19 related shortages

 

The CDC recommends four steps to putting on personal protective equipment (PPE).[165]

Precautions must be taken to minimise the risk of virus transmission, especially in healthcare settings when performing procedures that can generate aerosols, such as intubation or hand ventilation.[166] For healthcare professionals caring for people with COVID‑19, the CDC recommends placing the person in an Airborne Infection Isolation Room (AIIR) in addition to using standard precautions, contact precautions, and airborne precautions.[167]

 

The CDC outlines the guidelines for the use of personal protective equipment (PPE) during the pandemic. The recommended gear is a PPE gown, respirator or facemask, eye protection, and medical gloves.[168][169]

 

When available, respirators (instead of facemasks) are preferred.[170] N95 respirators are approved for industrial settings but the FDA has authorised the masks for use under an Emergency Use Authorisation (EUA). They are designed to protect from airborne particles like dust but effectiveness against a specific biological agent is not guaranteed for off-label uses.[171] When masks are not available, the CDC recommends using face shields or, as a last resort, homemade masks.[172]

 

Mechanical ventilation

Most cases of COVID‑19 are not severe enough to require mechanical ventilation or alternatives, but a percentage of cases are.[173][174] The type of respiratory support for individuals with COVID‑19 related respiratory failure is being actively studied for people in the hospital, with some evidence that intubation can be avoided with a high flow nasal cannula or bi-level positive airway pressure.[175] Whether either of these two leads to the same benefit for people who are critically ill is not known.[176] Some doctors prefer staying with invasive mechanical ventilation when available because this technique limits the spread of aerosol particles compared to a high flow nasal cannula.[173]

 

Severe cases are most common in older adults (those older than 60 years,[173] and especially those older than 80 years).[177] Many developed countries do not have enough hospital beds per capita, which limits a health system's capacity to handle a sudden spike in the number of COVID‑19 cases severe enough to require hospitalisation.[178] This limited capacity is a significant driver behind calls to flatten the curve.[178] One study in China found 5% were admitted to intensive care units, 2.3% needed mechanical support of ventilation, and 1.4% died.[41] In China, approximately 30% of people in hospital with COVID‑19 are eventually admitted to ICU.[4]

 

Acute respiratory distress syndrome

Main article: Acute respiratory distress syndrome

Mechanical ventilation becomes more complex as acute respiratory distress syndrome (ARDS) develops in COVID‑19 and oxygenation becomes increasingly difficult.[179] Ventilators capable of pressure control modes and high PEEP[180] are needed to maximise oxygen delivery while minimising the risk of ventilator-associated lung injury and pneumothorax.[181] High PEEP may not be available on older ventilators.

 

Options for ARDS[179]

TherapyRecommendations

High-flow nasal oxygenFor SpO2 <93%. May prevent the need for intubation and ventilation

Tidal volume6mL per kg and can be reduced to 4mL/kg

Plateau airway pressureKeep below 30 cmH2O if possible (high respiratory rate (35 per minute) may be required)

Positive end-expiratory pressureModerate to high levels

Prone positioningFor worsening oxygenation

Fluid managementGoal is a negative balance of 0.5–1.0L per day

AntibioticsFor secondary bacterial infections

GlucocorticoidsNot recommended

Experimental treatment

See also: § Research

Research into potential treatments started in January 2020,[182] and several antiviral drugs are in clinical trials.[183][184] Remdesivir appears to be the most promising.[133] Although new medications may take until 2021 to develop,[185] several of the medications being tested are already approved for other uses or are already in advanced testing.[186] Antiviral medication may be tried in people with severe disease.[144] The WHO recommended volunteers take part in trials of the effectiveness and safety of potential treatments.[187]

 

The FDA has granted temporary authorisation to convalescent plasma as an experimental treatment in cases where the person's life is seriously or immediately threatened. It has not undergone the clinical studies needed to show it is safe and effective for the disease.[188][189][190]

 

Information technology

See also: Contact tracing and Government by algorithm

In February 2020, China launched a mobile app to deal with the disease outbreak.[191] Users are asked to enter their name and ID number. The app can detect 'close contact' using surveillance data and therefore a potential risk of infection. Every user can also check the status of three other users. If a potential risk is detected, the app not only recommends self-quarantine, it also alerts local health officials.[192]

 

Big data analytics on cellphone data, facial recognition technology, mobile phone tracking, and artificial intelligence are used to track infected people and people whom they contacted in South Korea, Taiwan, and Singapore.[193][194] In March 2020, the Israeli government enabled security agencies to track mobile phone data of people supposed to have coronavirus. The measure was taken to enforce quarantine and protect those who may come into contact with infected citizens.[195] Also in March 2020, Deutsche Telekom shared aggregated phone location data with the German federal government agency, Robert Koch Institute, to research and prevent the spread of the virus.[196] Russia deployed facial recognition technology to detect quarantine breakers.[197] Italian regional health commissioner Giulio Gallera said he has been informed by mobile phone operators that "40% of people are continuing to move around anyway".[198] German government conducted a 48 hours weekend hackathon with more than 42.000 participants.[199][200] Two million people in the UK used an app developed in March 2020 by King's College London and Zoe to track people with COVID‑19 symptoms.[201] Also, the president of Estonia, Kersti Kaljulaid, made a global call for creative solutions against the spread of coronavirus.[202]

 

Psychological support

See also: Mental health during the 2019–20 coronavirus pandemic

Individuals may experience distress from quarantine, travel restrictions, side effects of treatment, or fear of the infection itself. To address these concerns, the National Health Commission of China published a national guideline for psychological crisis intervention on 27 January 2020.[203][204]

 

The Lancet published a 14-page call for action focusing on the UK and stated conditions were such that a range of mental health issues was likely to become more common. BBC quoted Rory O'Connor in saying, "Increased social isolation, loneliness, health anxiety, stress and an economic downturn are a perfect storm to harm people's mental health and wellbeing."[205][206]

 

Prognosis

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The severity of diagnosed cases in China

The severity of diagnosed COVID-19 cases in China[207]

Case fatality rates for COVID-19 by age by country.

Case fatality rates by age group:

China, as of 11 February 2020[208]

South Korea, as of 15 April 2020[209]

Spain, as of 24 April 2020[210]

Italy, as of 23 April 2020[211]

Case fatality rate depending on other health problems

Case fatality rate in China depending on other health problems. Data through 11 February 2020.[208]

Case fatality rate by country and number of cases

The number of deaths vs total cases by country and approximate case fatality rate[212]

The severity of COVID‑19 varies. The disease may take a mild course with few or no symptoms, resembling other common upper respiratory diseases such as the common cold. Mild cases typically recover within two weeks, while those with severe or critical diseases may take three to six weeks to recover. Among those who have died, the time from symptom onset to death has ranged from two to eight weeks.[47]

 

Children make up a small proportion of reported cases, with about 1% of cases being under 10 years, and 4% aged 10-19 years.[22] They are likely to have milder symptoms and a lower chance of severe disease than adults; in those younger than 50 years, the risk of death is less than 0.5%, while in those older than 70 it is more than 8%.[213][214][215] Pregnant women may be at higher risk for severe infection with COVID-19 based on data from other similar viruses, like SARS and MERS, but data for COVID-19 is lacking.[216][217] In China, children acquired infections mainly through close contact with their parents or other family members who lived in Wuhan or had traveled there.[213]

 

In some people, COVID‑19 may affect the lungs causing pneumonia. In those most severely affected, COVID-19 may rapidly progress to acute respiratory distress syndrome (ARDS) causing respiratory failure, septic shock, or multi-organ failure.[218][219] Complications associated with COVID‑19 include sepsis, abnormal clotting, and damage to the heart, kidneys, and liver. Clotting abnormalities, specifically an increase in prothrombin time, have been described in 6% of those admitted to hospital with COVID-19, while abnormal kidney function is seen in 4% of this group.[220] Approximately 20-30% of people who present with COVID‑19 demonstrate elevated liver enzymes (transaminases).[133] Liver injury as shown by blood markers of liver damage is frequently seen in severe cases.[221]

 

Some studies have found that the neutrophil to lymphocyte ratio (NLR) may be helpful in early screening for severe illness.[222]

 

Most of those who die of COVID‑19 have pre-existing (underlying) conditions, including hypertension, diabetes mellitus, and cardiovascular disease.[223] The Istituto Superiore di Sanità reported that out of 8.8% of deaths where medical charts were available for review, 97.2% of sampled patients had at least one comorbidity with the average patient having 2.7 diseases.[224] According to the same report, the median time between the onset of symptoms and death was ten days, with five being spent hospitalised. However, patients transferred to an ICU had a median time of seven days between hospitalisation and death.[224] In a study of early cases, the median time from exhibiting initial symptoms to death was 14 days, with a full range of six to 41 days.[225] In a study by the National Health Commission (NHC) of China, men had a death rate of 2.8% while women had a death rate of 1.7%.[226] Histopathological examinations of post-mortem lung samples show diffuse alveolar damage with cellular fibromyxoid exudates in both lungs. Viral cytopathic changes were observed in the pneumocytes. The lung picture resembled acute respiratory distress syndrome (ARDS).[47] In 11.8% of the deaths reported by the National Health Commission of China, heart damage was noted by elevated levels of troponin or cardiac arrest.[49] According to March data from the United States, 89% of those hospitalised had preexisting conditions.[227]

 

The availability of medical resources and the socioeconomics of a region may also affect mortality.[228] Estimates of the mortality from the condition vary because of those regional differences,[229] but also because of methodological difficulties. The under-counting of mild cases can cause the mortality rate to be overestimated.[230] However, the fact that deaths are the result of cases contracted in the past can mean the current mortality rate is underestimated.[231][232] Smokers were 1.4 times more likely to have severe symptoms of COVID‑19 and approximately 2.4 times more likely to require intensive care or die compared to non-smokers.[233]

 

Concerns have been raised about long-term sequelae of the disease. The Hong Kong Hospital Authority found a drop of 20% to 30% in lung capacity in some people who recovered from the disease, and lung scans suggested organ damage.[234] This may also lead to post-intensive care syndrome following recovery.[235]

 

Case fatality rates (%) by age and country

Age0–910–1920–2930–3940–4950–5960–6970–7980-8990+

China as of 11 February[208]0.00.20.20.20.41.33.68.014.8

Denmark as of 25 April[236]0.24.515.524.940.7

Italy as of 23 April[211]0.20.00.10.40.92.610.024.930.826.1

Netherlands as of 17 April[237]0.00.30.10.20.51.57.623.230.029.3

Portugal as of 24 April[238]0.00.00.00.00.30.62.88.516.5

S. Korea as of 15 April[209]0.00.00.00.10.20.72.59.722.2

Spain as of 24 April[210]0.30.40.30.30.61.34.413.220.320.1

Switzerland as of 25 April[239]0.90.00.00.10.00.52.710.124.0

Case fatality rates (%) by age in the United States

Age0–1920–4445–5455–6465–7475–8485+

United States as of 16 March[240]0.00.1–0.20.5–0.81.4–2.62.7–4.94.3–10.510.4–27.3

Note: The lower bound includes all cases. The upper bound excludes cases that were missing data.

Estimate of infection fatality rates and probability of severe disease course (%) by age based on cases from China[241]

0–910–1920–2930–3940–4950–5960–6970–7980+

Severe disease0.0

(0.0–0.0)0.04

(0.02–0.08)1.0

(0.62–2.1)3.4

(2.0–7.0)4.3

(2.5–8.7)8.2

(4.9–17)11

(7.0–24)17

(9.9–34)18

(11–38)

Death0.0016

(0.00016–0.025)0.0070

(0.0015–0.050)0.031

(0.014–0.092)0.084

(0.041–0.19)0.16

(0.076–0.32)0.60

(0.34–1.3)1.9

(1.1–3.9)4.3

(2.5–8.4)7.8

(3.8–13)

Total infection fatality rate is estimated to be 0.66% (0.39–1.3). Infection fatality rate is fatality per all infected individuals, regardless of whether they were diagnosed or had any symptoms. Numbers in parentheses are 95% credible intervals for the estimates.

Reinfection

As of March 2020, it was unknown if past infection provides effective and long-term immunity in people who recover from the disease.[242] Immunity is seen as likely, based on the behaviour of other coronaviruses,[243] but cases in which recovery from COVID‑19 have been followed by positive tests for coronavirus at a later date have been reported.[244][245][246][247] These cases are believed to be worsening of a lingering infection rather than re-infection.[247]

 

History

Main article: Timeline of the 2019–20 coronavirus pandemic

The virus is thought to be natural and has an animal origin,[77] through spillover infection.[248] The actual origin is unknown, but by December 2019 the spread of infection was almost entirely driven by human-to-human transmission.[208][249] A study of the first 41 cases of confirmed COVID‑19, published in January 2020 in The Lancet, revealed the earliest date of onset of symptoms as 1 December 2019.[250][251][252] Official publications from the WHO reported the earliest onset of symptoms as 8 December 2019.[253] Human-to-human transmission was confirmed by the WHO and Chinese authorities by 20 January 2020.[254][255]

 

Epidemiology

Main article: 2019–20 coronavirus pandemic

Several measures are commonly used to quantify mortality.[256] These numbers vary by region and over time and are influenced by the volume of testing, healthcare system quality, treatment options, time since the initial outbreak, and population characteristics such as age, sex, and overall health.[257]

 

The death-to-case ratio reflects the number of deaths divided by the number of diagnosed cases within a given time interval. Based on Johns Hopkins University statistics, the global death-to-case ratio is 7.0% (203,044/2,899,830) as of 26 April 2020.[7] The number varies by region.[258]

 

Other measures include the case fatality rate (CFR), which reflects the percent of diagnosed individuals who die from a disease, and the infection fatality rate (IFR), which reflects the percent of infected individuals (diagnosed and undiagnosed) who die from a disease. These statistics are not time-bound and follow a specific population from infection through case resolution. Many academics have attempted to calculate these numbers for specific populations.[259]

  

Total confirmed cases over time

 

Total deaths over time

 

Total confirmed cases of COVID‑19 per million people, 10 April 2020[260]

 

Total confirmed deaths due to COVID‑19 per million people, 10 April 2020[261]

Infection fatality rate

Our World in Data states that as of March 25, 2020, the infection fatality rate (IFR) cannot be accurately calculated.[262] In February, the World Health Organization estimated the IFR at 0.94%, with a confidence interval between 0.37 percent to 2.9 percent.[263] The University of Oxford Centre for Evidence-Based Medicine (CEBM) estimated a global CFR of 0.72 percent and IFR of 0.1 percent to 0.36 percent.[264] According to CEBM, random antibody testing in Germany suggested an IFR of 0.37 percent there.[264] Firm lower limits to local infection fatality rates were established, such as in Bergamo province, where 0.57% of the population has died, leading to a minimum IFR of 0.57% in the province. This population fatality rate (PFR) minimum increases as more people get infected and run through their disease.[265][266] Similarly, as of April 22 in the New York City area, there were 15,411 deaths confirmed from COVID-19, and 19,200 excess deaths.[267] Very recently, the first results of antibody testing have come in, but there are no valid scientific reports based on them available yet. A Bloomberg Opinion piece provides a survey.[268][269]

 

Sex differences

Main article: Gendered impact of the 2019–20 coronavirus pandemic

The impact of the pandemic and its mortality rate are different for men and women.[270] Mortality is higher in men in studies conducted in China and Italy.[271][272][273] The highest risk for men is in their 50s, with the gap between men and women closing only at 90.[273] In China, the death rate was 2.8 percent for men and 1.7 percent for women.[273] The exact reasons for this sex-difference are not known, but genetic and behavioural factors could be a reason.[270] Sex-based immunological differences, a lower prevalence of smoking in women, and men developing co-morbid conditions such as hypertension at a younger age than women could have contributed to the higher mortality in men.[273] In Europe, of those infected with COVID‑19, 57% were men; of those infected with COVID‑19 who also died, 72% were men.[274] As of April 2020, the U.S. government is not tracking sex-related data of COVID‑19 infections.[275] Research has shown that viral illnesses like Ebola, HIV, influenza, and SARS affect men and women differently.[275] A higher percentage of health workers, particularly nurses, are women, and they have a higher chance of being exposed to the virus.[276] School closures, lockdowns, and reduced access to healthcare following the 2019–20 coronavirus pandemic may differentially affect the genders and possibly exaggerate existing gender disparity.[270][277]

 

Society and culture

Name

During the initial outbreak in Wuhan, China, the virus and disease were commonly referred to as "coronavirus" and "Wuhan coronavirus",[278][279][280] with the disease sometimes called "Wuhan pneumonia".[281][282] In the past, many diseases have been named after geographical locations, such as the Spanish flu,[283] Middle East Respiratory Syndrome, and Zika virus.[284]

 

In January 2020, the World Health Organisation recommended 2019-nCov[285] and 2019-nCoV acute respiratory disease[286] as interim names for the virus and disease per 2015 guidance and international guidelines against using geographical locations (e.g. Wuhan, China), animal species or groups of people in disease and virus names to prevent social stigma.[287][288][289]

 

The official names COVID‑19 and SARS-CoV-2 were issued by the WHO on 11 February 2020.[290] WHO chief Tedros Adhanom Ghebreyesus explained: CO for corona, VI for virus, D for disease and 19 for when the outbreak was first identified (31 December 2019).[291] The WHO additionally uses "the COVID‑19 virus" and "the virus responsible for COVID‑19" in public communications.[290] Both the disease and virus are commonly referred to as "coronavirus" in the media and public discourse.

 

Misinformation

Main article: Misinformation related to the 2019–20 coronavirus pandemic

After the initial outbreak of COVID‑19, conspiracy theories, misinformation, and disinformation emerged regarding the origin, scale, prevention, treatment, and other aspects of the disease and rapidly spread online.[292][293][294][295]

 

Protests

Beginning April 17, 2020, news media began reporting on a wave of demonstrations protesting against state-mandated quarantine restrictions in in Michigan, Ohio, and Kentucky.[296][297]

 

Other animals

Humans appear to be capable of spreading the virus to some other animals. A domestic cat in Liège, Belgium, tested positive after it started showing symptoms (diarrhoea, vomiting, shortness of breath) a week later than its owner, who was also positive.[298] Tigers at the Bronx Zoo in New York, United States, tested positive for the virus and showed symptoms of COVID‑19, including a dry cough and loss of appetite.[299]

 

A study on domesticated animals inoculated with the virus found that cats and ferrets appear to be "highly susceptible" to the disease, while dogs appear to be less susceptible, with lower levels of viral replication. The study failed to find evidence of viral replication in pigs, ducks, and chickens.[300]

 

Research

Main article: COVID-19 drug development

No medication or vaccine is approved to treat the disease.[186] International research on vaccines and medicines in COVID‑19 is underway by government organisations, academic groups, and industry researchers.[301][302] In March, the World Health Organisation initiated the "SOLIDARITY Trial" to assess the treatment effects of four existing antiviral compounds with the most promise of efficacy.[303]

 

Vaccine

Main article: COVID-19 vaccine

There is no available vaccine, but various agencies are actively developing vaccine candidates. Previous work on SARS-CoV is being used because both SARS-CoV and SARS-CoV-2 use the ACE2 receptor to enter human cells.[304] Three vaccination strategies are being investigated. First, researchers aim to build a whole virus vaccine. The use of such a virus, be it inactive or dead, aims to elicit a prompt immune response of the human body to a new infection with COVID‑19. A second strategy, subunit vaccines, aims to create a vaccine that sensitises the immune system to certain subunits of the virus. In the case of SARS-CoV-2, such research focuses on the S-spike protein that helps the virus intrude the ACE2 enzyme receptor. A third strategy is that of the nucleic acid vaccines (DNA or RNA vaccines, a novel technique for creating a vaccination). Experimental vaccines from any of these strategies would have to be tested for safety and efficacy.[305]

 

On 16 March 2020, the first clinical trial of a vaccine started with four volunteers in Seattle, United States. The vaccine contains a harmless genetic code copied from the virus that causes the disease.[306]

 

Antibody-dependent enhancement has been suggested as a potential challenge for vaccine development for SARS-COV-2, but this is controversial.[307]

 

Medications

Main article: COVID-19 drug repurposing research

At least 29 phase II–IV efficacy trials in COVID‑19 were concluded in March 2020 or scheduled to provide results in April from hospitals in China.[308][309] There are more than 300 active clinical trials underway as of April 2020.[133] Seven trials were evaluating already approved treatments, including four studies on hydroxychloroquine or chloroquine.[309] Repurposed antiviral drugs make up most of the Chinese research, with nine phase III trials on remdesivir across several countries due to report by the end of April.[308][309] Other candidates in trials include vasodilators, corticosteroids, immune therapies, lipoic acid, bevacizumab, and recombinant angiotensin-converting enzyme 2.[309]

 

The COVID‑19 Clinical Research Coalition has goals to 1) facilitate rapid reviews of clinical trial proposals by ethics committees and national regulatory agencies, 2) fast-track approvals for the candidate therapeutic compounds, 3) ensure standardised and rapid analysis of emerging efficacy and safety data and 4) facilitate sharing of clinical trial outcomes before publication.[310][311]

 

Several existing medications are being evaluated for the treatment of COVID‑19,[186] including remdesivir, chloroquine, hydroxychloroquine, lopinavir/ritonavir, and lopinavir/ritonavir combined with interferon beta.[303][312] There is tentative evidence for efficacy by remdesivir, as of March 2020.[313][314] Clinical improvement was observed in patients treated with compassionate-use remdesivir.[315] Remdesivir inhibits SARS-CoV-2 in vitro.[316] Phase III clinical trials are underway in the U.S., China, and Italy.[186][308][317]

 

In 2020, a trial found that lopinavir/ritonavir was ineffective in the treatment of severe illness.[318] Nitazoxanide has been recommended for further in vivo study after demonstrating low concentration inhibition of SARS-CoV-2.[316]

 

There are mixed results as of 3 April 2020 as to the effectiveness of hydroxychloroquine as a treatment for COVID‑19, with some studies showing little or no improvement.[319][320] The studies of chloroquine and hydroxychloroquine with or without azithromycin have major limitations that have prevented the medical community from embracing these therapies without further study.[133]

 

Oseltamivir does not inhibit SARS-CoV-2 in vitro and has no known role in COVID‑19 treatment.[133]

 

Anti-cytokine storm

Cytokine release syndrome (CRS) can be a complication in the later stages of severe COVID‑19. There is preliminary evidence that hydroxychloroquine may have anti-cytokine storm properties.[321]

 

Tocilizumab has been included in treatment guidelines by China's National Health Commission after a small study was completed.[322][323] It is undergoing a phase 2 non-randomised trial at the national level in Italy after showing positive results in people with severe disease.[324][325] Combined with a serum ferritin blood test to identify cytokine storms, it is meant to counter such developments, which are thought to be the cause of death in some affected people.[326][327][328] The interleukin-6 receptor antagonist was approved by the FDA to undergo a phase III clinical trial assessing the medication's impact on COVID‑19 based on retrospective case studies for the treatment of steroid-refractory cytokine release syndrome induced by a different cause, CAR T cell therapy, in 2017.[329] To date, there is no randomised, controlled evidence that tocilizumab is an efficacious treatment for CRS. Prophylactic tocilizumab has been shown to increase serum IL-6 levels by saturating the IL-6R, driving IL-6 across the blood-brain barrier, and exacerbating neurotoxicity while having no impact on the incidence of CRS.[330]

 

Lenzilumab, an anti-GM-CSF monoclonal antibody, is protective in murine models for CAR T cell-induced CRS and neurotoxicity and is a viable therapeutic option due to the observed increase of pathogenic GM-CSF secreting T-cells in hospitalised patients with COVID‑19.[331]

 

The Feinstein Institute of Northwell Health announced in March a study on "a human antibody that may prevent the activity" of IL-6.[332]

 

Passive antibodies

Transferring purified and concentrated antibodies produced by the immune systems of those who have recovered from COVID‑19 to people who need them is being investigated as a non-vaccine method of passive immunisation.[333] This strategy was tried for SARS with inconclusive results.[333] Viral neutralisation is the anticipated mechanism of action by which passive antibody therapy can mediate defence against SARS-CoV-2. Other mechanisms, however, such as antibody-dependent cellular cytotoxicity and/or phagocytosis, may be possible.[333] Other forms of passive antibody therapy, for example, using manufactured monoclonal antibodies, are in development.[333] Production of convalescent serum, which consists of the liquid portion of the blood from recovered patients and contains antibodies specific to this virus, could be increased for quicker deployment.[334]

  

en.wikipedia.org/wiki/Coronavirus_disease_2019

The two-day-old gorilla born by emergency c-section on Wednesday evening had a procedure this morning at the San Diego Zoo Safari Park's veterinary hospital to fix a collapsed lung. Veterinary staff had been monitoring the baby gorilla with around-the-clock care when they noticed increased respiratory distress. The baby was breathing a lot faster and her heart rate was elevated. They did an x-ray and confirmed that the baby gorilla had a collapsed lung and had to undergo treatment.

 

A team of San Diego Zoo Global veterinary and animal care staff, joined by a human neonatal specialist and anesthesiologist from UC San Diego Health System, quickly assembled for a procedure to fix the collapsed lung. After carefully intubating the baby gorilla, they suctioned out a mucus plug that was in her right lung, likely aspirated at the time of delivery. Following the procedure the medical teams were able to re-inflate the lung. After a repeat chest x-ray, the team of veterinarians and specialists then concluded that both lungs were fully inflated and the procedure was successful. They covered the baby gorilla in blankets for warmth as she slowly woke up from the anesthesia used during the procedure. Once she was awake, the teams were able to remove the breathing tube and placed the baby on a nasal cannula with oxygen for continued respiratory support.

 

The baby gorilla will continue to be monitored with around-the-clock care by a team of veterinarians and animal care staff. The baby is showing progress and is breathing better on her own, but she is still receiving oxygen and supplemental fluids as needed.

 

"I would say that there are two things that differentiate her in how she acts compared to most babies that I take care of; first, she's a lot stronger when she grabs your hand, it's very difficult to release her grip - because that's her instinct - to grab her mom," Dawn Reeves, MD, neonatologist at UC San Diego Health System said. "Second, she can grab you with both her hands and her feet, which can be a little troublesome when trying to do procedures or exams. Otherwise she behaves very well," Reeves said.

 

The baby gorilla's mother,18-year-old Imani, is recovering after the emergency c-section surgery and is back in her familiar habitat, eating and doing well. Keepers at the Safari Park will continue to closely monitor the first-time mom as she recovers from her surgery.

 

"If this were a human you'd want no exercise for a few weeks after an operation like this, but within 24 hours she (Imani) was back with her troop moving around like nothing ever happened," Jeff Zuba, San Diego Zoo Global senior veterinarian said. "We're watching her closely, we're not encouraging her to move about like that but at this point she's doing great," Zuba said.

 

Saturday recap - I ended up spending 8 hours at A&E - only one hour of poking and prodding and the rest of the time waiting around. Had an ECG - fine - blood tests - fine - lots of poking and prodding and a cannula installed (which wasn't needed). Got referred from the A&E doc to a specialist and she - like me - wasn't sure what the cause of the sinus/ear issues was so she's put me on antiobiotic eardrops and topical antibiotic ointment and I've got a quick follow-up appointment on Tuesday morning. In the meantime, chewing on sweets is helping to keep the Eustachian tubes open....

I've been forced to develop a love affair with that cannula. Asthma since I was a kid; COPD since my early twenties. Allergies and crappy air quality + age and I need my supplemental oxygen more and more (not to mention my inhalers and other medications). I could never relate to healthy people, or the ability to breathe normally.

Protecting Tranquilized Bear — The kerchief over the bear's eyes protects it from dust and debris and reduces visual stimulation. The small tubing in its nose (nasal cannula) delivers oxygen to the animal while tranquilized. The scientists working with this bear are part of the Interagency Grizzly Bear Study Team (IGBST) — an interdisciplinary group of scientists and biologists responsible for long-term monitoring and research efforts on grizzly bears in the Greater Yellowstone Ecosystem (GYE).

 

The team was formed by the DOI in 1973 as a direct result of controversy surrounding the closure of open pit garbage dumps within Yellowstone National Park during 1968-72. For decades, large numbers of grizzly bears fed at these dumps and after the closure of this food source, the rate of grizzly bear deaths increased. Concerns for the population’s future led to grizzlies being listed as threatened under the Endangered Species Act in 1975.

 

IGBST members are representatives from the USGS, National Park Service, U.S. Fish and Wildlife Service, U.S. Forest Service, the Eastern Shoshone and Northern Arapaho Tribal Fish and Game Department, and the States of Idaho, Montana, and Wyoming. This group approach ensures consistency in data collection and allows for combining limited resources to address information needs throughout the GYE. Photo credit: Suzanna Soileau, USGS.

 

Learn more at: on.doi.gov/IGBST

 

#USGS #science #biology #bear #Yellowstone #NPS #FWS #USFS #Idaho #Montana #Wyoming #animals

I have never thought I would have found it. A Complete Dainty-Maid bag from USA. An adventure to find it. But it is here right now... It comes with an earigator I already had, and a lot of more things....

'Sir John Betjamen' emerges from the cloud of black exhaust just emitted by passing 66 554 on 4L37. I came here to get the field of flowering cannula in the background but the sun didn't properly appear from the high altitude cloud until I got back to Colchester!

The picture is taken on cliffs overlooking the north sea, just as a sea mist settled in, to the almost exact height of the cliffs. it was like standing on clouds. These are the moments you appreciate, and remember the most

 

Sorry for the lots of writing. At the beginning of the year, i resolved to be more open about myself. Of course, in my context, it means im still very very private and only about one tenth as open as most people, but i am trying to get better!

 

I've been told i could drop dead several occasions, by several different doctors. Four times in my life i've been diagnosed with blood clots, and the last time was close. Hours close

 

My question to myself is, if you've been given not just one, not two, or three, but four chances at life, how do you decide what is a good life? I didn't know what to do with my first life, and the second, third and the beginning of the fourth life hasn't seen much change. Is it enough to be a good person?

 

I keep thinking back to the day. At 650am i could barely walk up the street. I had to stop three times to walk 200metres. I was feeling so sick and shaky and seriously considered caling 999 then. But never did i imagine what it was. So i kept going. By 1230 that afternoon I asked to go home. I've never done that before. Luckily I changed my mind and went to hospital, expecting to be told I was being stupid and to go home. By 330 I was listed as critical and life threatening. (my life, i wasn't threatening someone else!)

 

It's what you remember in these moments. I remember the student doctor Matt was talking to me. At the time I never realised it, but he never left my side when i was in the side ward. I wonder now if he was told to stay there. Sneaky NHS! But really, he was awesome. He'll be a really good doctor one day. So will Katie, who was the doctor looking after me whilst the initial tests were being done. I could barely breathe, but she stayed so calm and relaxed. I was never in panic myself, but i'd have picked up if they were. I had been playing with the heart monitor, making the heart rate go up and down by moving and counting how long it took to recover to its then "resting" heartrate. Which i found later was much higher than my normal resting heartrate. Hmmmm, probably won't be doing that again. I started to get a bit more curious when they said my condition was "their worst suspicions confirmed". Really? So what is it then? I never really had chance to ask them at that point, owing to me struggling to breathe, and them whisking me to a monitored ward, with two nurses in two to look after me.

 

So there i was, in a monitored ward, installed directly in front of the nurses station, rather than by the empty window bay. Damn. I would have liked a view. By this time i've texted my dad to tell him i'm in hospital, and telling him not to call me because i can't breathe. Of course, he calls me...... Doofus!

So i set to getting myself comfortable. With an oxygen line coming in from the left underneath my arm to a mask over my mouth, with three heart monitoring wires going across my chest from the right, with a blood pressure squeezy thing (technical term, obvs') on my right arm that takes my blood pressure every hour. In a strange bed, being stared at by people i've never seen. All older than me by at least a couple of decades. Except the topless guy handcuffed to his bed, who seems to be having the worst comedown ever. Completely silent, but strained . Like he wants to tear away from himself, but can't. I don't know if i felt sorry for him, or glad he was handcuffed. He didn't seem to be aware of himself or his surroundings.

 

Oddly, at this point, i'm still not frightened, or scared. Should I be? I'd still describe myself as curious about it all. What happens next? I've never done this before. I soon found out. The nurse on duty introduced herself, and busied herself with taking results from the various monitors adorning me. The senior nurse then popped over just to check me over. It was him i first asked the question "how serious is this"? I liked the way he answered. Matter of fact and honest. "if you hadn't come in today, you would have collapsed and come in this weekend in an ambulance. Or worse. You'd have been dead by sunday/monday for certain". I can't remember his name, but he said he was going to work at another hospital tomorrow. He worked hard, and it showed in his face. But never in his attitude or his demeanour to me. He was someone else i liked.

 

The doctor doing his rounds then saw me. A gentleman doctor, with a kind face and a large waist. He had a smile that showed he knew what he was talking about, and that things would be ok. An earned confidence about him. I liked him, despite him telling the nurses I was not allowed to leave the bay. I was to use a commode or a bottle if i wanted to go to the toilet. If i have a recommendation for the NHS, it's to find a way around this. I could use a bottle, but not a commode. Not with only a flimsy curtain with ill fitting closings between me and the other patients. Can't they let you use a private bathroom, with walls and put a sign on the door saying "Patient xxx entered at 345pm", and then knock on the door at 348pm just to check they are ok? The door doesn't have to be locked, all it has to be shown is that it's occupied. Yeah, it's not a perfect system, but then again, they weren't perfect curtains!

 

So anyway, back to the doctor. He told me my condition was life threatening and critical. At this point my parents were there, so it saved me some explanation. Which was good, as speaking in sentences was something waaaaaaay beyond me at that point. How i wasn't to move in case the clots moved and if i needed anything, i was to call a nurse. Obviously i could move a little bit, but jumping out of bed and going for a wander was a no no

 

First night in a hospital ward. Ever. For anything. Didn't sleep more than half an hour at a time. I never sleep well in rooms with strange people anyway, and definitely not when there is activity around. Maybe in a previous life I was a prey animal, if you believe in reincarnation and all that. If i was prey, hopefully it was something eaten only by the biggest creatures. A dolphin gets eaten by sharks for instance. I'd have been a dolphin. A carefree idea of the rules, but respectful of them. Or am i talking about me now? Another discussion for another day :P (erhaps)

Not to forget about all the medical equipment around and on me. And a cannula in the crook of my left arm that kept catching on my oxygen tube. I was more scared of waking up with half my blood on the floor, than my lungs and heart stop functioning. It's only useful to worry about the things you can affect right? The rest will take care of itself.

 

Second day. I have a wash, but cant do it very well. Im way too tired too quickly and the wires get in the way. Breakfast is here. Im aware i can't use the toilet, so i eat sparingly. The toast was barely warm. The nurses change over. Again, a nice nurse, and i settle down for the morning and watch things unfold. I see a different doctor today. A lady who reminds me of Cate Blanchett. She asks me with a slight tone of speaking to a child "David, do you understand why we are all being so twitchy around you?" I reply "yes, because ive got massive bilateral pulmonary embolism". Although i hadn't really noticed people being twitchy around me. My nature is to stay low profile and out of the way. The doctor smiles and asks if i need anything, to which i reply no. What can I have? i cant use the bathroom, and i can hardly ask her to go and get me a starbucks. Although i was tempted, just for the sake of being cheeky and making someone laugh :) Thinking about it now, i wonder if its better to say "we can do this, this and this for you if you'd like?" I never knew what she could, to ask for it. But maybe for a busy doctor, its a dangerous thing to be too tied up with the small things that make a person feel better, but doesnt actually make them better. A doctor is there for everyone, not just for me. And there are a lot of patients

I also meet another senior nurse today. A lady, with brown hair and brown eyes, with a slight gap between her front teeth when she smiles. She smiles sweetly, with a glint in her eye and a smile that says you can challenge me, but i'll win. I like her too. She spoke to me about what i was drinking and eating. I didn't want to have the discussion that i had consciously dropped my intake of food and drink due to the toilet arrangements, but i did admit to drinking less. So she 'threatened' me with installing a drip in my arm. But in a nice, almost motherly way. So i agreed to drink more. Luckily she didn't push me about the food. Apparently it's not so important how often you eat, or don't eat as the case may be for the first few days, but it's really important you still drink every day. I already heard before hospital that people can only survive a few days without water, but can survive over a week without food, but in my defence, at this point in time, i didn't know how long I was going to be in hospital, and I was very conscious I couldn't use that bathroom!

 

Second night in hospital. I watched the sunlight on the buildings and roads slowly change to streetlights and car lights. It was interesting to watch a day fade to night like this. Something people don't do enough of. The other patients slowly fade to sleep, but im still awake. Partly because its still new to me, partly because im very aware of the medical kit working to monitor me, and partly because apparently i snore! Really loudly. So i dont want to deprive the other patients of sleep. I eventually do sleep better, but a few times i wake to see the concerned face of a nurse over me checking my pulse, as the monitor flashes red on the ceiling. "is there a problem?" i ask. "no" is always the reply, and as i'm in their care and i have to trust them, i go back to sleep. Wondering if i'll wake up. What can i do. It's all internal, i can make sure i don't move and follow the doctors instructions, but beyond that, im waiting for things to happen. Or hopefully not, as the case may be

 

Third day. Again struggled to wash properly, but by now im figuring things out and am wearing better clothes suited to staying in bed, so i dont get as hot and sweaty as i had been. The thought of the toilet is starting to intensify. I eat less for breakfast. Start thinking through my conversation with the doctor/nurse to be allowed to use the bathroom. I see the commode being delivered to other patient. Happily dont see them using it. Saggy assed old men is not something i need to see. Ever. My mum has bought an ipad. Im using it. God bless apple and technology. The hospital wifi is just strong enough to let me watch a film "despicable me". God, i love this film. Yeah, i nearly cried. But my ability to push things deep, out of the way and to one side comes through. Desperately trying not to think about other things coming through. Discussion with the medical staff about the toilet is just about set. A bit of pleading, a bit of common sense, a bit of stubborness, mixed in with a soft tone. Yeah, ive got this sorted.

Damn, the nurse im not so sure about is on shift now. Conversation will have to wait until tomorrow

 

Sleep a bit better on the third night. Im becoming comfortable with my surroundings now. Tonight a new patient keeps getting up, dressed and hiding in the bathroom. He wants to go home. He doesnt know where he is. He doesnt know where home is. Asks me for some money for a taxi. I say to talk to the nurses and see what they say. They put him to bed. Repeatedly. He repeatedly does as he is told, and then gets dressed and out of bed again. It's gone midnight before i get to sleep

 

Wake up at 6am. Conversation about the toilet is to be had today. Nurse approaches. I'm being moved to another ward. Conversation can wait. I get to my new ward. With my own room!! With a bathroom!! Wait for the nurses to unplug me from the now unneeded heart monitor and blood pressure tube. They connect up oxygen and ask if i need anything. My only question is how long will i have the room? They dont know, it depends if someone else needs it. Its normally for infectious patients. I say if they need to kick me out they can do, but they tell me to make myself comfortable. As soon as they leave, i use the bathroom. Much happier now. Im a fussy eater, but im very much looking forward to the breakfast menu. I have cornflakes, toast and jam, and tea. For a moment I have completely forgotten why im here, and im just enjoying the moment, feeling the room heat up with the upcoming sun. Things are getting better :)

 

Right now, i'm nearly five months off work. Other than the above, i have spent another 14 days in hospital since the third day described above. But thats for another time of writing. Right now, im getting tired and headachey. I've lost alot of my stamina and capacity to operate normally, but not the belief that I will get better. It'll just take time, and learning how to do things i could do before without thinking.

 

I still don't have the answer to what a good life is. I'd like to think i recognise the good in other people, and i have confidence i have some good in me. I'd like to think i'm a good person who occasionally makes bad mistakes. I'm still heartbroken over the person who blocked me, i still don't know what i did wrong. I reread the messages we exchanged several times. I've seen a lot worse go back and forth between other people. Maybe i said the wrong thing, but I meant it in the right way. Maybe it just wasn't meant to be. As i said to them at the time, i don't regret trying to make someone laugh or feel better, i only regret failing in that goal, and not having the chance to fix it when i do wrong, when i make mistakes, as all people do. I hope that's good enough

 

PS this is a story to help others in a similar situation, but if it helps anyone else, then even better. This was my first few days.. I'm doing better now. So will you

I took this macro shot of a syringe needle with a waterdrop by using a Canon EOS 60D with a Canon EF 100mm f/2,8 Macro USM lens.

 

*********************************************************************************************************

 

Camera: Canon EOS 60D

Focal Length: 100mm

Aperture: f/20

Exposure: 2,5sec

ISO: 400

 

press "L" for the best view

Basking in the daylight among the creepiest and ghouliest of Mortem Vis. Happy Church Day, Everyone!

Bauhaus - Rachel Skirt and Jacket

ED. TikTok Bunny White - Common

NEO: Nasal Cannula

 

#N21

#60LSale

#SL

#Fashion

#Halloween

#secondlifefashion

  

not very nice pink paw, but I survive, soon I am fine again :)

  

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BABUSHKA - SNAPSHOT OF A KILLER (Chapter Nine)

    

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Самые недра ада

THE VERY BOWELS OF HELL

 

West London, England

     

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" Keep her sedated and as uncomfortable as you possibly can until my return. I have a little matter to attend to before I have the pleasure of finally putting this bitch out of her misery ".

   

The stifled drone of hazy voices broke into the very depths of Tatiana's lurid nightmares, Visions of her formidable adversary walking out the strange room, the cacophony of dayglo colours and bizarre imagery swirling together in a rambling and incoherent form that slowly followed a pattern of darkness into light, of wild and wonderful shapes into images of normality. The rhythmic drip of a tap grew increasingly louder and the voice of a single male altered from muted tone to perfect clarity as her eyelids flickered wildly like soft satin head scarves in a wind tunnel, and the invasive pain of overhead fluorescent lights began to burn like flames, as she awoke.

 

Confused thoughts and feelings, the realization that her limbs could not move for the tethers that bound them tightly together, eyes scanning the vicinity for clues as to her whereabouts as instinctively she fought to free herself from the bindings which secured both arms and legs to a cold metallic medical table on which she lay.

   

The male to whom Agent Anastasiya had been issuing stern orders prior to departing the scene, gazed down on her from above, hidden behind a white surgeons face mask covering the lower half of his middle aged, pointy facial features, hands upwards and forwards of his torso, not unlike the posture of a kangaroo. Tatiana's head pounded like the big bass drum in a brass band, a searing pain that caused her to wince before regaining some semblance of composure. Waves of pain swept across her temple, the likes of which she had never before encountered, and a bitter taste filled her dry mouth, lips crusty under the tongue, a sharp jabbing pain in her left arm confirmed with a sideways glance at the white plastic cannula taped across her palm, the plastic tube from which went deep into the deep blue artery leading from her middle finger backwards, leaving a clearly visible and hardened vein that stood proud and angry from the torture it had obviously endured.

 

From the pain of the plastic intrusion into her flesh, Tatiana guessed that it must have been inserted for many hours, though her recollections of the events which lead to her capture and detention were only coming through as hazy waves in fits and starts.

   

Eyes following the machinery all around her, she noticed how the two long flexible cords from the three headed cannula led to an upright shiny chromed stand on which sat two full bags of differing liquids, suspended by metal hooks that glistened under the intensity of the lights. One paler in colour than it's stable mate and marked with white lettering too small and insignificant for Tatiana's bewildered eyes to make out, the other darker and unmarked. The third tap, directly at the base of the bothersome contraption, was temporarily capped by a small bright orange bung, traces of dried blood left a residue over the tape which lay in three small strips to secure the device in place.

   

" Oh that headache my dear ", the man quipped with an almost amused tone of voice that positively effervesced with self congratulatory sarcasm as he moved around to Tatiana's left hand side.

   

" I could give you something for it, Codeine would work, some water to take care of that Sahara like dryness that you are tasting right now in your mouth but then you'll be dead in a short while so it would really be a waste of your time and my resources ".

 

His eyes seemed to light up with the obvious smile that beamed from behind that face mask, the wrinkles in the corners of his eyes lighting up like a neon beacon, confirming his middle years, whilst the odour of tobacco emanating from the thin fabric protection was confirmed by the nicotine stains on his fingers as he prodded the Cannula, causing Tatiana yet more discomfort as the line within pushed against her vein.

   

On her right index finger was a plastic crocodile clip with a lead to a bank of machines to the right of the table, her pulse flitting across one of the screens at a reasonably steady rate, and two small circular discs lay affixed to the top of her chest, tiny metallic central balls connected by single leads to a heart monitor and a plethora of brightly coloured readings that Tatiana's eyes could not yet read as they tried to adjust to the reality of her plight.

   

“ Sodium thiopental, Left over from the cold war days, old and crude but so marvellously effective we find with a little dose of Narcosynthesis. You would have been singing like a canary and yet you don't remember a damn thing. You have to admire the beauty of the precious liquid, do you not? “, the man quipped, clearly amused by the situation and gratified by his own handiwork.

 

" Nice tits by the way. So pleasing to feel all, natural ones in these days of implants and surgical realignments, an area of the medical profession that bored me until the chance to take this opportunity came my way. If you are feeling any discomfort down below, it may well be from the roughness of the guards. Not that I saw them taking turns with you, you understand, but in my experience it's often been the case that they do in such circumstances. Well, who could blame them after all, such a pretty little wild animals aren't we ".

   

By now his right hand was stroking Tatiana's face gently, something much to her chagrin as she forcibly shook her head and made his attentions clearly unwelcome.

   

" Where did Anastasiya go to? ", Tatiana asked through pursed lips and an angrily flaring nose, the man smiling as he stepped away from her and walked to a silber metallic petri dish located on one of the side tables that contained blood soaked bandaging and the remnants of a large partly used hypodermic syringe. Gathering up the grimy syringe and returning to her, he popped open the small plastic securing lid to the drip line mid way between one of the fluid bags and the cannula and paused for a moment before inserting the needle tip into the plastic housing.

 

" I assure you that you need not worry your pretty little head over Agent Anastasiya, she'll be back to attend to your final moments shortly and ensure that your journey to the afterlife is as painful and unpleasant as is humanly possible. In the meantime, a little something to have you burningin agony from the inside, a concoction that I myself have developed, with a degree of considerable success if I might be so bold. "

 

Tatiana had already noted the leather restraining cuffs and the omission to tether both legs adequately, just enough play to allow her the opportunity to gather some power in her lower limbs, her right arm already turning inside the leather until her palm was flat to the bed side, pain searing through her body as she carefully began to bend her digits backwards, fingers and thumb tucked over and inwards, pushing back against her own hand, one of the tricks Sergei had taught her in counter interrogation tactics so many years previously. The man checked the two bags of liquid once again, oblivious to the imminent demise of his final breath as he inserted the needle and began to depress the plunger, the slightly orange coloured liquid making it's way into the plastic tubing and heading towards Tatiana's hand. Screaming in pain, Tatiana freed her right hand, pushing her midriff upwards from the bed and levering both legs violently upwards as she grabbed the syringe out of his hand, immediately planting the needle tip deep into his right temple and pumping the contents into his skull. Grabbing a scalpel from near Petri dish on the metal cabinet beside the bed, in an instant she had cut the leg bindings as both ankles locked around the shocked man's head, pulling him downwards and trapping his face into the mattress of the bed.

 

With her right hand she pulled at the cannula, tearing the see through securing tape off and ripping the lengthy plastic tubing out of her palm, a jet stream of fresh blood exploding from the gaping hole and spattering over the white coated man as she used the scalpel to cut the leather binding off her other hand.

   

The sweet taste of freedom was little noted before she ripped the heart monitoring discs and pulse leads from her naked flesh, pulling the man towards her until she had her left arm locked around his throat like a vice, placing the scalpel blade to his neck as she looked around.

   

“ Where the hell am I? “, she spoke angrily, the man grimacing under the pain of the assault as he managed a faint smile and replied.

   

“ The very bowels of Hell, my dear. "

   

" And you can get me out of here, right? ", she demanded, the man managing a faint laugh as he declined her question, fighting for breath as her hold increased, though clearly finding the situation quite amusing.

 

" Please, you have to help me, I'm burning, my head.... ". Eyes turning red, foam bubbling in the corners of his mouth, the man began to violently convulse and it was all that Tatiana could do to keep control of him as he shook and writhed before her.

 

" Then let me make it a little easier for you all, as you're no longer of any use to me it would seem. ", Tatiana snarled as she pushed the scalpel into the left side of his throat and pulled backwards until the blade came out just below his right ear. A muted scream of shock and a degree of gargling followed as Tatiana relinquished her fearsome grip, his hands raised to try and stem the tidal flow of blood from the gaping wound, to no avail. With force, she pushed the man onto the floor in front of her, directly into the plethora of stainless steel waste dishes. Rising up from the bed she spotted the CCTV camera in the left corner of the room, gathering up tray in her right hand and aiming it like a missile to disable the unit, which swivelled and turned away from her direction under impact. Eyes darting quickly left and right, she headed towards the only door into the room, above it a panic button in vivid red which she thumped for all she was worth. The droning alarm siren added to the pain in her head as she crouched down behind the door frame, and waited for her chance of making an escape.

   

Footsteps growing ever closer, voices elevated and tones of concern, as the door opened and a soldier rushed into the room. Combat greens, pristine pressed and black army issue boots bulled and glass-like shiny. Youthful flesh, no more than a fresh faced kid, bewilderment registering upon his face as Tatiana plunged her scalpel into the top of his thigh, rising to her feet and grabbing his Beretta 93 9mm automatic pistol before griping him by the chin and swivelling around to face the corridor outside.

   

Three other soldiers fell consecutively under the hail of twenty Luger 9mm cartridges from the magazine as she lifted the soldier and walked forwards from the room using him as a shield. Throwing him onto the ground as the final rounds were expelled, she reached down and took another pistol and machine gun which she slung over her right shoulder, from one of the freshly fallen corpses, dispatching the injured soldier with a single shot to the back of the skull, before moving deeper into the corridor, back to the pale blue painted walls and headed towards an intersection where four corridors converged in perfect harmony.

   

At that point, she came across a lone female civilian, mid twenties, smart attire with a pencil skirt over a petite frame and black high heels, long brown hair tied back with a single gold clasp, handbag around her left shoulder and a clutch bag in her hand, teary eyes testing water proof mascara that clearly was anything but. Tatiana pinned the young female to the wall, a surprised expression peeking over the forceful hand which gripped her mouth, preventing her from screaming. Tatiana momentarily removed her hand, forcing the cold steel barrel of her automatic pistol into the terrified girl's mouth, as she raised both arms in submissive fright.

   

“ Do you want to live longer than the next twenty seconds? ".

   

The girl nodded, a mouth full of metallic threat and a face full of fear, tears cascading as she looked straight into the eyes of the escaped killer.

 

“ Good, well that's a minor detail that we both currently have in common I guess. Do you speak English? “

 

“Uh Huh” the girl mouthed with subdued tone as she nodded.

   

“Uh Huh is not a language, try stringing a few words together”

 

“ I'm frightened ", the girl replied, liquid streaming from her eyes along with globules of thick mascara that trickled down her reddish cheeks like the banks of a breached river after a landslide of earth.

   

“ Don't be, you're not on my list right now. Do exactly what I tell you and you'll remain off that list. Get me caught and I will kill every person you ever loved before coming for you, starting with your husband. "

 

" Oh I'm afraid that's not possible as I'm not married ", the girl sobbed, now allowed the indulgence of two free hands to grab a tissue from her clutch bag to wipe her eyes.

 

" Your boyfriend then ", Tatiana continued.

 

" No, you misunderstand me, you see, I'm gay ", the girl spurted between the tears.

 

" Your girlfriend then "

 

The girl began balling once more as she explained, " She's just dumped me by text for another girl she works with...."

 

"For fuck's sake woman...", Tatiana was by now losing patience.

   

" Look, let me make it nice and simple for you bitch, help me or you die. OK. I need an exit. Quick. And do me a favour will you, try to act as naturally as you can or else you'll get us both killed. . The girl allowed her eyes to dart quickly to her left, towards the end of the corridor which curled away out of sight. Tatiana lowering the pistol from the girls face and pushing it into her rib cage with a menacing prod, eyes scanning the location feverishly.

 

“We need to exit via the stairwell and out onto the road, I'm parked there. We're not supposed to do so but I do it all the time and security here is pretty lacking at the best of times, you know, macho men and their stupid guns and all. Here's my level one pass that will get you through the security door, and my car keys "

   

“Keep them”,Tatiana quipped, “You're driving”.

   

Down the corridor and through the security door, the green light flashing merrily to afford exit into the South Stairwell as the card was entered, the pair entered the car park and located the terrified woman's shiny black pearlescent Porsche 911 Carerra, the doors opening as she blipped the black leather key fob.

 

" How much are they paying you for Christ's sake! ", Tatiana exclaimed as she ran a finger along the seductive bodywork and beckoned the girl over.

 

" I would have thrown you in the trunk but seeing as it's actually in the hood and not big enough to store anything bigger than a handbag, you'd better get inside. The smell of leather and real walnut wood permeated the confines of the capacious boot as Tatiana closed it down behind her, instructing the woman to drive her to the safety of city. The escape was made, freedom found and whether or not the young Porsche owning lesbian would live to see another sunrise depended upon the mood and whims of a natural born killer.

     

.

   

Rewritten on August 1st 2011

 

Originally penned in August 2010

  

Photograph taken of a Porsche 911 just off Bedford Street near The Strand in Central London, England, at 06:20am on July 14th 2011.

 

Nikon D700 28mm 1/125s f/4.0 iso200

 

Nikkor AF-S 24-70mm f/2.8G ED IF. UV filter. Nikon GP-1

  

LATITUDE: N 51d 30m 33.53s

LONGITUDE: W 0d 7m 27.46s

ALTITUDE: 43m

 

A photo taken after my Knee Operation on my Iphone in March

Today I received a photograph of my 10 year old granddaughter Kamrey. She was smiling – smiling despite being connected to numerous tubes, monitors and a nasal cannula for breathing. She was having a short break from the face mask that normally supplies her oxygen. Kamrey was severely...

 

www.glimpseofheavenbook.com/to-live-greatly/

© Rob Wiltshire

 

This is moments after I came to following my op. My wife helped me take a photo of myself for my 365, but I was just concious enough to know I didn't want to post up a picture of my face with NG tubes and oxygen masks covering it. So I quickly took a photo of my arm before I fell asleep again!

Klein muisje mag de kabel vasthouden.