Achives from Author

Covid Diagnostic and Antibody Testing Updates for Orange County

By editor
July 7, 2020

We have been pushing the mantra of--

Know if you’re contagious

Know if you’re immune 

Test. Test. Test. 

We are all aware of the large spike in new Covid cases recently. This has created a unprecedented demand for the PCR swab test.

We continue to do these curbside on a near daily basis. That will not change during the current crisis.

However the labs we use -such as Lab Corp and Quest have informed us that due to this large demand results may be delayed a few days. Where we were receiving results in 2 or 3 days , we are being told to expect a 3 to 5 business day turnaround and sometimes up to a week.

That is understandable since there’s a finite number of machines but a large increase in the number of tests.

I advise all of our patients who undergo swabbing with symptoms to stay isolated until the results are back.

Additionally, we have been researching the so-called “quick swabs” which give results in under 24 hours. The sad fact is I cannot justify the high number of false negatives associated with the quick test.

Therefore Caduceus and PDQ will not be offering the test until we can be assured of a better accuracy rate. We would discourage our patients from seeking or taking the test, as tempting as it is to have a quicker answer.

Gregg DeNicola MD, Chief Medical officer


MEET YOUR ORANGE COUNTY COVID TEAM

By editor
July 1, 2020

A Message from our CMO-

With movie theaters being closed, I’ve found- like many of you-the magic of Netflix. And since I do not have sports to follow, I gravitated towards sports movies. 

I found that no matter what era or sport, the main characters varied little. It appears that success of a team is predicated on a stereotyped group of defined roles.

It reminded me of the Caduceus Covid Team we assembled in mid-March to objectively diagnose and treat the wave of cases we were diagnosing.  The characters were eerily similar. There are many advantages to treating some conditions with a team approach, and a new serious one like Covid has been best fought with just such a team. 

Like an old sports movie, there is always a head coach who is tough but fair. In the older movies, he wore a fedora and chomped on an unlit cigar. His game plan appeared to yelling things like "GO GO GO" and "FIGHT FIGHT FIGHT!!”
“Yours truly” is the Covid Team’s "head coach.” I actually do have a fedora, and when gatherings were allowable, was known to enjoy a cigar at a summer BBQ. And with the volume our team has with Covid cases, the strategy of yelling GO! and FIGHT! has been effective.

Then there is the quarterback- good looking, popular, and pulls off the winning score by overruling the head coach and calling some creative off the wall plays.
Our quarterback Is Dr. Mary DeNicola (Doctor of Nursing Practice).  I hope to avoid political backlash by divulging Mary is my wife of 44 years, as I say she is good looking and popular. And she has consistently pulled off one win after another, fighting off this unpredictable and deadly bug. We form the game- I mean treatment -plan together, but she is on the iPad over 12 hours a day making creative and life-saving decisions on our Covid patients. I know with her “play calling” our patients are in excellent hands.

Of course, every winning team has excellent Special Teams. 

Our OBGYN Covid consultant is Dr. Nathaniel DeNicola, Senior Fellow on Health Economics and Chair of the ACOG Department of Telehealth. Yes, you do see a trend--to be a member of the team it does help to be named DeNicola--and in Nathaniel’s case, my first born son. As a board certified OBGYN, we refer him cases involving GYN issues and all Covid patients that are pregnant.  Yes, they have special needs that require a specialist with Covid knowledge and experience.

Our pediatric Covid consultant is Dr. Cyndy Krepps-Hoffer (another Dr. of Nursing Practice) with the most beautiful South Carolinian accent on Earth.  And astonishingly, she is NOT a DeNicola! She is an excellent clinician with extraordinary diagnostic skills, which is so important with pediatric Covid cases. All Covid related kids issues are referred to Cyndy, under the auspices of the team. Recently, Cyndy diagnosed a MultiSystem Inflammatory Syndrome in a child that previous doctors had missed. This condition hits kids with Covid exposure, yet they do not test positive. A few days in the ICU and -thanks to Cyndy--a life saved.

One roll in all sports movies is the “play by play’ guy. He keeps the audience up to date on the goings-on, and despite trying to be objective always roots for the home team. When they win the big game, he beats up the announcer on his left with a rolled up program, who coincidentally always was for the other team. Our play by play person is Talia Wright. Whew! Another non-DeNicola. Actually Talia's maiden name IS DeNicola, and yes -full disclosure--is my sister. 
Acting as a concierge, she keeps all the patients and providers informed, of appointments and results, late into the night if necessary.  I do not believe she has ever beaten anyone with a program, she can get quite irate when labs delay test results.

Another essential character is the water boy (water person in 21st century jargon). He offers comic relief, always smiling and joking around. He has the uniforms clean, Gatorade handy, helmets painted, and talks the star player into playing in the Big Game despite his girlfriend dumping him.
Our water person is Pam Dukes. Pam is not related by blood, however has been in the DeNicola family almost 50 years and has a permanent smile painted on her face. She keeps the team in good spirits and does whatever it takes to oversee 200 patients with Covid and related conditions. Phone calls, getting the video visits working, tracking down labs, and even making daily runs to TruBru coffee house next door to keep everyone awake. Without Pam, there is no team.

I understand  nepotism invites criticism . But I counter with an iron clad argument--using pizza of course (the Covid Team’s theme). You have all had Pizza Hut--and it is a competent pizza. They are a big pizza system, and have many resources available to them. 

Now compare with the pizza at Tony’s Little Italy in Placentia. Tony’s is family owned and run by Tony Manzella since 1978, with his wife and son (also named Tony).  They aren't part of a big company. Yet you taste the care and passion the Manzella family brings to their pizza--the best I have ever tasted. And I admit to tasting a LOT of pizzas!
I pray our Covid team matches Tony’s results with Covid instead of Pizza.

The team enrolls patients from positive swabs or antibody tests, and referral from friends and other doctors. All visits are conducted by telemedicine, varying from daily to weekly appointments. Treatment protocols are followed and change frequently, depending on what we see working and not working.

We prescribe total isolation while infected. 

And total bedrest. 

We trace close contacts--which we define as being within five feet for at least 15 minutes the 15 days prior to symptoms or a positive test. Yes, we know the two week incubation period and six feet rule. But 5-15-15 is easier to remember. 

Depending on details of the case, we prescribe the "Double Z's" and the Covid Cocktail. (Further described in a previous blog).

Our #1 goal is to have Covid patients die far in the future of something OTHER than Covid. #2 goal is to keep them off of a ventilator. So far, we are batting a thousand on both goals. 

ADVICE?
1.  If you test positive, self-isolate. Do not leave your room. Get under the care of a doctor or team. It doesn't need to be ours. But do NOT attempt to ride it out our on your own. That could be a fatal mistake.

2. If you test antibody positive, prepare to repeat it every few months to ensure the immunity is working.

3. If you have Covid, call all your contacts you were within 5 feet of for over 15 minutes within the past 15 days. Get them tested.

4. If you have Covid and are pregnant or are post-operative from a gynecological surgery, you need a specialist.  If you are positive and are under 18, you need a pediatric specialist.   It does not have to be our special teams but you do need special treatment.

5. Know if you're contagious. Know if you’re immune. Test.Test.Test

This is our Covid Team. We will expand it as the virus grows. We treat aggressively, and change protocols frequently. And we work very hard- no hunkering down for the TEAM.

To end with a word from the coach to the team (with apologies to Herb Brooks)-- Covid Team, great moments are born from great opportunity. You were meant to be here. This is your time. Now go out there and BEAT COVID!!!

Gregg Denicola MD
Chief Medical Officer 
Caduceus Medical Group


Covid Facts About Transmission- A Message from our CMO

By editor
June 19, 2020

In a very different era, before the Jimmies and even Jay, we had Johnny. And my favorite version of Johnny was “Carnac the Magnificent.” Carnac was a seer who, in full turban, would give the answers to a sealed question. Confused? It went something like this....
 
Covid-19, Al Capone, and Plaquenil.
(The envelope tears open....)

"Name an evil bug, an evil thug, and an evil drug!”
(We will use Plaquenil on the right patient but wanted to give equal time to the Anti-Plaq readers in the audience)
 
Ok, let’s try a few more… 
 
Houston Astros, Disneyland, and the World Health Organization.
(Tear the envelope.....)
 
Name three places that run a Mickey Mouse organization.
(That's for all the Dodger fans in the crowd)
 
OK, OK I’ve got a million of ‘em....
 
Household contacts, traveling, and large gatherings.
 
Name the top three sources of Covid exposure in the Caduceus Covid-19 Program.
(I know, not funny. But true.)
 
One more…
 
A barista, a doorknob, and a salad bar.
 
Name three sources NEVER named as the exposure to Covid in the Caduceus Covid Program.
 
In looking into how people catch Covid, we think back to the famous quote of the convict Willie Sutton. When asked why he robbed banks, he said "Because that’s where the money is.”

With our Covid numbers climbing in the wake of reopening our cities, we should look to where the virus is. The evidence shows clearly:
-You stand a very high risk of contracting the virus if you have close exposure to an active case. 
-Your chance of catching it using an unsanitized public restroom is very low. 
 
Studying cases in China, Europe, New York and California, all the data tells us it is close up, person to person exposure that spreads the virus. That is why cases dipped with stay-at-home orders. Assuming your household was free of virus, you had little risk with no exposure to infected individuals. Now with the lockdown relaxed, why are we seeing the current spike, where in other counties no spike was seen with reopening?
 
What we have now is accurate data we did not have in March. The experts identify "droplet contact" as the main mode of transmission. The virus primarily lives in the nose and mouth (and lungs of course). If the microscopic droplets carry from an infected person’s nose/mouth to your nose/mouth, it is VERY easy to catch.
If they fall to the ground or other surfaces they die pretty quickly. This is new data different than what we first thought.
 
What is bothersome is that if the droplets are very small they can travel far, much more than 6 feet. Remember that feather at the end of Forrest Gump, that fluttered for nearly a city block before landing? Covid is lighter and more mobile than that- you get the idea.

More worrisome is we now know Covid can be expelled just by normal talking and breathing, not only by sneezing and coughing. That is why we have seen large numbers from concerts and church services where crowds shout and sing loudly, expelling the virus many rows over. In fact singing turns out to be a major culprit, since they breath in deeply and expel the air forcefully. Add to the equation that the viral load of Covid is much higher than a virus such as the flu, and you see how quickly it can spread.
 
The literature tells us that if you live with someone Covid-infected your risk of contracting it is roughly 20%. The CDC sets parameters of 15 minutes of unprotected contact with someone less than 6 feet away as a very high risk situation, hence the need for masks, plexiglass, and distancing. Fist bumps and elbow bumps are not going to keep you from being infected. Neither will being young and healthy. Distance will.
 
And I know this is blasphemy but wiping surfaces with Lysol, taking away the soda fountain, removing the office coffee pot, and leaving your shopping bags at home are most likely doing very little to prevent the spread. In fact, probably nothing. Instead, preventing close contact in break rooms, locker rooms, group bathrooms, and elevators is much more critical. 
 
Of course for maximal effect, it helps to know who is actually infected. In Denmark, Covid testing has been offered free of charge to every citizen. Germany combined massive testing with contact tracing, a very sensitive subject here in the US.

And you know what they found? Schools were never the primary source of Covid despite what was believed. In contrast to California's schools being closed, Denmark immediately re opened theirs, with no increase in Covid cases. In California the effect of online classes has been less than ideal, while our new cases keep climbing despite school closures.
 
One major issue is that when someone is diagnosed with Covid here, isolation and quarantine appear to be mere suggestions. Many of our cases diagnosed still leave the home for errands, one gentleman even returned to work, against medical advice of course. If they live with their partner or roommate, they assume isolation means sitting on the far side of the couch without a mask.  But in New Zealand which has declared themselves free of Covid, total isolation was mandated. They required a test-of-cure, whereas in the US we do not. (Caduceus does, within legal and ethical limits.)
 
We do not have to look abroad, we have data right here in the USA. A county of Ohio reopened with a DECREASE in cases recently. How did they do that? They made an aggressive effort to markedly increase testing. And when new cases were found, they were put in strict isolation. I’m not aware if they did contact tracing, but it wouldn't surprise me. And even with INCREASED testing, they now see LESS cases. So much for blaming more testing for any higher cases reported, right?
 
So where are the new cases coming from? Data tells us household work and other close person to person contacts. Nursing homes. Public travel, especially boats and planes. And large gatherings such as parties and yes, protesting. Basically anywhere where lots of people are in prolonged, close contact.
 
Where do we NOT see the newer cases coming from?  Amazon boxes. Shopping bags. Light switches. Buffets. Dry cleaners. Hiking trails. Sunbathing on the sand. 
 
So perhaps we need to intensify prevention of close contacts without masks, and relax a bit on how often a counter is wiped down. Even if churches reopen consider doing online worship until the cases drop. But as long as your beach towel is a safe distance from others, you are most likely safe enjoying a Laguna sunset from the sand.  Want to take a quick trip to Napa? Renting a car poses little risk. Flying or train---beware. 
 
At Caduceus, we are guilty of disinfecting our rooms and cleaning our doorknobs. Yet we also created lobbyless offices. Patients are taken directly to the exam room or texted when the room is ready.  Our staff is tested regularly for Covid, and have their temperature taken at the start of their shift. We treat patients with a fever or infection via telemedicine only. All of our Covid testing is done curbside. Even routine labs are drawn curbside. And we offer every patient having blood drawn a Covid test. We urge our patients to continue to come in for their routine health care needs. We commit to them the lowest risk to Covid exposure possible. 
 
Conclusions?

-Avoid person to person close contact for greater than 15 minutes whenever possible
-Avoid large gatherings especially where there is shouting, singing, speeches, and heavy breathing. Special areas of concern are karaoke, clubs, bars, gyms, and churches.
-Avoid visiting nursing homes and hospitals unless essential
-Avoid plane, bus, boat, train, Uber travel unless essential. 
-For any close contact wear your mask, respect the plexiglass, wash your hands.
-If you test positive for heaven’s sake ISOLATE. That means your own bedroom, your own bathroom, and do not engage with any other housemates. If you must leave your room and go to the kitchen, everyone should wear a mask. Do not leave the house until you test negative. If your meals are being prepared for you, they should be left outside your door. You should not watch TV in the family room unless you are alone.
-If you test positive, think hard of all your close contacts in the previous 14 days. Implore them to get tested. If you are not infected, but know someone who is positive and had contact with them, YOU should get tested.

For the last conclusion let’s revisit Carnac…
 
Test. Test. Test.

(Envelope please)
Name three ways you will know if you’re contagious--or immune. 
 
Remember…
Know if you're contagious.
Know if you're immune.
 
Gregg Denicola MD
Chief Medical Officer 
Caduceus Medical Group


A Word of Caution as We Reopen in California

By editor
June 12, 2020

As we reopen our cities, schools, restaurants, and theaters, we can celebrate the Covid-19 virus has finally flattened the curve, and new cases are dropping over California. 
 
Just like the flu, the Covid virus is dying off after four months, and society can finally resume life as it was in 2019, before this worldwide nightmare began.  Antibody tests are showing many of us have immunity, and those that don’t will be able to get the new vaccine later this year. The shutdown from March to May worked, and we can lift it knowing we can live our lives more normally and watch our businesses reopen safely.
 
That was the blog I was planning on writing when we started to see the pandemic worsening last March. Trouble is, everything in that first paragraph is FALSE. 
 
A Wise Man once said, “The truth is only arrived at by the painstaking process of eliminating that which is UNtrue.”
 
So:
•    The curve is not flattening.
•    Covid is nothing like the flu; trust me.
•    It is not dying off, even with warmer weather.
•    Life as it was in 2019 is not going to happen in 2020.
•    Antibody tests are showing less than 5% of us have immunity. So we are prone to still be victim to Covid thru the rest of the year. 
•    Any vaccine that is effective will most likely not be available wide spread until 2021.
•    The two month shutdown DID prevent the devastation seen in Wuhan, Milan, and New York, but DID NOT bring down the number of new cases here in California.
•    We will reopen our businesses, restaurants, and theaters, but do so knowing we risk more cases, not less.
 
Numbers tell the story…
Global new cases reported to WHO on April 1- 72,736
Global new cases reported June 8- 131,296 
 
Ok but that’s the entire world....the numbers must be better here in the US....New York has reported a decrease in new cases?
 
New cases in USA reported on April 1- 22,559
New cases in USA reported on June 8- 28,918
 
Ok but that’s in the whole country...California did a massive stay at home order....we must be better?
 
New cases in California April 1- 1,298
New cases In California June 8- 3,097
 
Ok but that counts Northern California---you know how “loosey goosey” they are right? How about Los Angeles?
 
New cases in LA April 1- 513
New cases reported June 8 (for June 7 data)- 1,523
 
Ok, but LA has such high density; how about here behind the “Orange Curtain” where we love our 1/3 acre lots?
 
New cases in OC April 1- 104
New cases OC June 6- 274
 
Since no one likes to be Chicken Little, I asked my colleagues to help make sense of these numbers.
 
Well, for one thing I’m told, there is more testing now. More tests= more cases. True. The data shows about twice as many tests here in California in June than April.  Yet finding more cases is not overly reassuring because it shows THERE ARE STILL NEW CASES APPEARING. 
 
You see termites in your kitchen. You don’t like that. So you go to other rooms looking. You find more termites. You don’t say, “well I only found more termites because I looked for them.” You still need to call Orkin and deal with them. You don’t relax until you walk around the rooms and find...NO termites!
 
We are still finding lots of termites…I mean viruses.
 
Another colleague said, “actually the death rate is down since April.” True. That IS reassuring.
 
Another factoid…the cases appear milder now than April. Maybe Covid mutated into a milder virus. Maybe with more testing we are finding cases earlier. And now we have some idea of what works, so are treating cases more aggressively than in April. Also very reassuring.
 
It may be interesting to look back at the last 2 Corona virus mutations that caused SARS (Severe Acute Respiratory Syndrome).
 
SARS 1 first appeared in China November 2002. Last reported case was May 2004. Hasn't been seen since, but only 8,000 total cases were reported, mostly in Asia. 800 total deaths. Why so much milder than Covid? A shorter incubation period. Not a high penetrance rate (not very contagious). Never went worldwide. And it disappeared as suddenly as it came. After two years.
 
MERS started in November 2012 in Saudi Arabia. Still around, but has a very low penetrance. There were only 1300 cases the first year and another 1300 cases from 2013 to 2020. Never really went worldwide. 
 
Things in common with Covid?

  • All three mutated from bats.
  • All three began in November, two in China.
  • All three cause a severe lung eating respiratory illness with higher than expected fatality rate than other Corona viruses.

 
So why no lockdown with the other two mutations? And was this lockdown even necessary? 
For one, the 14 day incubation period for Covid is huge. That’s a long time an infected person can spread it.
 
For another, the viral load appears very high with Covid, making it very easy to spread and catch.
 
Lastly, this virus plays by its own rules. It’s fair to say- short of HIV- no previous virus was so virulent, easily mutating, and difficult to track and treat.
 
So it appears as the lockdown eases, we should prepare for even more cases. Across the country, results are mixed. California, Utah, Arizona, North Carolina, Arkansas, Florida and Kansas all are showing a rise in cases in June, and all relaxed the lockdown just prior to that. 
 
Napa County is reporting a large increase in cases now, tracing them to gatherings over the Memorial Day weekend, citing that pesky 14 day incubation.  New York City, on the other hand, is showing lower cases. It will reopen its economy the week of June 15th.
 
How about the success of South Korea and of New Zealand, both now reopening having virtually eliminating Covid? They combined a lockdown with isolation, quarantine, large scale testing, and contact tracing. Something to ponder if our numbers continue to rise.
 
This does not mean, as CMO, I oppose our reopening. On the contrary. What this virus accomplished was to show us how long a country can shut down. I’ll call it the "60 Day Phenomena." 
 
For the first 30 days, there was general acceptance that a lockdown was wise. We saw what happened in Wuhan, Milan, and New York. Yes it would hurt and possibly put us in a recession, but "we were all in this together" and had to hunker down "in these uncertain times" as we accepted the "new normal.”
(I don’t know about you, but if I never hear any of those clichés the rest of my life, I’d die happy).
 
Then, for the next 30 days, we were still isolated, but cracks appeared. Politics entered. Social media allowed some to choose sides, yet we stayed in our homes, and kept our businesses and schools closed.
 
What we have learned is an entire country will tolerate a quarantine for about 60 days. That’s about it. Then, we want to get haircuts. Go to the beach. See a movie. Have a margarita after work, and tacos on Tuesday. And yes, even gather and demonstrate if the cause is just.
 
If we see a rise in cases "THEY" will have to come up with another strategy. Shutting down normal life is unsustainable. At least past 60 days.
 
So have we satisfied the Wise Man and eliminated that which is untrue? Can we now state the truth?

Conclusion?

- Prepare for more Covid and presume its continued spread. This will not end quickly.
-Test. Test. Test. It appeared to work in South Korea and New Zealand. PCR swabs. Antibodies. Know if you are contagious. Know if you are immune. 
-If you become positive, isolate. Totally and completely. Keep testing until you turn negative before coming out of isolation.
- Wearing masks, social distancing, hand washing, avoiding people in general if possible are reasonable safeguards until those numbers fall. 
- Take all positions you see on social media and even mainstream media cynically. You really do not need anyone to influence you on what is right. Just look at the raw data. We will know when we are safe because Covid will fade away.

 
But it’s not fading anytime soon.
 
Gregg DeNicola MD 
Chief Medical Officer
Caduceus Medical Group


Ode to the Mask... A Message from our CMO

By editor
June 4, 2020

Ode to the Mask (with apologies to any other “Ode to the Mask” ever written)
 
Oh my wondrous mask!
You protect me from viruses unknown
You are the mightiest defense I own
 
Oh my magnificent mask!
Some accuse that you are a sham
Others say you are worse than spam
 
Oh my beautiful mask!
Sometimes you hide a smile
Or show an image of teeth quite vile
 
Oh my noble mask!
My fear of the virus conquers me
So I hide behind your veil pretending to be free
 
Oh my misunderstood mask!
Where does this contempt of you derive?
When your only goal is to keep me alive?
 
Every day, I receive dozens of emails asking our guidance on wearing face masks during the pandemic and recent reopening of our cities. Many make it clear how they want the question answered. Some feel it is a case of government overreach and unnecessary. Others feel it is an important part of the slow road back to normalcy.
 
Since I feel the answer is obvious, I try to research the literature to convert an opinion into a fact. Big mistake.
 
Our government experts first encouraged mask wearing.  Now Dr. Fauci says it’s unnecessary.  The WHO and CDC both reversed policies mid-stream based on little actual evidence.
 
What about peer reviewed medical journals, ostensibly relying on hard data and having no political agenda? Think again.
 
The respected NEJM has a new "article" from Harvard concluding masks are not necessary outside of health care facilities, calling mask wearing "a reflexive reaction to anxiety.” However, no numbers were offered, nothing prospective or retrospective. So it is an opinion. From Harvard nonetheless…but still an opinion.
 
Enter Sarah Arrowsmith, a scientist at Arizona State University. She published her data on using CLOTH masks. As a matter of fact, ones she made personally.  Acknowledging only N95 masks will block the virus and that there are insufficient N95’s to supply all medical facilities, let alone the country, she studied the efficacy of a cloth, homemade mask. 
 
Arrowsmith’s mask caught roughly 95-99% of particles that ranged in size between 0.07 and 0.209 microns—about the size of a coronavirus particle.  (The average Covid particle is 0.125 microns)  The results were reproducible.
 
Turns out how many viral particles are "caught" by the mask is an industry metric well studied. Doing nothing is a rate of 0. A cotton hanky loosely held over the nose/mouth actually blocks 28% of Covid particles. A normal surgical mask from the local OR? 80%. And one guess the percent of the N95 mask? Bingo! Yes that’s how they got the name---a 95% blockage rate.
 
Ms. Arrowsmith’s homemade cloth masks rivaled a surgical mask and even the revered N95’s. In fairness, Ms. Arrowsmith found the best results with double ply cotton, and found the mask had to be well sealed ABOVE the nose to work that well.
 
I know what you are saying: "Dream On.  Do you really expect me to ‘Walk That Way?’ You're letting ‘Sweet Emotion’ get in the way of your opinion." 
(Sorry couldn't help that.)
 
When there is conflicting data, I've always resorted to a wacky tactic.  I ask what I would do if I were the patient. (Or my family.) If I knew I had Covid19, I’d wear a mask EVERYWHERE. Well in fact, I wouldn't get within 50 feet of anyone, but that’s me. If a family member was bringing me my meds, I’d wear a mask, whether I was in a health care facility or not.
If I didn't have Covid-19, but had to interact with someone who was known to be Covid19 infected, I’d wear a mask. Absolutely.  Sorry Dr. Fauci, WHO, CDC, and the NEJM. 
 
But what about a normal Joe going to the grocery store, restaurant, or dry cleaners? The odds are high there is no Covid around. No need for a mask then right? I’m going with the mask. We have no idea where the virus floats. And a mask helps. Even homemade ones.
 
They work in the OR, ER, and whenever doctors need to be safe. The mask in the hospital keeps the physician from infecting YOU if they have any bug unknowingly. It also protects the provider if YOU have any bug unknowingly.
When you cough or sneeze, you are told to cover your mouth/nose with your hands. It’s common sense and courtesy. Is a mask that much worse than covering yourself, except you’re doing it for normal breathing? It is as much of the equation as hand washing and social distancing.
 
On social media, I’ve read posts saying “I HAVE A MEDICAL CONDITION THAT PROHIBITS ME FROM WEARING A MASK--YOU CANT ASK ME WHAT IT IS DUE TO HIPAA AND IM NOT GOING TO WEAR ONE.”
 
Good Grief. There are no medical conditions in my career where I ever told someone NOT to wear a mask. If they have COPD or asthma, you WANT them to wear a mask so as not to get an infection. A mask does not reduce your oxygen levels. 
 
Another post I read said “I WILL NOT ALLOW A GOVERNMENT TO FORCE ME TO WEAR A MASK.”
 
Seriously? I don't think there is a law requiring you to wash your hands, cover your mouth with  a sneeze, or take an occasional shower. You do it as a sign of respect and it’s the right thing to do. 
 
Most recent studies on Covid show the particle can travel with normal air currents quite far; one study said 50 feet and it doesn't need to be via a cough. Just breathing it out is enough. 
 
We diagnosed someone with Covid-19 last week. She had no idea where she got it. We had to go back 14 days and have her recall ALL her contacts during that 14 days. Since she went to stores etc there are hundreds of people  exposed who do not know it. Were they all more protected if she was wearing a mask? (She was.) I say yes. NEJM says no. You can choose for yourself.
 
So when do you wear a mask? We don’t have that data. We ask you to be patient as we collect it. We need to see how many never-maskers get the virus vs. always-maskers. As we reopen our cities, we plead for the safer course, wearing masks--even if future data shows it was unnecessary. 
 
So our advice?

Wear a mask while waiting in lines, when shopping, and riding in cars with people on buses or trains. Wear a mask at the doctor’s office and depending on the type of work you do, on the job. At least for now.
 
It’s the right thing to do.
 
Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group


Covid 19 Universal Antibody Testing

By editor
May 28, 2020

An Important Message from Our CMO
 

If you have been following our blogs since the Covid-19 pandemic started, you know our mantra:
 
Test.Test.Test.
 
If you are concerned you have Covid-19, it’s the swab. If you think you've had it, it’s the antibody blood test. For possible proof of immunity, it’s the antibody.
 
In doing over 1,500 antibody tests over the last few weeks, we have found good accuracy-over 95%. But will a positive IgG antibody really translate into immunity going forth?
 
We should know in the next 90 days, as our cities reopen. 
 
Unfortunately, we are seeing only a 4% positive rate from all we test. The vision that the antibody tests would unveil a large population immune from the virus has been a delusion, and only by knowing the antibody status of everyone going out in the community will we collect the data necessary to plan the next steps of this devastating pandemic.
 
Therefore, as Chief Medical Officer, I am calling on ALL Caduceus patients to consent to having an antibody test.
 
To assist in this undertaking, we will be requesting you to agree to a test and our medical staff will add this test at the time of each blood draw done at a Caduceus location. 
 
Results take 15 minutes, and you will be offered to wait, or to go home and we can message you back same day in your secure patient portal account the results.  If you prefer us to contact you by phone or email instead we can do that too. 
 
Whether you choose to have the test or not, please keep directing your Covid-19 questions, comments, kudos, and critiques to us.
 
For medical questions about this blog post you can email mousecalls@caduceusmedicalgroup.com.
 
To make an appointment for a video visit from your phone for Covid-19 antibody or any other medical needs, please email our appointments team at videovisits@caduceusmedicalgroup.com.
 
For any other general questions or assistance please email us at support@caduceusmedicalgroup.com.
 
 
We take every email seriously and foresee the current advice to be a small portion of this saga - as we evolve in these uncharted waters.

Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group 


CMO Perspective on Covid-19 over the Last Two Months

By editor
May 21, 2020

COVID-19….the first 60 days from the Caduceus perspective. 
 
Caduceus started testing for Covid in mid-March. We began treating patients within days and started accepting referrals in early April. Overall we have tested over 2000 patients in our three OC testing sites and have actively treated over 85 cases with a "Covid Team" approach. Approximately half have recovered; the other half are receiving regular ongoing treatment.
 
Around half are previous Caduceus patients, the other half came under our care once diagnosed. The distribution is split between North, Central and South OC 33% each. In general, most of the early cases were in South OC, and the more recent cases were based up North. Half the cases were diagnosed the first three weeks of testing, with a slowdown after April 7. Since that time, we have still had a steady flow of new cases new weekly. From the start we began meticulous record keeping. 
 
We have heard in other areas more cases are diagnosed in men. Not with us, the gender split is 50/50. As for seniors having more cases- that has not been our experience. Over half of our cases are under 40. Only 10% are seniors over 65.
 
Two hospitalizations have been recorded from our patient population, both to the ICU, ages 62 and 69, both healthy, both recovered. 
 
No deaths have been reported. 
 
As for many cases being asymptomatic, nope. Less than 10% of our cases are diagnosed symptom free.
 
As for what we hear about the most common presenting symptom being fever or cough? Guess again. 90% present with fatigue as the biggest symptom. Only 80% have fever at all, and almost half have parageusia (loss of taste and smell).
 
Early on, we saw the need for an aggressive strategy for treating even mild cases. The pattern was actually frightening with the first dozen cases.

A typical case-

  • Day 1 Fatigue, maybe cough
  • Day 2 Fever
  • Day 3 Worsening cough
  • Day 4-6 Copious fluid in chest feeling like they are drowning
  • Days 7-15 More of the same, some a bit better, some worse. Air hunger, severe at times
  • Days 16-21 Slow recovery

One patient suffered significant illness for 25 days. No; not a senior.
 
We find a regimen of "Double Z's" helps a few...Zinc and Zithromycin. 
 
A "Covid Cocktail" is very helpful once a positive swab was found. ... Sudafed, Promethazine, and Albuterol inhaler. This is designed to combat mucus and open the airways.
 
Once a cough or air hunger develops we teach aggressive "Pulmonary Toilet" AKA Hygiene.

  • Turn, cough, and deep breathe
  • Incentive spirometry
  • Postural Drainage and percussion

As many times a day as could be tolerated, at least three.
 
We see them via telemedicine frequently and daily if necessary. 

One severe case in March was given Plaquenil AKA Hydroxycholoquine, almost as a last resort. There was immediate improvement so we used it again. And again. Every case improved. No cardiac issues. In fairness, we have been using Plaquenil in our practice for many years for connective tissue diseases, so felt comfortable with its use. Plus it was a five day course, whereas most lupus patients are on it a lifetime. The risk/reward ratio seemed to favor its use. In all we prescribed it 15 times; all 15 reported improvement.
 
We are aware this does not match scenarios from other centers, even the CDC, but as they say in sports – “we gotta call ‘em as we see ‘em.”
 
Severe cases are the hardest to treat, simply because there was no playbook for their treatment. They universally report an air hunger, feeling of drowning, copious mucus, and the sensation of not enough oxygen even with a deep breath. Several informed us of a near-death sensation. The look in their eyes - even over a video visit on their phone -was haunting. Would they all have recovered without the aggressive treatment we described? No one knows. Yet as victims recovered, we had the comforting feeling the “Big Guy” was guiding things.
 
Despite all measures we mentioned, the #1 factor in improvement is bed rest- complete and total.
Bed.  Couch.  Recliner. 
 
Almost 25% suffered a relapse after recovery, and the number one factor in those cases was discontinuing bed rest. 
 
We attempt to check a test-of-cure on all of our cases. On average it takes 30 days  to turn "swab-positive" to "swab negative."  Almost all swab positive cases are showing antibodies, but it’s taking 30-60 days to do that. Whether the antibodies will prevent a re-infection via immunity still needs to be established.  Theoretically it should.
 
Mysteriously, there are another 25 patients--taking us to over 100 cases--that have identical courses to our Covid-19 cases, right down to the air hunger, copious mucus, near drowning and parageusia. However, they are swab negative. Multiple times.
 
False negatives? Doubtful given the well established PCR technique. A Covid mutation unrecognized by the PCR test? That’s our hypothesis. We are treating them identically to swab positive patients, with the exception of withholding Plaquenil. Perhaps because of withholding it, these patients are sicker longer and have a tougher road to recovery.
 
As the city, county and state begin to re-open, we must prepare for a "second wave." 
 
Our advice based on what we have learned?
 
1. Avoid proximity to ANYONE sick. Do NOT forget how easy it is to catch Covid-19 and the long 14 day incubation period.
2. If you feel fatigued or have a fever, get to bed and get tested ASAP. DO NOT attempt to fight this off by yourself. Stay under the care of a physician.
3. Social distancing, masks, hand washing, AND avoiding unnecessary travel are still wise, although unpopular. At least until the numbers fall more.
4. If you test swab-negative Do NOT become complacent and assume it’s a common cold. You know the saying  "If it quacks like a duck...."
5. Test. Test. Test. Either for the swab or antibody depending on your individual needs.
 
If you are a patient, we share this so you may avoid the virus and hopefully resume some type of normalcy. 
 
If you are a physician, we share this information as part of the Hippocratic Oath we all took......"I will remember there is art to medicine as well as science. I will respect the hard won scientific gains of those physicians in whose steps I walk in, and gladly share knowledge as is mine with those who are to follow…”
 
Gregg DeNicola MD
CMO
Caduceus Medical Group

If you would like to schedule a Covid-19 swab and/or antibody test or for other any other medical needs including annual exams, urgent care, or medication refills please email us at videovisits@caduceusmedicalgroup.com.  


Antibody Testing.. Fact or Schiznick??

By editor
May 14, 2020


Since there are no sports to entertain us, let’s play a new sport we can do from our homes....we call it “Covid FACT or SCHIZNICK??”  Ok; we COULD call it TRUE or FALSE but what fun is that?

We will make a statement about Covid and you have to figure out if it is FACT..a true-ism, or SCHIZNICK- we are just fooling around. 
OK, ready?  Let’s commence!

The antibody test for Covid will confirm you cannot get re-infected...Got your answer? 
OK… Soooo the answer is-
SCHIZNICK!
Fine; we cheated a little on this one. Yes, if you have IgG antibodies it implies immunity—i.e. you are not going to get re-infected....but three problems;

1. The Covid virus may have mutated, in which case you can still get the mutated form.
2. Covid looks like other corona viruses and the antibody test may have picked up the wrong corona virus.
3. No one knows how long the antibody lasts; experts are guessing 1-3 years. Key word-guessing.
We still advise you get the antibody test--so far it’s been a good marker for immunity.

The antibody test will tell you if you've had Covid19 lately.
And drumroll....
SCHIZNICK!
Unfortunately, data is telling us only 60% of Covid victims will turn IgM positive--and even then it may take four weeks from infecton. But that is the idea of getting the antibody test. If your IgM is positive, you did have Covid lately.

If my Covid antibody is positive, I will still need the vaccine when it is available.
and......
FACT! 
We told you above that it’s unlikely the antibody to Covid will give lifelong immunity ---1-3 years is about it. The vaccine may not give lifelong immunity either, but they are shooting for at least five, maybe 10 years--kind of like a tetanus shot. 

The antibody test may not be "free;” not all insurances are covering it...
Is this a trick question? Doesn't the law require it to be covered?...well.....
FACT!
Here we have the classic case of conflicting facts.  Federal law relieves patient responsibility for "Covid testing" but health plans are allowed to not cover tests that are not FDA approved. Most antibody tests available now are FDA "authorized" as opposed to "approved.” Yes; as Chick Hearn would say, "ticky-tack". So far, our experience is around half of payors are covering it outright and half are "working on it.” For those plans, you may be asked to pay $75 and be reimbursed if and when they do pay, which we predict will happen.  We doubt payors will refuse once the Feds give them a call. 

If someone has had Covid, they will be immune eventually.
Hmmmm and.....
FACT!
Using data from SARS1, MERS, and from Asia and Europe, it appears about 99 % of Covid19 cases will turn IgG positive, implying immunity. But unlike other viruses, it is taking 30-90 days for this to show up. 
So if you tested positive on April 1, it may take until late June to turn the antibody test positive. We say be prepared for a retest if you are checking the antibody too early.

Employers who want to test their staff prior to them returning to work should have them get the antibody test.

Seems obvious right?   Noooooooooooooooooo…
SCHIZNICK!!
This is a double edged sword. To test immunity and know if the staff will not be infected; yes, the antibody test is indicated. But less than 10% of the population is testing positive so far. For the employer to assure customers the staff is not contagious; they should actually get the nasal PCR swab for the actual virus. Ideally they would order BOTH the antibody test for immunity AND the nasal swab for active virus.

How did you do?  Here is the scale-
0-7 correct - You need to keep reading the blogs to increase your Covid knowledge 
8 correct -CONGRATS! You know more than Dr. Fauci and Bill Gates combined!

Gregg DeNicola MD 
Chief Medical Officer 


If you would like to schedule an antibody test or for other any other medical needs including annual exams, urgent care, or medication refills please email us at videovisits@caduceusmedicalgroup.com.


COVID 19 ANTIBODY TESTING- WHAT YOU NEED TO KNOW

By editor
April 29, 2020


Since March 1st, we have evolved—
 
-First there was no test available for Covid 19.
- Then came the nasal PCR swab PCR to show us evidence of the live virus.
-And now, antibody testing has arrived. 
 
Depending on your age, you can hear Roseanne Roseannadanna in the distance.
 I know a lot of you are asking, what is an antibody test? Do I need one? Where do I get this test? Do I have to pay for it or is it free? Do I come to you or do you come to me? Can you do it from my car curbside or do I have to go into the office? Do I see a doctor first? If I have had Covid 19 do I get one? If I haven’t do I get one?   
 
Well dear patients; you sure ask a lot of stupid questions! God bless Gilda Radner looking down with a smile...
 
Of course these are not stupid questions at all.  Let’s answer succinctly.
 
This is a perfect time to bring up the old adage LET THE BUYER BEWARE…
 
The WHO has put out many cautions that the antibody test may not actually predict your immunity. Many experts are also cautioning that the antibody test may not actually predict immunity since COVID-19 is such a new virus; it would be dangerous to rely on a test that has no track record.
 
At Caduceus, we completely agree. On the other hand, it’s “the best we got.” It appears clear that if you need a high degree of assurance of your immunity, you should pass on the antibody test for now.
 
However only by doing antibody tests on a large population of people will we be able to find out if it’s accurate. A true catch 22.
 
Covid 19 is a virus and when it is in your body acts as an antigen. Your body forms antibodies to fight off the virus.  You need a test to find out if you've had Covid 19 and to check for immunity.
 
Some health plans are paying for it; others will not tell us yet. You may be asked to pay $75 if it’s unclear your health plan will reimburse for it. We are also offering a cash price for those uninsured of $99 which includes the video visit screening and curbside antibody test from your car. 
 
Caduceus is only doing testing curbside. The staff will be bundled up well in PPE. We advise against having the test inside a medical office or hospital. At Caduceus, a physician’s order is required, and the doctor will help you interpret the test. It is NOT a simple positive/negative as with the PCR nasal swab.
 
You SHOULD consider having one no matter if you've had Covid 19 or not. 
 
Two cautionary tales…
 1.  In our opinion, antibody tests available prior to April 20th are very suspect. Distributors were frankly “shady” and prices were all over the map, there were high false negative rates, and no FDA emergency blessing. We searched high and low to find one that we are comfortable with recommending for our patients and the community at large.   All antibody tests are NOT the same. Before having one vetted, stay away from sites that charge over $125, do not require a doctor’s order, give you results in two minutes, require you to enter a lobby with other possibly sick patients, or in general appears sketchy. This is one test you may want to avoid the “Motel 6 variety.” Hold out for the “Four Seasons” version. 2.  Studies are showing it may take up to 90 days for the antibody to “show up” on the tests. If you were exposed in early March that means ideally you'd be tested in June. Realizing most patients will not want to wait, be prepared to be re-tested in the summer if you test negative now.

 
Let’s have a little fun....and play doctor....NO not that game!  Instead I’ll give you FOUR short cases and you guess which is the right test; nasal PCR swab or blood antibody?
 
Case 1-
Suzy is 44 and has a fever, cough, and loss of taste for the last week. Two weeks ago she went to the grocery without a mask and the deli worker did sneeze a couple of times near her. What test should she have?  ANSWER- Nasal swab. It will show active Covid 19 virus accurately. The antibody test will be negative for weeks more. 
 
Case 2-
Sam is 55 and went to a New Year’s Eve party where a couple were coughing and saying they were “getting over a flu bug.”  A week later, he spiked a high temperature, started coughing, and had chills and body aches. He went to an urgent care where they diagnosed the flu and gave him Tamiflu. It took two weeks to recover, and Sam now believes he may have actually had Covid 19 since the couple at the party was hosting a Chinese exchange student over holiday break.  What test for Sam?  ANSWER - antibody test.  The virus is most likely out of his body but the antibody test will reveal if he has antibodies against Covid 19, thus confirming that was his proper diagnosis in January. 
 
Case 3-
Tammy is 26 with an active social life and who also cares for her frail 79 year old grandfather. A month ago, a close friend tested positive for Covid 19. A week later, Tammy had a mild sore throat and low grade fever for two days. She did not get tested. She wants to be sure she is not a carrier so she does not spread Covid 19 to her friends or grandfather. Which test to order?  ANSWER- A PCR nasal swab will rule out her being contagious. An antibody test does not test for active virus but would tell Tammy if she indeed had Covid 19 but NOT if she’s a contagious carrier. 
 
Case 4-
Joe is 50 and has been furloughed from his job for a month now. He has been well, with no symptoms or known exposure. His boss has announced his intent to reopen the office and resume operations sometime in May, but he is requiring all staff to show whether they have had Covid 19 and if they are immune.  What test does Joe ask for?  Answer- An antibody test will actually give Joe TWO results on antibodies; IgM will tell us if he has had Covid 19 recently. IgG will confirm immunity. A PCR nasal swab fails on these criteria. 
 
Did you have a perfect score at FOUR for FOUR? If so we may want to deputize you! I mean every Sheriff Taylor needs his Barney right?

Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group

 

Please follow these directions to request an antibody test:

  • Email videovisits@caduceusmedicalgroup.com and include your full name, date of birth, cell phone, and if you are not an existing patient any insurance information or if you will be paying cash. 
  • A staff member will email you back same day between the hours of 8-5 M-F.
  • You will be scheduled for a video visit antibody screening (just like a Facetime call) from the comfort of your home on your cell phone or other mobile device.  If you do  not have a cell phone you can also use a laptop or desktop and to guarantee the best connection we do recommend using a mobile device.
  • The medical provider will review with you on the video call the four possible readings and then direct you to one of our two curbside testing sites in Yorba Linda or Laguna Beach.
  • You will receive a call back from a staff member or provider the same day to review your results.  

Covid 19- Our CMO Answers Your Questions

By editor
April 14, 2020

AN IMPORTANT MESSAGE FROM OUR CHIEF MEDICAL OFFICER GREGG DENICOLA MD

Is this the real life? 

Is this just fantasy?

Caught in a landslide; no escape from reality.

Freddie Mercury did not know his lyrics would be so prophetic when he wrote them 45 years ago. He asked two very poignant questions but never really answered them, unless you count Scaramouche, Galileo, or Figaro as an artistic reply. 

We will use this blog to answer three common questions that have been popping up in our emails. (Disclaimer- these answers are based on solid facts, but ARE still opinions. Expert opinions may vary.)

1. I feel fine. But can I be an asymptomatic carrier? If so, when will I not be?

2. What’s the deal with the antibody tests? When can I get one? My employer wants me to have one before they let me return.

3. Are things getting even a LITTLE better? As CMO when do you feel it’s safe to end the quarantine?

1. If you have no symptoms, and an accurate IGM antibody or nasal PCR test shows a Covid19 infection, you are an asymptomatic carrier.

It doesn't matter if you had symptoms and now are resolved, or never had symptoms. A positive PCR swab is the gold standard to determine if you are contagious. It IS possible to have viral particles in your nose and NOT be contagious. We just don't know if you are or not. No test exists to determine that. An antibody test does NOT tell you if you are contagious.

Keep in mind COVID19 is also called SARS2-- SARS 1 began in China in 2002 and is also a coronavirus so we do have some precedent to which we can look back. Using data from previous SARS outbreaks from Asia and Europe, the virus hangs around for at least three weeks and possibly three months or longer. Can it last a year? Or...gasp...forever? Hopefully not, but we simply do not have the data to tell us that answer. 

What if a person is a month out from having the infection but keeps testing positive? Assume they are contagious. 

Our answer?

If you have symptoms, GET TESTED. If you have exposure, GET TESTED. If you are positive, KEEP GETTING TESTED. If you are positive, STAY ISOLATED
Do not bother with an antibody test. Get a nasal PCR. Caduceus has ample tests as of this writing. 

2. Antibody tests are available through almost every drive through location, even big box stores. Caduceus has them available. But beware of false promises.  A quick “Antibody 101,” we receive two readings; IGM, which tells us if you've been infected recently and also an IGG which theoretically confirms immunity--that is, are you protected from a future infection, such as is the case with measles. 

Looking at SARS data from a few years ago, only 55% of patients converted a positive swab to an IGM. So to tell of a recent infection, it is pretty lousy if this SARS is similar to the last one.  But 99% DID convert the IGG by 90 days from infection. So the antibody test is not really useful until months after the infection appeared.  Again…that’s IF this SARS is like previous SARS. (DISCLOSURE-I am quoting ONE study from China. We have no idea if this SARS2 is going to act like SARS1.)

We hear many employers "requiring" antibody tests before allowing staff to return to work. That logic is fine if all they care about is immunity, but to allow the employer to say they have a virus-free workplace they really need the PCR nasal swab. Also, IGG antibody may take months to show. We may want to rethink the value of antibody tests for now.

One reasonable time to check with an antibody test is for those who feel they may have had Covid 19 in December or January and are now recovered. A negative antibody screen now would essentially rule out that possibility. 

Our answer? 

There is little reason to have an  antibody test at this time. A repeat nasal swab after symptoms have resolved is the gold standard. An antibody test 2-3 months from the infection would add reassurance the patients is both IMMUNE AND NON- CONTAGIOUS.

3. Globally and nationally, the numbers are stabilizing. Here in Orange County we are seeing less demand for testing and less positives per day.  One obvious reason is we are seeing less infections in general. In fact, almost none. Usually this time of year we see:

  • Strep throat--now? Nope.
  • Hand foot and mouth? Nada.
  • Roseola? Nix. 
  • Viral respiratory infections? Forget it.
  • Stomach flu? Negatory.

And STD’s? Haven’t seen the requisite case of gonorrhea or chlamydia in months; monogamy and celibacy appears to have cured that--for now.  Why? Because no one is coming in contact with anyone. Even housemates can’t spread something they can’t catch. We may have found the answer to cure all infections....life long quarantines. 

As the number of new cases fall, we may see the social isolation loosening, and masks, and X’s on store floors, but we must be concerned about a "second wave" of Covid 19.  Almost certainly we will have one. Until we have herd immunity, via a vaccine, the carriers will infect others. 

So ending the quarantine? 

Our answer?

If you want someone to diagnose and treat Covid 19, we’ve got this.For the cost/benefit analysis of effectiveness of loosening the quarantine, you'll need to ask our president, or governor, or Dr. Fauci, or Bill Gates. Maybe even Jake from State Farm. I'm thinking his guess is as good as anyone’s.

Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group