Achives from Author

September Patient Newsletter Orange County

By editor
September 15, 2023
Join us for "Dinner with the Docs" Medicare 101 Event

Looking for an easy way to learn about your Medicare options?

Medicare's Annual Enrollment Period (AEP) is October 15th -December 7th. Cut through the confusion of Medicare during open enrollment and join us for our next Dinner with the Docs presentation led by CEO Gregg DeNicola MD.  Dr. DeNicola will provide a clear overview to help you navigate the Medicare landscape.  

A community Medicare representative will also be on-site to answer questions and if preferred, schedule a more extensive complimentary one-on-one consultation to help with the following during open enrollment:
-How to compare plans to choose the right one for you
-Which Medicare plan options are available to you
-How to maximize your benefits and make the most out of them
-Up-to-date Medicare information

Space is limited so email or call 714-646-8058 to RSVP today! RSVP's are required and you need NOT be a patient to attend; the event is open to the public so please bring a family member, co-worker, or friend.  Dinner is provided.

What- "Dinner with the Docs" Medicare 101
When- Wednesday, October 4th,  5:30 pm
Where- 18200 Yorba Linda Blvd. Ste 250 (Caduceus Family Physicians event center) Level Two
 
Confirm Your RSVP
September is Healthy Aging Month 

September is Healthy Aging Month - an annual event focusing on the positive aspects of growing older. During this time, we look to highlight the importance of habits that can help you stay healthy as you age. 

Physical Activity- Regular exercise and preserving muscle mass can help you maintain your health, independence, and overall mobility as you age. It may also aid your energy levels, sleep, strength, and more. Exercise can also reduce the risk of stroke, heart attacks, and obesity — and it may even help prevent different forms of cancer like prostate and colon cancer. 

Healthy Eating- Your diet has a direct influence on health and well-being in many ways. From bodyweight to the prevention of conditions like high blood pressure, heart disease, certain cancers, and type 2 diabetes. For most adults a healthy diet includes healthy fats, complex carbs, and good amounts of protein. Eating a high quality Mediterranean diet is recommended. 

Getting enough sleep- Most adults need 7 to 9 hours of sleep every night. Not getting enough sleep can affect your mood, memory, and cognitive function. Studies have found that those in their 50's and 60's that had 6 hours of sleep or less were more at risk of developing dementia.  Getting a good amount of sleep is also associated with a lower risk of obesity, heart disease, and lower rates of insulin resistance.

Mental Health- It’s important to maintain social connections throughout your life. Isolation and disconnect can inevitably create feelings of loneliness. Studies show that loneliness causes a higher risk of heart disease and depression in older adults. Stress can also play a factor. Cortisol (the stress hormone) levels naturally increase after middle age. This increase in stress may actually cause changes in the brain. Learning to manage stress is key in minimizing its effects. Our behavioral health partner, Chiron Psychological Inc., is here to help any counseling and hypnotherapy needs. 

Fall Prevention- Did you know that one in four older Americans falls every year? Falls are the leading cause of both fatal and nonfatal injuries for people over the age of 65. Falling and fear of falling may prevent older adults from staying active, which leads to reduced mobility, diminished quality of life and actually increases their risk of falling.

Caduceus and PDQ Urgent Care & More can provide a fall risk assessment at any upcoming appointment or same day visit and for those deemed high risk, we can schedule a complimentary fall risk assessment in your home with our community partner Home Safety Advisors. Check out the latest podcast with Home Safety Advisors on "Health Talks with Dr. Trinh, on OC Talk Radio" to learn more about fall risks and prevention. 
 
Reserve Your In-Office Fall Risk Assessment
 

“Green Docs” is a podcast dedicated to helping expectant mothers understand how our changing environment, and climate change specifically, is threatening pregnancies and our general health. 

Our CMO Nathaniel DeNicola MD is the co-host of this informative podcast. Listen to the most recent interview here. 

CMO Patient Blog- Hurricane Hilary Safety Tips

By editor
August 18, 2023

August 18, 2023

To Caduceus patients and the community:

At present, Hurricane Hilary is due to reach Southern California in the next two days and is projected to be the most intense tropical storm we have seen in 80 years. This would include heavy rainfall, severe winds, and power outages.

While hurricane projections can vary widely (as I remembered well from my residency in New Orleans), here are some safety tips if hazardous conditions do occur.

  • Use caution when going outdoors and avoid driving in torrential rains. Southern California roads are not accustomed to hurricane-level amounts of water.
  • Be aware of slick surfaces that can lead to a fall. Caduceus has been offering Fall Prevention Screening to all patients – you may be surprised by your actual risk. For example, 1 in 4 pregnant women experience a fall during their pregnancy.
  • Avoid hazardous conditions by scheduling a video visit online, request in your patient portal, by live chat from our website, or our dedicated appointment line at 844-807-8558.
  • For Caduceus 4 Women patients: take advantage of our remote monitoring services with e-Lovu health to track mom’s blood pressure and baby’s heartbeat from the comfort of your home.
  • Protect your indoor environment by securing loose doors, windows, or other openings.
  • For patients with respiratory disease, like asthma, or severe allergies – avoid being outdoors during times of high winds. This could be worse than the typical Santa Ana winds.
  • Check that you have medication refills to last you one week. If you need a refill, contact your provider through your patient portal.
  • Prepare a “go bag” in the case of evacuation or extended time without power:

-Phone and computer chargers plus pre-charged battery packs

-Drinking water

-Non-perishable food and snacks

-Games that don’t require electricity

-First-aid kit

  • Follow Caduceus on social media for health alerts and as a backup if phone lines are down:

-Facebook, Instagram, or Twitter

Of course we hope this is all “full of sound a fury, signifying nothing” but Caduceus is here for you, rain or shine!

Nathaniel DeNicola, MD, MSHP, FACOG
Chief Medical Officer | Caduceus Medical Group

CMO BLOG- UV Safety Awareness Month Orange County

By editor
July 27, 2023

Summertime and the livin’ is easy…

From George Gershwin’s opera lullaby to Ella Fitzgerald’s jazzy soundtrack right up to Sublime’s beach-rock sensation, “Summertime” has been synonymous with sunny, soothing goodness. Then Lana Del Rey came along and introduced “summertime sadness”, and who knows what to think?

Here at Caduceus we prefer the former, brighter version – but it does come with some precautions. So this summer we’ll give you all the health tips you need to keep the livin’ easy and avoid sizzlin’ like a snare.

First, let’s talk sunscreen.

You saw in our monthly newsletter that July is UV Safety Month, which means paying extra attention to protecting your skin from the sun’s damaging UV rays (both UVA and UVB). When it comes to sunscreen there are two basic types: chemical and physical.

Chemical sunscreens are like a “sponge” – sinking into your skin and absorbing UVB rays before they get to your tissue. They tend to be more popular because, well, they are simpler to wear and don’t leave filmy residue. But there are some caveats: the chemicals need time to work so apply 30 minutes before sun exposure; they do not filter UVA rays (which can cause wrinkles); some of the chemicals themselves are a problem so look for a “parabens free” label to avoid hormone disrupting effects.

Physical sunscreens act like a “shield” – creating a physical barrier that sits atop the skin blocking both UVA and UVB rays. Because they don’t absorb into skin these are often good choices for people with sensitive skin, for pregnant women, and children. The only real downside to these are the pasty white residue; there’s a reason the lifeguards use them!

Whichever sunscreen you choose there are a few common rules:

  • Reapply every 90 minutes
  • Use SPF 30 or higher
  • Wear sunscreen every day – dermatologists agree that this is the best habit for healthy skin. Many face moisturizers have sunscreen for this reason. Remember UV rays get through office windows, car windows, and are present on cloudy days.
  • Any sunscreen is better than no sunscreen – the best sunscreen is the one you wear.

You can see more details about sunscreen and beauty products with the CMO interview in Laguna Beach Magazine.

Second, we’ll review overall summer health.

Wearing sunscreen is just one step to protecting your skin while enjoying the sunshine. Other considerations are just as – or even more – important.

Timing – the best sunscreen is avoiding the sun altogether. Yes we know it’s Southern California and you want to enjoy it! But be mindful of peak sun exposure: 10a to 4p. Also you should download the OSHA Heat Index app to keep track of local alerts.

Remember: everyone is at risk for overheating – especially people over 65 years old, those with medical conditions like asthma and heart disease, and pregnant women. Check out the CMO interview with Emmy-winning meteorologist Miri Marshall talking specifics on heat and health.

Hydration – you probably learned growing up to drink 8 glasses of water per day. Based on good evidence? Not really. If you were looking for a number something between 2-3 liters would be closer to the right answer – but the best advice is to drink water well ahead of thirst. If you’re feeling thirsty you’re already behind. Water containers like glass and ceramic are preferred over plastic bottles especially for daily consumption.

Clothing – in some ways this is the best sunscreen of all. It doesn’t mean wearing big heavy clothing on a hot day. Brimmed hats, light colored long sleeved shirts, cover-ups, and UV-resistant clothing all get the job done.

Air Quality – don’t forget about the air pollution. It’s not just Canadian wildfires blowing smoke our way; some types of air pollution like ozone are greater during extreme heat waves. Download the EPA AirNow app to get real time air quality updates and avoid times of high alert.

Summary: Summertime is one of the best times of the year in Southern California for outdoor fun and you should enjoy it. These health tips can keep the livin’ easy and worry-free while you swim, surf, and generally soak up the sunshine. Wear sunscreen everyday, avoid peak sun exposure, drink tons of water, and track apps for daily alerts on heat and air quality.

Caduceus offers complimentary skin screens to check for a specific mole or mark that could be dangerous. Make an appointment here, or visit one of our future Dinner With The Docs Skin Screen events.

Nathaniel DeNicola, MD, MSHP, FACOG
Chief Medical Officer | Caduceus Medical Group

CMO BLOG- Tis' the Season- Allergy Testing 

By editor
June 1, 2023

New Allergy Testing: Scratch and No-Sniff

Ah-choo!  

Yes it’s that time of year again when April showers have borne May flowers, and with that allergy season arrives in full bloom.  Let’s hope you’re not allergic to puns.  So if you’ve recently noticed a scratchy nose, watery eyes, and sensitive skin – not to worry, we can start from scratch to combat that sniff.

Caduceus has been itching to announce our new allergy testing: a skin scratch test available at all office locations.  No needles, no pain, and no need to wait.  Caduceus patients can sign up for testing today and receive their results within 1-3 days.

So, who should be tested?  

The short answer is anyone.  While allergies can occur at any age, typically they appear in childhood and peak in early adulthood.  Typical symptoms include sneezing, runny or stuffy nose, itchy or watery eyes, itching mouth and skin, and fatigue.  Less common symptoms could be unusual rashes, sinus headaches, swollen lips and tongue, and even behavioral changes.  

You should also know that allergies generally come in three seasons – spring, summer, and fall – so we find ourselves right in the middle of peak exposure.  And remember all that rain we had from January through March?  Well Southern California experts project that the extra downpour will break up pollen and create a stronger season than usual once the winds of summer arrive.

Now what should you do if you think you have allergies?

First, get tested.  As common as allergies are this time of year, many other conditions can mimic this histamine-driven response: an infection like the “common cold”, sinus infection, non-allergic rhinitis (runny nose), food sensitivities, and medication side effects.

So you can direct yourself for allergy testing – but make sure you discuss the results with your doctor to make an assessment and treatment plan.

Other proactive things you can do to keep allergies under control:

  • Saline sprays. These over-the-counter saltwater sprays can flush out your nasal passages. They help clear out pollen and other irritants.
  • Protection. Reduce exposure to pollen: Don't do outdoor activities when pollen counts are high. Most pollen peaks between 5 a.m. and 10 a.m. each day, and can also be high around midday when it’s warm and windy. 
  • Helpful foods. Eating something spicy can thin mucus and clear congestion. A teaspoon of honey can soothe your throat if it gets irritated from coughing all day. 

In summary:

  • Allergy season can be nearly year-along and affect anyone, and this year in Southern California could be especially itchy. 
  • Caduceus offers on-site testing with a scratch test – no painful needles – with results in 1-3 days. 
  • Make an appointment with your doctor to review these results and make a treatment plan – so you can stop and smell the flowers worry-free.  

Nathaniel DeNicola, MD, MSHP, FACOG
Chief Medical Officer | Caduceus Medical Group

PATIENT BLOG ORANGE COUNTY OZEMPIC

By editor
May 19, 2023

The Doubting Doc- Ozempic, Wegovy, Mounjaro...Oh My! Weight Loss FAQ's

Let’s play a short game of Jeopardy…
 
Answer:
I need to lose weight
I'm overweight
I'm obese
I'm fat
I'm going to stop eating carbs
No, meat
No, gluten
No, dinner
I'm going to exercise more--at least twice a week
 
Question:
What does a typical doctor hear 99 times a day from their patients?
 
Especially post Covid, we are seeing more obesity than ever. Recent studies put at 80% the number of people over their ideal body weight.
 
With obesity comes obesity humor. While its felt to be in poor taste to fat shame anyone, since MY BMI is teetering around 30, maybe I should poke fun at myself.
 
Why does me remembering my diet not kick in until my 10th donut?
or
My wife and I went on a diet and lost 10 pounds combined...she lost 20 just herself!
 
We define obesity as a BMI over 30. (All you need to calculate your BMI is your height, weight, and Google.) As doctors, our advice has been very simple over the years- diet, exercise, reduce stress, and if all else fails, have surgery to shrink the stomach.
 
But weight loss surgery seems a bit extreme for most, and diet pills had their share of issues- some are not safe or are addictive. Others have poor long-term results. Most were only good for 20 pounds. Few were FDA approved for weight loss.
 
Introducing…the current game changer for weight loss in patients who need to lose 25 or more pounds!!
 
GLP-1 agonists.
 
In plain English, they reduce hunger and food intake at the biochemical level. They are considered by the medical community to be safe and effective.
 
The three most popular choices are Ozempic, Wegovy, and Mounjaro. Since we don't have a horse in this race, let’s discuss each one to see if any may be right for you or a loved one. Remember, Caduceus never allows drug "detailing,” so no Laker tickets were used in preparation for this blog. Not even a coffee cup.
 
Ozempic (Semaglutide)
 
It is FDA approved for Type 2 Diabetes---it is NOT FDA approved for weight loss, but patients who take it tend to lose weight---10-15% of body weight is common. Many patients have been able to reduce or go off diabetic, lipid, and hypertensive medications with the weight loss. It requires a weekly shot and a monthly follow-up. Once weight loss is established, it is safe to continue taking it long term. In fact, going off of it risks returning to you to your original weight.
 
Wegovy (Semaglutide)
 
It is an identical version of the drug Ozempic - with a few differences. For one, the dose used can be higher, resulting in higher weight loss. For another, it IS FDA approved for chronic weight management, and NOT for diabetes. You will need a BMI of 30, or 27 plus a "co-morbidity" such as hypertension or high cholesterol for FDA approval and insurance payment. Otherwise the cost, weekly shots, and monthly long term follow-ups apply to both.
 
Mounjaro (Tirzepatide)
 
It is a GLP-1 agonist plus it inhibits a second peptide that curbs appetite and produces "early satiety"--i.e. you feel fuller faster. It is FDA approved for diabetes but has an application into the FDA for approval for weight loss. It is expected to be approved, which would give it the distinction of the only medication that is FDA approved for both diabetes AND weight loss. In fact, the FDA has agreed to "fast-track" its weight loss approval. It also is the same weekly shot story, but the dose can be pushed even higher than the semiglutides. In head-to-head studies, Mounjaro has the highest weight loss, but the most side effects. The cost is comparable.
 
There were "Hollywood whispers" that Adele, Rebel Wilson, and Kim/Khloe Kardashian all have used these medications successfully---but in fact all four, they deny it loudly, saying diet and exercise were the methods for their weight loss. Being trusting, we will take them at their word. We do caution our readers that it is very difficult to get a 30-pound weight loss (or more) with diet and exercise alone, especially keeping it off.
 
Since nothing is too good to be true, what are the downsides to taking these meds? I counted five right off the bat.
 
1. They are expensive unless you allow us to get insurance approval. About $450/week, maybe half that if you try to use a compounding pharmacy (see BEWARE below). That is just for the drug itself. Most office visits may be paid for by the insurance company if there is medical necessity.
 
2.They are so popular, no one takes them anymore (Thanks to Yogi Berra for the inspiration) --meaning their popularity has caused severe shortages in some areas. Finding the meds may be tough depending on the doctor and pharmacy you pick. Hopefully the shortages are being fixed.
 
3.The main side effects are GI- nausea, cramping, etc. Some report an intolerance for alcohol. Rare reports of hair loss. These seem more pronounced with Mounjaro.
 
4.To maintain the weight loss you probably will take the medication long term--and still diet and exercise. Seems there's no getting around that advice.
 
5. You ideally need an experienced provider who can help select the right medication,  know how to get insurance approval if necessary, and correctly adjust the dose monthly.
 
And now for this commercial break---endorsed by the CEO and CMO of Caduceus:
 

  • At Caduceus and PDQ Urgent Care and More, we have trained providers to assist you if you feel you may benefit from these medications.
  • We can do most of the visits via Zoom telehealth if preferred. 
  • We will assist in selecting the medication best suited for you depending on your health conditions and weight loss needed, plus the financial situation. Also, we will work hard to obtain insurance pre-authorization.
  • If a compounding pharmacy is to be used, we will vet them for you.
  • If you need a quick lesson in giving the subcutaneous shots, we will teach that to you.

My BMI is so high, when I contracted a case of flesh-eating bacteria -they died from exhaustion.


Certainly, there are various options for getting this prescription--let us offer a few cautions.

  1. There are hundreds of "online weight clinics" offering these meds with a quick ten-minute video visit. There are too many other legit choices to resort to these; we plead you to use caution.
  2. Many "clinics" offer just one drug, and have you enroll in a "subscription" model where you pay one monthly or even yearly fee to cover the compounded medication, office visits, blood work etc. Where subscriptions are great for your TV streaming, beware of using them with your health care. Most legit doctors do not need to resort to a subscription gimmick that ties you down to that provider long term.
  3. Beware of providers that do not require blood tests, do not ensure you are up to date on your screenings, or decline to offer to teach you how to give the shots. These are signs of a "mill" and should be avoided.
  4. "No need for preauthorization" advertised. Either they may be dispensing counterfeit medications, or using a compounding pharmacy that may or may not be legit.
  5. The FDA has announced they will be investigating these meds from compounding pharmacies - why?

Semaglutide is governed by the regulations that restrict compounding pharmacies from making replications of patented therapeutics.

In defiance of these regulations, some compounding pharmacies have compounded semaglutides with other medications, thinking that gets around the FDA scrutiny.

It doesn't. 

If this is all Greek to you, we get it. Just be very careful accepting "cheap" or "generic" semaglutides. If you cannot vet them, be sure your doctor can.

I for one, am not offended when I am called overweight-- I'm much bigger than that.


In Summary:

  1. At least three newer medications are available to assist with chronic weight loss management and may be FDA approved and/or covered by insurance.
  2. These medications are not addicting, not short term solutions, and recognized as safe and effective by most doctors.
  3. They all require a weekly shot, a monthly follow up, and serial blood tests - as well as diet and exercise.  
  4. There is NO evidence any celebrity has ever used any of these medications. 
  5. Be aware of possible shortages, inexperienced doctors, shady online weight loss clinics, unvetted compounding pharmacies, or poor technique at giving your own shots.

I'm so obese my blood type came back "gravy." 


Gregg DeNicola MD CEO & Chairman
Caduceus Medical Group & PDQ Urgent Care & More 


If you feel you or a loved one may be a good candidate for these medications, please reach out to us TODAY:

  • Call our dedicated appointment line at 844-807-8558
  • Request an appointment through your patient portal account
  • Live chat from the Caduceus website or app

PATIENT BLOG ORANGE COUNTY Colorectal Cancer Awareness

By editor
May 19, 2023

As we near the end of Colorectal Cancer Prevention Month, Caduceus would like to highlight for our patients that awareness of gut health is just the beginning.  With proper education and screening, colon disease can be treated, defeated, or avoided altogether.

First, let's talk about the late form to be avoided: colorectal cancer. It's the third most common cancer in both men and women in the United States, but the good news is that it's also one of the most preventable. Screening tests can detect abnormal growths in the colon, such as polyps, before they become cancerous.

The US Preventive Services Task Force recommends that people with an average risk of colorectal cancer start regular screening at age 45. I know, that likely sounds too young for something like this. But for people with a higher risk, such as a family history of colorectal cancer, screening may need to start earlier.

Others who should be screened earlier are people with:

  • Inflammatory Bowel Disease
  • Personal or family history of colorectal cancer or colorectal polyps
  • Genetic conditions like familial adenomatous polyposis (FAP) or Lynch Syndrome

Now you might be thinking that screening sounds like a good idea, but you’re dreading that right of passage exam.  We’re here to get you through to the other side.  While colonoscopy is the most common and often the preferred method (yes with the option for medication), there are other routes including stool tests, flexible scopes, and virtual colonoscopy.  These can be discussed with either your primary care doctor or your Gastroenterology specialist.

But screening isn't the only thing you can do to prevent colorectal cancer. You can also make lifestyle changes that can reduce your risk, such as:

  • Eating a healthy diet that's high in fiber and low in red and processed meats
  • Maintaining a healthy weight
  • Exercising regularly
  • Quitting smoking
  • Limiting alcohol consumption

You should also know that colon cancer has started to skew younger: a new study from the American Cancer Society found that 1 in 5 cases diagnosed today occurs in adults younger than 55, compared to 1 in 10 in 1995.  While no one cause has been identified – genetics, the microbiome, and low screening rates are all believed to play a factor.

So in addition to keeping up with your screening be sure to watch out for worrisome symptoms: abdominal pain, unexplained weight loss, changes in the frequency, size, or appearance of stools, and rectal bleeding.

In the end, trust your gut.

Taking care of your colon is an important part of overall health. By maintaining a healthy lifestyle and getting screened regularly, you can reduce your risk of colorectal cancer.  

If your health plan requires a referral, please schedule an in-office visit or Zoom call with your primary care provider (PCP).  You can book directly from the button below or request an appointment through your patient portal.

If your health plan does not require a referral, you can book a Zoom call with our GI advanced care practitioner for your colonoscopy screening, that would be needed prior to booking your procedure. You can request an appointment from the button below or request directly through your patient portal. 


Nathaniel DeNicola, MD, MSHP, FACOG
Chief Medical Officer | Caduceus Medical Group

Fall Prevention Orange County

By editor
February 23, 2023

Keep the Spring in your Step

In a few weeks we will face that annual ritual of resetting our clocks while reciting, “spring forward, fall back.”  But this year at Caduceus it’s “spring forward, fall not.”

That’s right, this spring we are making falls a thing of the past.  Caduceus is proud to announce its Fall Prevention Program complete with clinical counseling, supply recommendations, and a free home inspection. 

Why focus on fall prevention? 

Well, first and foremost, falls are a common problem among senior citizens that can lead to serious injuries and reduced independence.  According to the Centers for Disease Control and Prevention, one in four Americans aged 65 and older falls each year – and less than half tell their doctor!  Since falling once doubles the chance of falling again, it’s time to talk about it.

The health risks of a fall may seem obvious – like broken bones in the arms, wrist, or hip – which can reduce independence and hinder daily activities, but there are other concerns.  Head injuries can be especially dangerous for seniors or people taking blood thinners, which can exacerbate a brain injury. 

Plus, even if you don’t actually suffer a spill, just the fear of falling can be a problem – people who limit activities become weaker and deconditioned, which among other things increases the chance that the dreaded dive occurs after all.

So let’s break the fall before it happens, and it helps to know who is at risk.  Several factors can increase a senior's risk of falling, including:

  • Age-related changes in balance, coordination, and vision
  • Lower body weakness
  • Vitamin D deficiency
  • Chronic health conditions such as arthritis, diabetes, and dementia
  • Medications that can cause dizziness, drowsiness, or other side effects
  • Environmental hazards, such as uneven floors, poor lighting, and loose rugs or carpets

Remember it’s not only seniors who can get tripped up.  Anyone recently discharged from the hospital, those recovering during postoperative care, and people who live alone should also use some extra caution.  And let’s not forget about expectant mothers – as 1 in 4 pregnant women experience a fall during pregnancy, and 1 in 10 fall multiple times. 

Ok, so how do you prevent this free fall from health and independence?  We at Caduceus have you covered.  First, you can take the following steps:

  1. Exercise regularly to improve balance and strength. This can include activities such as walking, Tai Chi, or water aerobics.
  2. Review and follow your medications with your doctor or health professional. Some medications can increase the risk of falls.
  3. Remove tripping hazards from your home, such as loose rugs, cords, or clutter. Keep frequently used items within easy reach to avoid the need to climb or stretch.
  4. Use assistive devices, such as a cane or walker, to help with balance and stability.
  5. Make sure your home is well-lit, especially in areas you use at night, such as the bathroom and bedroom.
  6. Wear shoes that fit well and have non-slip soles. Avoid going barefoot or wearing socks.
  7. Have your vision and hearing checked regularly and wear glasses or hearing aids as prescribed.
  8. Look into a medical alert system; some are covered by insurance.
  9. Consider installing handrails or grab bars in your home, especially in the bathroom.

Second, get your home inspected!  As a service to Caduceus patients we are offering a free home inspection with a safety score to help identify preventative measures and keep that spring in your step. 

In conclusion, falls are a common problem among senior citizens that can lead to serious injuries and reduced independence.  Many age-related and environmental risk factors can be mitigated with proper counseling and home safety checks.  To schedule a home inspection email support.


Nathaniel DeNicola, MD, MSHP, FACOG
Chief Medical Officer | Caduceus Medical Group

CMO PATIENT BLOG ORANGE COUNTY- RSV FAQ's AND WHO IS HIGH RISK?

By editor
January 13, 2023
Aw-chew!
Uh oh.  Well maybe it’s nothing…
 
Aw-chewww!
Ok that was a good one.  That’s it, get it all out of the system.  Two sneezes and off to wor…
 
Aww-chewwwwy!
Oh boy.  What do I do now?
 
You’ve come to the right place.  Here at Caduceus & PDQ Urgent Care we have you covered.
 
The first thing to know is that respiratory viruses are still on the rise – yes, other than COVID-19 – particularly Respiratory Syncytial Virus, or RSV.  This is a highly contagious virus that can cause severe respiratory illness in children, pregnant women, and older adults. 
 
RSV is a leading cause of bronchiolitis and pneumonia in young children and can be particularly dangerous for premature infants and those with underlying health conditions. Pregnant women and older adults with weakened immune systems are also at increased risk for severe RSV infection.
 
Symptoms of RSV infection may include coughing, difficulty breathing, and a runny nose. In severe cases, the virus can lead to hospitalization and, in rare cases, death. 
 
But not to fear, because the next thing to know is that it is preventable.  The best way to prevent RSV infection is to practice good hygiene, such as washing your hands frequently and avoiding close contact with sick individuals.

Best Practices To Prevent Transmission of RSV

-Wash your hands frequently with soap and water for at least 20 seconds, especially before touching your eyes, nose, or mouth.
-Avoid close contact with people who are sick, and stay home if you are feeling unwell.
-Cover your nose and mouth with a tissue or your elbow when you cough or sneeze, and dispose of used tissues immediately.
-Clean and disinfect frequently-touched surfaces, such as toys, doorknobs, and light switches, daily to help prevent the spread of germs.
-Avoid touching your face, especially your eyes, nose, and mouth, as this is how the virus can enter your body.
-Avoid crowded public places, especially during peak RSV season, which typically runs from late fall through early spring.
-Keep infants and young children away from people who are smoking or who have recently been in contact with smoke, as the virus can be inhaled in cigarette smoke.
-Avoid placing an infant in a car seat or stroller with a blanket, as the blanket can trap smoke and other pollutants close to the infant's face.
-If you are a parent or caregiver of an infant or young child, do not allow them to share pacifiers, bottles, cups, or eating utensils.
-If you are a healthcare worker or caregiver for high-risk individuals, wear a mask and gloves. 

Let’s examine more who should be most careful during this RSV season.  
 
Children are at the greatest risk for RSV infection, especially those under the age of two. Premature infants and those with chronic lung or heart conditions are particularly vulnerable to the virus. It is important for parents to be aware of the symptoms of RSV and to seek medical attention if their child is showing signs of infection.
 
Pregnant women are also at increased risk for severe RSV infection, as the virus can be transmitted from mother to baby during delivery. Pregnant women should take extra precautions to avoid exposure to the virus, such as avoiding crowded places and washing their hands frequently.
 
Older adults, especially those over the age of 65, are also at increased risk for severe RSV infection. This is because the immune system weakens with age, making it harder for the body to fight off the virus. Older adults should take steps to protect themselves from RSV, such as getting vaccinated and practicing good hygiene.

GroupRisk for RSV infection-

-Children under 2 High
-Premature infants High
-Children with chronic lung or heart conditions High
-Pregnant women High
-Older adults over 65 High 

In terms of treatment, it’s important to know that there is no specific cure for RSV infection; which is why prevention is so important.  Early monitoring by a health professional for those at high risk is the best approach.  You can augment your monitoring at home with a pulse oximeter: typical numbers should be above 95% – and contact your healthcare team right away for numbers less than 90%.  
 
Supportive care for fever and pain can be provided with medications like acetaminophen (Tylenol) and non-steroidal anti-inflammatories (Ibuprofen, Advil, Motrin).  Most individuals with the virus will recover on their own within a few weeks. However, severe cases may require hospitalization and supportive care, such as oxygen therapy and fluids.
 
Also remember, your cough and sneeze might not be RSV at all.  As a recent LA Times article advised us, we are currently facing a triple threat of respiratory viruses: RSV, COVID-19, and Influenza.  While the symptoms may be similar, there are some key differences between the three infections.
 
Symptoms of RSV infection may include coughing, difficulty breathing, and a runny nose.
 
Symptoms of COVID-19 may include coughing, difficulty breathing, and fever. Other common symptoms include loss of taste or smell, body aches, and fatigue. 
 
Symptoms of influenza, or the flu, may include fever, body aches, and a cough. Other common symptoms include chills, fatigue, and a sore throat. 

Infection    (Common symptoms) (Incubation period)
-COVID-19  (Coughing, difficulty breathing, fever) (2-14 days)
-Influenza (flu) (Fever, body aches, cough) (1-4 days)
-RSV      (Coughing, difficulty breathing, runny nose) (1-7 days)

One key difference between the three infections is that some individuals with COVID-19 may not have any symptoms at all, while symptoms of influenza and RSV infection are typically present. Additionally, the incubation period (the time between exposure to the virus and the onset of symptoms) is typically shorter for RSV and influenza than for COVID-19.

In summary, RSV is a highly contagious virus that can cause severe respiratory illness in children, pregnant women, and older adults. To reduce the risk of infection, it is important to practice good hygiene and avoid close contact with sick individuals.  To have that cough or sneeze examined we at Caduceus & PDQ Urgent Care are here for you with our online chat, same-day urgent care appointments, and telehealth checks from the comfort of home. 

Nathaniel DeNicola, MD, MSHP, FACOG
Chief Medical Officer | Caduceus Medical Group

CMO Covid Blog Orange County Natural Antibodies "Get No Respect"

By editor
March 1, 2022

Natural Immunity- The Rodney Dangerfield of Covid

"When I was born the doctor came out to the waiting room and said to my father, “I’m very sorry. We did everything we could…but he pulled through.”

"My mother had morning sickness AFTER I was born."

Rodney Dangerfield was born Jacob Cohen in New York in 1921. His first job was writing jokes for standup comics under the name Jack Roy.  Making a living was hard so to support his wife and family he sold aluminum siding and finally quit show business altogether at age 30.

He was so little known he once said, "At the time I quit, I was the only one who knew I quit."  At age 40, he tried comedy again. No one would book him. He was puzzled; he felt his jokes were good, so what was the problem?  "I played one club—it was so far out; my act was reviewed in Field & Stream."

Then- an epiphany. His whole life he never had been shown respect--from his parents to his teachers, and then in his job. He was a 40-year-old loser. And this was in real life.  He changed his name to Rodney Dangerfield and based his new act on a self-apparent truth- that he was a loser who got no respect.

The rest is comedy history. 
For the rest of his life, he would start off his act with four words that sent the crowd into hysteria--"I get no respect.”

"My mother never breast fed me. She told me that she only liked me as a friend."
"My father carries around the picture of the kid who came with his wallet."

So now to discuss the Rodney Dangerfield of the Covid pandemic--Natural Immunity ("NI").  It's what you have in your blood to help prevent future Covid infections-IF you have had Covid. 

Natural Immunity gets no respect.
Multiple Studies show it is superior to vaccination immunity- But no one asks for proof of it.
Concert Halls? The fat lady sings on NI. Ballparks? You're OUT, NI.
Airlines? Take a flyin’ leap.
Cruise Ships? Take a long walk off a short pier, natural immunity.
They want to see your vaccine card.
Natural Immunity? That and $2.50 will buy you a cup of coffee.

"My natural immunity test result fell in a sandbox--and the cat kept covering it up." 

Even more disrespectful is when you go to events such as concerts and ball games. If you do not have your full vaccine card, they WILL accept a negative "rapid" test---which is useless. It is not even indicated in people without symptoms. In fact, it may be harmful, giving a false sense of security when in fact you are actively spreading Covid with a meaningless false negative test in your pocket.
But try showing proof of natural immunity--you may as well be showing your Amazon gift card.

Clearly, being fully vaccinated AND the proud owner of natural antibodies would be ideal-but arguably unnecessary.

Teachers-doctors-pilots-and even the critical truck drivers and longshoremen we need for the supply chain have been fired despite having good proof of protection from natural immunity.  Illustrating further the lack of respect for natural immunity - a booster six months old is considered protective-despite loads of evidence it may be worn off by then.  Our public health officials and government have not even approved a needed 4th dose of the vaccine-- here is a CDC quote from a few days ago:

"At this time, CDC does not have a recommendation for a fourth dose/second booster for most Americans," said Scott Pauley, a CDC spokesperson, referring only to people who are not immunocompromised.
Yet we see thousands of people contracting Covid with three doses, especially if the third dose is over four months old.

The CDC told natural immunity they weren't as good as vaccine immunity to prevent Covid.  Natural immunity said, "I want a second opinion!"
"Ok, you’re ugly too!" said the CDC.

Natural immunity gets no respect.
NI works because the immune system works.
Working as an alarm system that sends out soldiers when the alarm is sounded, the soldiers stay around after they neutralize the perpetrator. This is true of a true intruder (like Covid), or an impostor that tricks the alarm company to send out soldiers (like vaccines).
In both cases they are sitting in your blood stream awaiting a new infection--making it difficult to get infected once the antibodies are in your system.
The facts are that the soldiers are bigger and better from an actual Covid infection than the soldiers that responded to the imposter antigen. And yes, I have proof.
Yet the natural immunity gets no respect. Just like Rodney.
It makes sense that the antibody response is linked to length and severity of a Covid infection.
A moderate to severe case, lasting two to three weeks with possible ICU admission will give a much higher level of natural immunity than a mild case lasting a few days.
Hence the need for a blood level. Our public health systems have not yet come up with a number you should stay over to proclaim your protection.

Natural immunity--it gets no respect.
CDC director Rochelle Walensky signed the John Snow Memorandum last fall which stated: "There is no evidence for lasting protective immunity to Covid following natural infection." Evidence? You say you want evidence??
Oh, I got your evidence!!!
At the respected Johns Hopkins, a 2021 study showed 99% of post-Covid cases had antibodies TWO YEARS after infection. They also found natural immunity from prior mutations DID protect against Omicron.
Meanwhile, Kaiser Southern California published a study showing Moderna antibodies fell to 60% and just 16% against Omicron only 6 months after the vaccine.
For an unknown reason the CDC refused to release their data on reinfection from natural immunity ----
until now. It revealed natural immunity THREE times more effective of preventing hospitalization and almost FIVE times as effective in preventing Covid infections when compared to vaccination. 
The data is there- and it shows natural Immunity gets no respect.
"Last night my wife met me at the front door. She was wearing a sexy negligee. The only trouble was, she was coming home."
If you are still not convinced, we have good data to support using natural immunity as "protective," I will submit a list of studies that DO give natural Immunity the respect it deserves at the end of this blog -so as not to bore those of you who are believers. What is interesting is that all the studies showing the positive effect of natural immunity do NOT post "levels" as we have been advising since last year.
At Caduceus and PDQ Urgent Care & More we increased the protective level to 500, but that appears to be more important in assessing the length of time the antibodies stay in VACCINATED patients.
Except for very mild cases, natural immunity appears to always be over 500 for at least 6 months. (Our data only.)
Why the cold shoulder from our public health officials and government?
One may be the goal to have EVERY American vaccinated, and by giving credence to natural immunity, this goal may not be achieved.
Which is noble, but not scientifically accurate.
A second theory is that because there is no "number" to call the cutoff on antibody testing, and the liability so high if they get it wrong, they need to do much more research to allow for that magic number to be arrived at.
Sounds reasonable-other than the fact that we now have TWO YEARS of data to determine an accurate number. Plus, ALL natural immunity appears to produce high antibody levels for quite a while, so in most cases of NI, the antibody count itself is less important.
Also, the CDC does not even advise a second booster, no matter how long from the third shot it is. And our numbers show many of those patients suffered serious Covid infections this last December and January. Even cases that had to be admitted.
To be logical, public health authorities should hold boosters and natural immunity to the same standard.
Why the lack of respect for NI?
Could it be that the government--who bought and distributed all the vaccines, and even all the monoclonal antibodies, are hesitating to advise anything they can't control and monitor?
Ok -that one is for the conspiracy theorists among you.

Dr. Aaron Kheriaty, a professor of Psychiatry and Human Behavior at the medical school and director of the Medical Ethics Program at UCI Health, was termed in December because he declined to be vaccinated, citing his natural immunity was at least equal to the vaccine.  Dr Kheriaty, as well as thousands of similar teachers, doctors and nurses should be reinstated -assuming they show proof of natural Immunity.
There is precedent--Connecticut has suspended its vaccine mandate for state employees with natural immunity and Starbucks is rehiring staff that was terminated for being unvaccinated allowing natural immunity to do its job.
Led by Dr. Marty Makary, a group of esteemed Johns Hopkins physicians have called on public health officials to recognize the data on natural immunity.
The notion that ONLY the unvaccinated can spread the virus and ONLY the vaccination can prevent its spread is wrong.

We call on those in a position to do so - to research and give natural immunity the respect it deserves- -right up there with vaccinations.

We call on those states with vaccine mandates to recognize natural immunity as protective.

We call on our Military to restore full rank to soldiers dishonorably discharged because they only showed natural immunity.

It's time to give natural immunity the respect it deserves.

As Spike Lee would say--"Do the right thing."

As Rodney Dangerfield would say: "I told my doctor, “Doctor every morning when I get up and look in the mirror, I feel like throwing up. What’s wrong with me?" He said, “I don’t know, but your eyesight is perfect.”

Natural immunity asked the Public Health Official if it could go ice skating on the lake.

“Wait ‘till it gets warmer!” They said.


Gregg DeNicola MD Chief Medical Officer
Caduceus Medical Group, PDQ Urgent Care & More, PDQ Telehealth 

Epidemiological studies- 

  • Lancet 2021 in a population-level observational study, people who had had COVID-19 previously were around 85% protected against reinfection.
  • Eur J Clin Invest. 2021 in a retrospective observational study using national Austrian SARS-CoV-2 infection data, people who had had COVID-19 previously were around 91% protected against reinfection.
  • Clin Infect Dis. 2021 In a retrospective cohort study in the USA, people who had had COVID-19 previously were 88% protected against reinfection.
  • MedRxiv. 2021 In a retrospective observational study in Israel, SARS-CoV-2-naive vaccines had a 13·- times increased risk for breakthrough infection with the delta (B.1.617.2) variant compared with those who had had COVID-19 previously.
  • MedRxiv. 2021 In a retrospective observational cohort of laboratory staff routinely screened for SARS- CoV-2, people who had had COVID-19 previously were 100% protected against reinfection.
  • Clinical studies- Lancet.2021 In a large, multicenter, prospective cohort study, having had COVID-19 previously was associated with an 84% decreased risk of infection.
  • Lancet Respir Med.  2021 In a prospective cohort of US Marines, seropositive young adults were 82% protected against reinfection.

Latest Covid Treatment FAQ's Orange County

By editor
January 5, 2022

ANNOUNCEMENT from CMO-


A woman calls a law firm,
"This is Schwartz, Schwartz, and Schwartz. How may I help you?"
"I would like to talk with Mr. Schwartz."
"Oh sorry; he is in court all day."

"OK, in that case let me speak to Mr. Schwartz."
"Apologies. He is on vacation."

"Then let me speak to Mr. Schwartz." "Speaking!"

(With thanks to Henny Youngman.)

As this story illustrates, there are times you really don't want to answer a question. But eventually, you have no other choice.

You have a sore throat. Cough. Maybe a fever. You test positive for Covid. You contact us and ask, "What can you give to treat it?"

A very legitimate question. But not so fun to answer.

Because it is frequently followed by a request for Hydroxychloroquine. Or Ivermectin. Or a Vitamin combination.
Lately, CoQ10 is a popular request.

You may be tempted to mimic the formula unsuccessfully used by
quarterback Aaron Rodgers. He declined to disclose his secret formula, but did state in an interview prior to his positive PCR he was taking a cocktail of Hydroxychloroquine, Ivermectin, CoQ10, zinc, Vitamin C, and D.

NONE of these treatments have been shown through ANY valid study to prevent or treat Covid. Hence Rodger’s recent Covid infection.

So what DOES prevent Covid?
Only one thing...a vaccine. And unlike vaccines we are used to, it has a relatively high failure rate. Their main advantage is they DO prevent severe cases, hospitalizations, and my personal favorite thing, to prevent-death.

And what DOES treat Covid? Well, none of those modalities mentioned above. Going into our third year of dealing with this virus, five therapies appear to have passed the tests of efficacy (working) and safety.

  • 4 of the 5 have FDA authorization, either emergency or standard approval.
  • 2 of the 5 are indicated only in hospitalized patients with severe cases.
  • 1 of the 5 is not currently available, at least in Orange County.
  • 1 of the 5 is very difficult to access, at least in Orange County.
  • 0 of the 5 "cure" Covid; they all reduce symptoms, and risk of death.

Here they are:

1. Remdesivir and 2. Baricitinib.
They are only given in the hospital. They are very effective in reducing days in the hospital, days on high flow oxygen, chance of needing intubation, and of course risk of death. So, unless you are tucked into your hospital bed, 2 of the 5 are off the list.

3.  Paxlovid and Molnupiravir, oral outpatient anti-viral agents just approved by the FDA. So why not prescribe these to our patients calling?

  • They are NOT to be used for prevention.
  • They must be used within five days of symptoms starting, which is a very narrow window to get a positive test, which is also required.
  • They are ONLY indicated in cases with a high likelihood of progressing to severe disease, hospitalization or death. Which limits to whom they can be prescribed.
  • But the biggest issue--it simply isn't available. We have called dozens of local pharmacies - nada. Some expect to not have it in common use until spring.

4.  Which leads us to the only other FDA approved (emergency use) treatment- Monoclonal Antibodies (MAB).

So far, they appear to be game changers. Safe, few side effects, and a very high success rate.

In fact, almost every case we have followed up on were improving. We do not specifically check for Omicron, but the MAB’s appear to be working in current strains we are seeing in Orange County.

And they are free, thanks to our federal government cutting a deal with Regeneron labs to supply the country with them. (A reasonable administration fee is allowed to be charged.)

Monoclonal antibodies are laboratory-produced molecules that act as substitute antibodies that can restore, enhance, or mimic the immune system's attack on viruses--in this case Covid.

A fair analogy is vaccines have the SWAT team waiting for the Covid perpetrators and neutralize them on entering the nose--I mean house. With MAB’s the SWAT team rushes the house once the perps have already entered. Either way, antibodies are doing the work.

PDQ Urgent Care, in partnership with Infusion IV Hydration & Injection Therapy, in conjunction with Caduceus- has been approved to administer MAB’s and has given approximately 50 doses in the last few weeks. However, allocations are sparse, and we run out quickly. We never know if more allocations are coming, since it is in short supply nationwide.

Recently it was reported the entire Houston area would run out of MAB’s and unsure if they can get a new allocations soon. With no other proven therapies, demand is far ahead of supply.

(Conspiracy theorists: I have been unable to verify the head of Houston MAB distributions is a Dodger fan.)

To answer the many questions about receiving MAB, let’s skip the questions and go straight to the answers:

  • To receive the MAB’s, you need to be referred by a PDQ provider. This is done via a video visit. Easiest way to do this is via the PDQ app, or live chat on the website at pdqurgentcareandmore.com. If they are closed, I suggest a Mouse Call, also available on the app or website.
  • You also agree to a follow-up video visit a few days after the MAB infusion.
  • (Advice- download the PDQ app. You can do all your Covid stuff anywhere your phone is via live chat. PDQ is then literally in your pocket.)
  • You will need to be positive by either a PCR or Antigen test and present the test at the time of the infusion.
  • You will need to be mildly to moderately ill, with a high likelihood that you may progress to a hospitalization. If you already have a severe case, you should go to the ER for possible admission to receive Options 1 and 2 above.
  • If you have Covid but are relatively healthy and improving, you should not receive MAB’s.
  • With supplies so limited, we are giving priority to our own loyal patients. It is not required to be a preexisting PDQ or Caduceus patient, however.
  • Your costs for MAB’s are modest. The two video visits are billed to your insurance. If you do not have insurance, they are under $50. The infusion fee is paid at the time of administration and is NOT billed to insurance. It is currently around $200-300.

What if you qualify for MAB’s but cannot find it? Or you are sick, but do not meet the criteria for MAB’s? We have looked and found one other therapy to replace MAB’s if needed.

Enter Option 5- Fluvoxamine aka Luvox. This is actually a type of psychiatric medication, meant for OCD in the category of drugs known as "SSRI’s.”

Luvox acts by increasing levels of the brain chemical serotonin. In addition, the drug has other biological properties that could quell inflammation triggered by COVID-19.

Why is this different than the other off label drugs touted by social media?

Well, this one has actual peer reviewed studies to support it. Yes studies--as in multiple ones. Its main claim to Covid fame is it prevents the cytokine storm responsible for the severe double pneumonias, ARDS, ventilators, and even the “long hauler” symptoms. 
And the studies are not in obscure journals. It was given passing marks from both
JAMA and The Lancet.

It is not FDA approved, and at least one local pharmacy told us they will not fill prescriptions for it until it is. But it has been taken by millions of patients over the last 30 years with a good safety profile.

Since it is an off-label use, many physicians will be resistant to use it, given the drama of Plaquenil in 2020. But our Covid team will consider it if all other options hit a dead-end.

Again, you will need a positive Covid test, and a video visit. It is NOT for prevention, and only for higher risk patients.

That's about it.

Five treatments with decent supporting data. But to review, only MAB’s are a realistic treatment to prevent hospitalizations and death.

Of course, having the antibodies ALREADY lying in wait for the dreaded spike protein is much preferred--and that means taking the vaccine, AND a booster OR check your antibody counts every 4-6 weeks as we have been advising. (Ok, nagging.)

In summary:

  1. There is no treatment shown to prevent Covid
  2. There are only five treatments showing respected data on treating Covid successfully.
  3. Only one is a current viable option for outpatients- Monoclonal Antibodies. And they work.
  4. Get vaccinated and boosted, or at least check a total antibody count regularly as your best bet to stay out of the hospital -or worse.
  5. PDQ, in partnership with Infusion IV Hydration & Injection Therapy and Caduceus, is an approved site for MAB’s. Allocations are sparse and there is no guarantee they will continue.

Just ask Houston.

We began with Henny, let’s end with Henny.

A man goes to his doctor and says "Doctor, I have Covid and I'm afraid I am going to die!"
The doctor says, "Nonsense! You'll live to be 80!"
"But I AM 80!" says the man.
"See? What did I tell you!!!!" 

Sincerely,

Gregg DeNicola MD Chief Medical Officer
Caduceus Medical Group

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