Achives from Author

Covid 19 Coronavirus September Updates- The Hard Facts on Our Progress in Orange County

By editor
September 4, 2020

CMO Covid Corner


A quick visit to the archives for a new take on an old TV show…
 
Who can you trust for Covid-19 advice?
 
Not WHO
Nor FDA
Nor even the CDC blog...
 
Just little ol' us...
We're UNDERDOG!
 
At Caduceus, we are used to being an underdog. Our entire annual revenue would possibly fit in Kaiser’s petty cash fund.  Mammoth health "systems" in Orange County, like Providence and Memorial, are comparable to Costco’s size next to our little boutique practice.  And the government agencies in the above rhyme have billion dollar budgets with some of the greatest health care minds in the world.
 
Yet here we are in month nine of the worst pandemic in our lifetime, and no end in sight. Perhaps it’s time to listen to the “Underdog.”
 
Let’s look at what our prodigious health agencies have told us so far. FYI, all the data we publish forth comes from their own websites or newsletters.
 
WHO-
The World Health Organization is an agency of the United Nations. It is funded by its members. The top three financial contributors?

-The USA
-Bill Gates
-The UK

Despite it ravaging Asia and then Europe, the WHO did not proclaim Covid-19 a pandemic until March 11. We started curbside testing for flu and strep in February, and added Covid-19 tests on March 12.
 
They have not advised universal testing, only those with symptoms or close contacts.
They advise stopping a quarantine on a swab-positive case once symptoms have resolved.
They determined a positive swab without symptoms can be due to "prolonged viral shedding.”
They have told employers they "may" want to require a negative test before people return to work after infection. 

On April 24, they told the public that antibody tests showed no evidence of immunity. They now have reversed course on that position.

On June 7, they did not advise routine mask wearing. On June 8, they changed their position.

And what has their advice accomplished? Almost 300.000 NEW cases a day worldwide now, compared with fewer than 100,000 at the end of May. Perhaps tighter controls are in order?
 
FDA-
The Food and Drug Administration is a truly bipartisan part of the Federal Government, yet empowered through Congress. So, they both have their fingerprints on the crime scene here.

Let’s see…Plaquenil. It was given emergency approval for Covid-19 in March. In June, they revoked it. Now they say they won’t approve it, but a doctor is approved to use it in the hospital or a clinical trial setting. Keep in mind that once the FDA approves any drug for ANY condition, ANY doctor may use that drug for another indication "off label,” it’s done daily on thousands of drugs. It is not "illegal" to use Plaquenil for Covid-19. But trying to follow the FDA advice is like playing Whac-A-Mole.  
 
Let’s look at the Abbott "rapid test" for Covid-19...it was given emergency use authorization in the spring.  Then several academic centers found "adverse events” (translation-bad mistakes) with the test informing thousands of patients they were Covid negative when they were actually positive.Yet the FDA approval stood. They simply put out a "warning" of the high degree of false negatives.

And now, they have just approved a new "quickie" Abbott test, coming out in October with a better false negative rate. Ummm…according to Abbott....no academic center has tested it yet.  And the FDA still approved it. 

And the result?  Only PCR swab tests have data with acceptable false negative rates. FDA approval of "antigen" tests (i.e. quickie tests) have exposed thousands of Americans to Covid-19 unknowingly.

On the flip side, thousands of Covid-19 patients have improved with drugs such as Decadron, with no FDA approval
At least right now, FDA approval--or lack of it---appears to be of little importance.
 
CDC-
The Centers for Disease Control is a federal agency. If you want to trace how Covid-19 became out of control in the US, we can start here. The first confirmed case in the US was January 20.  Yet the CDC delayed widespread testing for over a month. Worse, CDC tests were found to be faulty, and investigations show the CDC did not follow their own protocols regarding pandemics. 

And although Caduceus was the first to start testing for Covid-19 in Orange County, we had to wait until March 12 because the CDC had not made tests available to the health care community until that date. It would be April before the testing was available to the general public. And even then, everyone was running out of tests. This debacle lay in the hands of the CDC.

This was definitely a pandemic prior to March 11. 

A US Department of Health and Human Services (HHS) investigation into the COVID-19 testing crisis is under way.
But that isn’t all; the CDC admitted they inflated results by combining IgM antibody results with positive PCR swabs. 
Even now, they admit they were wrong to not advise testing close contacts of known Covid-19 patients with no symptoms, and now do advise it...four months too late.

They also discourage a test of cure (re-swab) after a Covid-19 infection. It is easier to have a Michelin restaurant allow substitutions than have the CDC advise us to test.  And we shouldn't forget the CDC website told us in the spring to only wear masks if social distancing was not possible.

And what has our federal agency designed to protect us accomplished? 
New cases in US March 30-19,000 
New cases in US August 30- 44,000. 

How is minimizing universal testing working out for you?
 
How about the White House Task Force---headed by Dr Fauci, under President Trump?
 
On February 29, WE WERE TOLD "NO NEED TO CHANGE WHAT WE ARE DOING" in regards to the large wave approaching. He has also flip flopped on the travel ban (first against it, then for it). He first spoke of masks being optional, and then changed his mind. The lockdown? First for it, then against it.  More flip flops than Labor Day in Laguna Beach. 
But this is truly a bipartisan gaffe; both Nancy Pelosi and Joe Biden downplayed the upcoming carnage in February when we needed a strong push to test from all of our leaders. 
 
We must mention our own Orange County Health Department leader Nichole Quick was forced to resign after death threats when she put out a mandatory mask order.  Her replacement understandably reversed the order. The job doesn’t pay enough to risk an execution.

When the state also passed a mandatory mask order, the Orange County Sheriff said he would refuse to enforce it.
Our own OC Health Department is calling our patients telling them no need to retest after an infection. As recently as last week, other health departments through the state are doing the same thing.

And Governor Newsom locking down, reopening, and then locking down again-without advising mandatory testing? 

How effective are our state leaders in getting this under control?
New cases in California March 25- 471
New cases August 25- 6,004

More testing anyone?
 
At Caduceus, we have been consistent with our message from Day One.

*Know if your contagious (PCR Swab) 
*Know if your immune (Antibody blood test)
*If your positive strictly quarantine until PCR swab is negative (Average 14 days) 
*Get tested bimonthly, or monthly depending on your risk and activity level

 
-Keep in mind the main three methods of transmission:
 1. Respiratory secretions (Wear a mask)
 2. Close contact with the virus (Social distance)
 3. Crowds (Hunker at home, avoid gatherings)
 
If our leaders had put forth--and enforced--such measures, our transmission rate would have plunged and lockdowns would have been unnecessary.

A few other facts...
Would reviewing Avian Flu help us with Covid-19?
This influenza is spread from infected birds, not bats. And does not wreak the havoc Covid-19 does. No help here.
 
How have airlines dealt with Covid-19?
Some block middle seats. Most require masks. Some upgraded their disinfecting policy. Most stopped serving meals. So far, little effect on the rate of Covid-19 spread has been noted. Nothing here to assist us either.
 
Is there an association between frogs and Covid-19? According to Ethos, a famed vet blog, It is neither considered likely that Covid-19 will be found in frogs nor as a cause of disease, nor that frogs function as a reservoir that allows spread to humans.

So, for extra credit, can we actually use Wally Cox's monologue from the famed cartoon to adjourn?
 
Sure, easy:
Where can we best find Covid-19 advice?
 
Not bird
Nor plane
Nor even frog

Just little ol' us
Heh Heh 
Underdog.
 
Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group

Now Offering Covid-19 Coronavirus Diagnostic Nasal Swab Results in 48 Hours or Less

By editor
August 21, 2020


(With apologies to Messrs, Chandler, Hammett, Spade and Marlowe...)
 
THE BIG SLEEPY SWAB 
 
A novella in 5 acts
 
Act 1- The Wife
 
I have two rules. First, I don't follow any rules. Second, rules are for suckers. 
 
It was a balmy August morning, the early morning fog hovering over my beach town - so thick it made pea soup look like Evian. The town is an artist colony, and has the personality of a eucalyptus tree swaying in a Santa Ana wind. My name is Diamond. You can call me Samme. 
 
My rent for the summer was overdue, more than a high school senior’s library book. I was sitting in my office wondering where the rent money would come from when she knocked. She walked through my door the way a princess walks into a dive bar. She sported strawberry blonde hair and wore that dress. A dress so tight it looked like it had been tattooed on. Not the expensive tattoos. More like the kind the sailors get at the docks.
She looked like she jumped from the USS Gorgeous and didn't wear a life vest.  She had bad news written on her like it was 9-11-01.
 
"Mr. Diamond?" she cooed.
"Samme. What can I do for you Angel?" I snapped back. 
"You’re the best diagnostician in town, and I need to find out what is killing my husband Frank.  Can you help?"
I was intrigued. "Tell me more," I instructed.
She shared, "You know the drill. Headache. Cough. Low grade fever. Going downhill." 
"Doesn't sound so fatal to me," I chimed back.
"I took him to a specialist. Told me he had 48 hours to get on treatment. But he couldn't pin it down. I figure you’re our last chance."
I knew this would take some legwork. 
"Your name Angel?"
Frances Frackle. You can call me Fanny," She said with a purr. 
“I better get started Fanny. Oh, speaking of coughing, you'll need to cough up my fees,” I reminded her.
"Of course Samme. Name it,” she declared.
 "$89 for an office visit. $69 for video visit from your phone," I said.
"Sure Samme; anything," Frances responded.
 "That's not all Angel---plus expenses,” I told her.
 
She agreed so I went on…
"Get Frank down here now. Pull up curbside. Keep him in the car. Have him lay low. My people will take care of the rest.”
I knew the clock was my enemy.  I also knew what I needed - a beach house and a vacation. What I had was a white coat, a straw hat and -for protection- a #10 blade scalpel. 
 
Act 2- The Masks
 
My first stop was downtown. A little boutique on Main Beach. The owner was a little blonde number named Heidi. She was so petite a 20 MPH offshore wind would take her to Catalina. I went there because Heidi  makes the masks she sells by hand. And everyone in town gets their masks from Heidi. I knew she could help.  She knows everyone in town and everything that's happening too. 
 
"Hi Princess," I greeted her.
"Samme, don't call me that! You know that's sexist!"
"Sorry Heidi. Just being true to the genre."
"Oh why didn't you say so? Sorry- I wasn't around in 1947,” Heidi reminded me. 
"So Heidi,” I asked, “have you seen Frank Frackle lately?”
"Are you kidding? Everyone knows he won’t wear a mask. He’s been walking all over town sans mask. I saw him on the street and I offered him free masks; he just said the whole thing was a hoax," Heidi retorted with the roll of her eyes.
 
I knew it.  Frank Frackle--an Anti-Masker.
I threw 1,000 bits on the counter and took my favorite mask--jet black with nuthin’ on it. I knew there was more to this caper than I was bargaining for.  There was a killer out there and it was my job to find him...or it.
 
 
Act 3---The Mechanic
 
After a quick club sandwich from Penguin's, I decided to drop in across the street at the local mechanic. Mechanics always bugged me. That’s the trouble with mechanics. You get all set to hate them and then you meet one that goes human on you.
 
Jim was a happy Pollyanna type of fellow that you couldn't miss due to his thick Scottish brogue .When he spoke you expected to see him wearing a kilt with bagpipes and eating a meat pudding. His hands were big. As big as plates of spareribs, and twice as greasy- grease from a '47 Hudson.
 
Jim tuned up every car in town, and knew every car owner and when he saw me he said, "Hey Mr. Diamond, its ty-em  fer yer old jaloopy to get 'er oil changed.”
Jim was right. Of course it was.
"Next week, my friend. I'm checking on Frank Frackle; has he been in the shop lately?" I inquired.
"Matter of fact, 'e was just 'ere loost week. Broot 'is Rolls in,” he remarked.
"Notice anything unusual?" I inquired.
"Yes indeed. He refooosed to use our hand sanitizer--we poot it out here on the counter and ask the coostumers to use it. He said it was all a cone-spiracy!” Jim sighed.
Figures. No mask. No Purell. I was getting the picture crystal clear and it wasn’t pretty. Or as Jim would say "purty."
"Ok Jim, thanks for the dope. And better add a loob n’ filta to the jaloopy toon up next week, eh?" I quipped trying to impress with my new accent.
"Worst Scottish brogue imitation I’ve eva heard mista Diamond,” said Jim with a broad smile, “and stay oot of trouble."
 
A little trouble I don't mind. It’s big trouble I have a problem with. 
 
Act 4- The Restaurant
It was 6:54 PM -the time for most guys to go home and get in their slippers, and light a thick Cuban cigar.  But for me it was suppertime and time to go to my regular hangout next to my office, a little Creole place. The residents of my beach town will eat anything that is plant-based, gluten free, and held loosely with toothpicks. Me, I needed a steak. 
 
Michael, the owner, sported a full head of hair whiter than a salesman’s teeth after his dental appointment.  He was as smooth and strong as a garlic milkshake.  He quickly escorted me to my regular table, #4, in the corner where open windows gave a breeze as welcome as a slice of bacon at Zinc. His wife Cindy came to take my order. A tall drink of water, Cindy was as sweet as a baby's smile and her eyes revealed a brutal honesty. 
 
"The usual Samme?" she asked.
"No, Cindy, I’ll take a steak."
She was shocked.."But Samme you always have gumbo?"
"Trying to be true to the genre Cindy," I said.
"Ohh…gotcha," she said yelling over to Robert the chef, "one 1855 steak for Mr. Diamond, Robert!"
 
I asked Cindy and Michael if they have seen the Frackle’s lately.  "Oh how can I forget Samme. They were here last week, no social distancing and walking around hugging and kissing everyone. We had to ask them to leave. He said we were infringing on their human rights.”  No surprise there. Frank Frackle touched all three bases, but there would be no home run...no mask, no hand washing, no social distancing. A blind man on a galloping horse could see this picture. 
 
I finished my steak. Robert had cooked it exactly to order, matching how I was feeling. Burnt on the outside. Cool on the inside. 
 
Part 5 -The Reveal
 
The following day, Fanny reappeared in my office.  She looked as inconspicuous as a rattlesnake on a white tile floor. "Mr. Diamond, I must say you are stupid. A stupid person. In a stupid business. On a stupid mission!” she cajoled.
"I get it," I agreed. "And now I must make a stupid diagnosis. Because you see, Fanny your husband is suffering from Covid."

"Good guess Mr. Diamond. But you can’t prove it- you can’t prove a thing," she argued. She went on, “the quickie tests are inaccurate. The PCR test is the only thing that can diagnose him, and those take 3-13 days for a result. And the specialist only gave Frank 48 hours to live without a diagnosis. It appears my dear husband’s number will be up very soon."
 
"Oh but Fanny I can prove it,” I said with an evil grin. “I used the new PCR test now available at Caduceus. We swabbed him curbside yesterday and I knew we would have the results within 48 hours. And as this report clearly shows, Frank is indeed suffering from Covid 19--no doubt a consequence of being an anti-masker, anti-hand washer, and anti- social distancer. A mere $189 and I hold the proof here, in plenty of time to get him on inhalers, some pulmonary hygiene, and maybe a little Decadron. Frank should be fine!"
 
"But I had it all planned,” Fanny said and stopped abruptly.

"Yes, Fanny. You are named the beneficiary in his multi-million dollar life insurance policy. Knowing he felt Covid was a hoax, you paraded him all over town to get him infected. Thinking we could not diagnose him in 48 hours, you came to me to avoid you being a suspect. But I have the smoking gun right here."

"Nonsense!” yelled Fanny.
 
"This is an IgG moderate complexity antibody test you took at Caduceus two weeks ago, showing you are likely immune. So you knew you couldn't get Covid yourself as you tried to infect your husband. And that dear Fanny is the reveal our dear readers have been patiently waiting for---you were brought down by a 48 hour PCR swab and a moderate complexity antibody test."
 
"But Samme, aren't we going to be true to the genre? The wife always becomes a femme fatale who then falls in love with the detective and they run away together?” she asked out of desperation.
 
"Sorry Fanny. I'm going to take a load off you, and put the load right on me..."
 
I left the office and walked a block to Thalia Beach. I had a date with sunset, a beach chair, and a Laguna Feast taco.
.
 And Covid? It’s like a cheap bourbon. And I put it on ice.
 
 
Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group
 

Introducing the expedited PCR Diagnostic Nasal Swab.  Test available to all, whether or not you have symptoms, needing clearance for travel, work, school, employee testing for your business, or just want some piece of mind.  Know if you are contagious in 24-48 hours MAX. (Only available as $189 cash price.)
 
Reserve your video screening from your phone today and then come curbside to one of our locations for your test, no appointment necessary.  
 
Learn more and/or request on-site employee testing for your business, school, or organization.
 
Email any medical questions about Covid to mousecalls@caduceusmedicalgroup.com. 

CMO and Caduceus Covid-19 Coronavirus Team August Updates

By editor
August 13, 2020


I’m not looking to fight with you
Frighten you or tighten you
Drag you down
Chain you down
Or bring you down
All I really want to do
Is discuss Covid with you
 
Ok, so we took some liberty with Mr. Dylan’s poetry.  It’s time to look at the path we have traveled the last five months. 
 
We began Covid testing March 11, and enrolled Covid patients in our program immediately. We published our observations a couple months ago, and a lot has changed since then. Let’s revisit what we have learned.
 
We have tested over 7,500 patients for Covid- both the swab for the virus and the blood for the antibodies. We have diagnosed or been referred roughly 750 cases as of this writing.  That corresponds well to the national average of a 10% positive rate with broad scale testing.
 
Our false positives have been under 1%--as advertised by the literature.
 
False negatives? Around 5-9%- again, as expected. 
 
So any speculation by pundits on social and mainstream media stating the tests are inaccurate is hooey. At least in our admittedly limited practice the tests are reliable.
 
What is noteworthy is in May we had just passed the 100 mark of cases. So the other 650 cases have been found in the last three months. This is partially explained by our ability to procure sufficient tests to allow testing five days a week at multiple sites, as well as a corporate program that brings us company employees to test. Admittedly we have been aggressive in encouraging our patients to test, and obtained more innovative tests that allow earlier detection of antibodies. The new moderate complexity antibody tests we offer have been very impressive indeed. 
 
Nonetheless, the number of new cases exploded.  In June our new cases per week doubled. July? Quadrupled! Why?
Yes, we reopened perhaps too soon, and definitely not smart. Beach weekends, protests, church services, BBQ’s, and parties all contributed their part to the deluge in cases. 
 
At one get together in a beach town, ONE unmasked person with not-yet-diagnosed Covid, caused the infections in EIGHT other party goers. Remember, we said the 14 day incubation period combined with being very contagious was a perfect storm? Well, there ya have it.
 
Of the 750 cases, about 100 never showed symptoms.
400 have recovered totally.
250 are under active care.
Only nine needed hospitalization--yes a 1.2% rate. This compares to a 4.6% rate nationally. 
And yes, still no deaths (insert sign of the cross being made).
 
More stats that may be of interest---
85% of those that swab positive formed IgM antibodies--again just as the biologists would predict based on other viral diseases.
 
Even better, after eight weeks, 95% form IgG--the antibody that theoretically confers immunity. This is in line with SARS 1 in 2005, another Coronavirus mutation. 
 
More evidence that the doom-and-gloom of the non-experts is baloney. These numbers are exactly what the immunology textbooks would have predicted.
 
We have seen the virus change though, at first, fatigue, fever, and cough were the three most common symptoms.  Now fatigue is still #1, but headache and diarrhea have replaced cough and fever. That's right, in April 80% of new cases had a fever. Now it’s just over 50%. So much for the temperature-at-the-door test huh?
 
At first, we were treating primarily a respiratory illness. Now we need to look for--and we have seen- blood clots, cardiac and muscle inflammation, strokes, kidney failure, and major depression.
 
Covid appears in some patients to cause a cascading inflammatory response that can affect literally every major organ system. 
 
The lungs still require the most attention. We still give the double Z’s (Zpak and Zinc) but have recently seen a better response to Augmentin and Doxycycline to the Zpak. 
 
We still push aggressive pulmonary hygiene...we obsess over keeping the lungs free of mucus to avoid a life threatening pneumonia...perhaps a factor in our low hospitalization rate. 
 
I'm sure we would get emails if I failed to mention Plaquenil.  We used it successfully until Lancet and New England Journal published articles showing no effect. Within weeks of publishing these two previously respected journals were forced to retract those studies for faulty data. The political backlash regarding using Plaquenil was unlike anything I have seen in over 40 years of practice. I’ll simply leave it at Plaquenil being in our tool box and our decision to use it is between our patients and our doctors, on a case by case basis.
 
We have found a couple of new treatments more effective than Plaquenil.
 
One is Decadron, the steroid. The studies are using it on in-patients to prevent intubation. But we found using it early in patients with obvious inflammation turns the corner quickly. Decadron helps to reduce inflammation and calms down an overactive immune system.
 
The other is Symbicort--a steroid inhaler (Budesonide) with a dilator (formoterol), used with almost any respiratory symptom.  There is no doubt to us that Decadron with or without Symbicort is a game changer. 
 
There IS one "magic bullet" for Covid cases that are very sick...convalescent plasma. Yes, they take the plasma from patients who have shown IgG, and infuse it into the sicker patients. So far, a 100% IMMEDIATE SUCCESS. Well, in fairness, we have had it used in six of the nine hospitalizations, and it worked every time. Yes, more evidence that IgG DOES bind to the Covid antigen and will prevent a second case.
 
Even more evidence: How many cases of a positive swab that converted to an IgG antibody have we seen?  Around 150.  How many of these have contracted Covid for a second time? That’s right...Zip. Zero. 
 
The problem lies in how long the IgG will hang around. We had one patient lose it in a month. In another case it only lasted two months. Using SARS 1, Chinese, and European data, it should last four-six months in most people. So to get herd immunity, we will need an effective vaccine. We cannot count on our natural IgG to protect us for years as it does against measles.
 
 
Other observations:


Smokers, vapers, diabetics, and obese patients are a much higher risk of a severe case and hospitalizations. The patients we encouraged to purchase a pulse oximeter as well as an incentive spirometer had a much easier time managing their Covid.
 
Since June, Covid in our practice is a disease of the YOUNG. Our average age is 36 for a new diagnosis. How many cases are diagnosed in seniors over 65 in our population? Would you believe less than 10%? Good, because it’s lower---UNDER 5%!
 
We respectfully and strongly disagree with the CDC and our own Health Department that the quarantine may end after a week of no fever or symptoms, with no re-swab necessary.  There is simply no evidence that a positive swab with no symptoms is not contagious. I have a challenge for the CDC/Health Department--take off your mask and let one of my Covid cases that swabbed positive but have no symptoms for a week cough in your face. Case closed. 
 
We have seen a change in behavior by the Covid patients as the summer dragged on. Now, only 15% of our cases agree to be re-swabbed.  That may relate to the young age of these patients, the seniors tend to be more compliant. 
 
Only 25% of newly diagnosed agree to quarantine---that’s not a typo.  Many may agree to stay at home for a week, but do not avoid household contacts; many even go to work. I’m not making this up. They travel, go out to eat, go grocery shopping. They use how sick they feel to guide them. But they are very contagious until they swab negative. 
 
If we want to look at why our August numbers are still high, we need to look no further than the poor compliance on re-swabbing and quarantining. 
 
Overall, we have learned a lot about treating Covid since March.  Meds have changed, symptoms have changed, and patient compliance has changed. Early bedrest, use of steroids-oral and inhaled, and aggressive surveillance via telehealth all play a part in keeping our patients out of the hospital and ventilators. And we are encouraged by the immediate improvement of all patients receiving convalescent plasma.
 
Conclusions?
1. Test Test Test. Know if you’re contagious. Know if you’re immune. If you're contagious, QUARANTINE. If you’re not immune, wear your mask, stay at home, social distance and hunker down. It may save your life.
2. If you are positive, QUARANTINE and RE-SWAB! Do not risk infecting others by spreading your Covid particles.
3. If you have IgM or are recovering from Covid, have your antibody checked every 4-6 weeks until your IgG is positive. Then you may want to still check your antibody every 4-6 week to see how long it will last.
4. If you must come into contact with people (job) or elderly (visiting grandparents) we advise a monthly swab. Yours truly has a swab every 10 days, to reassure my patients, and come to think of it, to reassure ME.
5. To help those who need convalescent plasma, contact the local blood bank directly if you are IgG positive. You may save someone's life.
 
To paraphrase Mr. Dylan:
 
I do want to straight face you
Chase you, track you, and trace you
Disgrace you and confine you
All I really want to do
Is have you die of something OTHER than Covid
After many years pass through
 
Sorry Bob.  I guess it’s time for my boot heels to be wanderin'…
 
Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group

NOW OFFERING ORANGE COUNTY MODERATE/HIGH COMPLEXITY COVID-19 CORONAVIRUS ANTIBODY TEST-

By editor
July 30, 2020

OK, another game....Let’s pick something "low" complexity, and then counter with the first "high" complexity thing we think of...Ready??

Low complexity........floating in your pool on a rubber raft.
High complexity...taking on Class V rapids in the Grand Canyon.
 
Got it? Easy huh? OK OK let’s do a few more...
 
Low complexity...driving a Kia to the grocery store.
High complexity...driving auto pilot in a Tesla X in Downtown LA.
 
Low Complexity....making a grilled cheese sandwich from the Betty Crocker cookbook.
High Complexity...making a grilled cheese sandwich from James Beard winner Nancy Silverton’s cookbook.
 
Low complexity...binge watching "Breaking Bad" on Netflix.
High complexity…binge watching "Northern Exposure" from old video cassettes.
 
Alright.. so.. how does this tie into Covid? Well, the drive-thru tests for antibody offered throughout Southern California are "point of care,”meaning the test is run right then and there from a finger stick. It does NOT require government approval since it is "CLIA" waived. 

CLIA stands for "Clinical Laboratory Improvement Amendments.” CLIA is federal agency that mandates their approval for a lab to run tests and charge for them. And to get CLIA approved is quite a process...we have gone through the process and it would have been easier to get approval to launch a spaceship a la Elon Musk. 

To allow some tests to be done in old fashioned physician offices, like urinalyses, pregnancy tests, and strep screens, CLIA "waives" the tests they feel are "low complexity.” The current generation of antibody tests are low complexity and thus CLIA waived and able to be done at the "point-of-service" instead of having to be couriered to a clinical lab.
 
Are moderate/high complexity tests more accurate? Kinda…Maybe. Depends on how you define "accurate.”
 
In general, they can pick up cases earlier or with a lower "count.” They are more complex to design and run, hence the term "moderate/high complexity.” And, of course more expensive. (You saw that coming right?)
 
Let’s illustrate with an example I know a lot about...food!

The grilled cheese from Betty Crocker IS a legit grilled cheese. And decent too. No false advertising there.

On the other hand- Nancy Silverton's grilled cheese? OMG. I mean just the ingredients are high complexity....here they are verbatim:
 
•    1/3 Cup Olive Oil, Extra Virgin
•    2 ½ Tbsp. White Wine Vinegar
•    2 Tbsp. Kosher Salt
•    1 Tbsp. Freshly Cracked Black Pepper
•    2 Medium Yellow Onions, Sliced into 1/8-Inch-Thick Slices
•    ¼ Cup Whole Grain Mustard
•    8 oz. Gruyere cheese, sliced into 24-32 1/16 inch-thick slices
•    Whole country sourdough loaf

I could go thru the actual process but it would be easier to explain how to split an atom. Nevertheless at the end of the process, you also have a grilled cheese sandwich. Just unlike any you've ever had. 

The point is; both are grilled cheese. One is just high complexity. (Full disclosure-I do not receive a kickback from Nancy-but if you want to enjoy the best grilled cheese you've ever had I highly recommend her sandwich cookbook, Nancy Silverton's Sandwich Book: The Best Sandwiches Ever--from Thursday Nights at Campanile.) 

Now we can compare that to the office pregnancy test. It is accurate and picks up the pregnancy a day or two after the missed menses. The OTC test from the drugstore may need you to be 3-5 days late. Both are low complexity. But the moderate/high complexity CLIA approved test can pick it up a bit earlier than either of those that are CLIA waived. It isn't technically more accurate; just more sensitive. It picks up the hormones at a lower level.
 
You can see where this is going with Covid antibodies. The usual test available in the past through Caduceus and PDQ Urgent Care and More (and other facilities) is CLIA waived. It gives us two antibodies.. IgM -which tells us if you have had Covid, and also IgG which implies immunity. Despite what I read on both social media and mainstream media, it IS accurate. But it requires a decent antibody load to pick up the antibodies.

What is antibody load? It’s like having a single shot latte to wake up mid-day compared to a triple shot espresso. It’s easier to pick up caffeine if you are analyzing the triple shot compared to the single shot. A moderate/high complexity "caffeine test" can pick up the single shot, the low complexity just the triple shot.
 
We have partnered with KOS labs here in Orange County and Healgen Labs in Houston for a "New Improved" antibody test that is moderate/high complexity and thus requires CLIA approval. 

There are some differences between the new test and the current one being offered.
 
*The current test uses a finger stick, the new one needs a blood draw.
*The current test gives a same day answer, the new one takes overnight. 
*The current test has about a 10% false negative rate, the new one less than 5%.
*The current test picks up the antibodies 4-16 weeks out, the new one weeks earlier. 
*We of course bill insurance, but if you need to pay cash the current one costs $75, the new one is $85. 
 
As CMO I endorse the newer test if you are having the antibody test. 

We have been searching for the most accurate antibody test to offer our patients and this appears to be the gold standard.  It can still be drawn curbside. And of course, the sooner you find out if you are immune the better for all involved.

The better sensitivity and accuracy outweigh the overnight wait and the $10 price bump. We will now be using the "moderate/high complexity" test as the default. If you prefer the finger stick/same day/low complexity test we of course will honor that. We will keep both tests available.

And because I know I’ll get emails inquiring, I am not aware of this test being offered by other Orange County groups, but it may be. If they require a blood draw and an overnight wait, good chance they are offering the moderate/high complexity test. To be legal they would need to be partnering with a CLIA approved lab.
 
And of course the video visits are from the privacy of your home and the testing is from the comfort of your car.
 
Conclusions? 
1. If you want to know if you've had Covid, you need an antibody test looking for IGM.

2. If you want to know if you are immune, you need an antibody tests looking for IgG.

3. If possible have a "moderate/high complexity antibody test" in lieu of the low complexity version. We work hard to not run low on inventory, and I still ask EVERY Caduceus patient to have an antibody test.

4. So far, there has not been a reported new positive Covid test in a patient with a positive IgG--at least that I can find. A positive IgG should reassure that you are immune.

5. KNOW IF YOU'RE CONTAGIOUS (Swab)
    KNOW IF YOU'RE IMMUNE (Antibody via blood)
    Test.Test.Test.
 
Ok; let’s do one more…
 
Low Complexity....Reading this blog eating a bologna sandwich.
High Complexity...Reading this blog eating a Nancy Silverton grilled cheese...no way you'll pay attention to the blog!


Gregg Denicola MD
Chief Medical Officer 
Caduceus Medical Group


 

Testing Testing 1-2-3

By editor
July 16, 2020

COVID 19...Testing…Testing...Testing… 1-2-3    
 
For my fellow baseball fans, this is a good time to recall the beloved Yogi Berra who told a post-game interviewer after a bad loss...
 
"We made too many wrong mistakes."
 
That sums up my viewpoint on our response to the Covid pandemic, both nationally and here in California. I have been purposely apolitical during the crises, and deflected blame, preferring to look ahead, not behind. Yet it is clear Yogi is right---both political parties have made too many wrong mistakes. 

If our elected leaders had pushed for universal testing early on (as we have advocated) many of the lockdowns and closures could have been avoided. 

We have been dealing with the nightmare that is Covid for four months, although it feels like four years. And in those four short months, we are learning so much every day.  When I look back and see what little we understood last St. Patrick’s Day, and then look at our current state-of-the-art, what we have mastered bears sharing here.
 
What I read on social media and here on mainstream media is so misleading, it’s actually frightening.

  • The swabs are part of a conspiracy to pay the hospitals more and are being falsified.
  • The antibody tests are inaccurate and IgG does not give you immunity.
  • Someone sent a swab dipped in a cup of coffee and it came out positive.
  • Only get tested if you are deathly ill.
  • Get tested daily to be safe. 
  • Someone's uncle can arrange for a swab to come back in two hours for $1500 cash.

Schiznick. All of it. 
Let’s deal with the bare facts.
 
If you follow Caduceus and PDQ you know our mantra... TEST.TEST.TEST.
and our slogan…

KNOW IF YOU’RE CONTAGIOUS
KNOW IF YOUR IMMUNE
 
CONTAGIOUS?  DO I HAVE COVID?
To find out if you are contagious or infected, you need a test for the virus. The gold standard is the PCR Swab.Things are changing there. At first, it was a long skinny wire that doubled as a brain biopsy. In the last six weeks, the labs are giving us a shorter swab, with equal accuracy. It is NOT just a Q-tip, its fibers pick up more mucosa and the virus is now known to reside primarily in the lower part of the nostrils. 
 
The problem is time. A finite number of testing machines are in play.  With the recent huge demand, swabs must wait their turn. So a 3-5 day wait has morphed into a 7- 10 day wait for results. For some people, that simply is too long.
 
Enter the newer "quickie" tests. Some are self-serve. Some use oral swabbing. Some do not need a doctor’s order. Many urgent cares offer them, as do the drive-up centers sponsored by local governments and large companies like CVS. And the results can be same day or one day. One catch----way too many (IMO) false negatives. Up to 20 % in some trials. These tests may be acceptable if the airline or your job just wants a negative test, and you feel great. But if you want to KNOW you REALLY are negative, I advise against the quickie tests. 
 
The companies that sell the quickie tests even warn you to repeat all negative quickie swabs with the PCR--which will take 7-10 days. So the only people who really benefit from the quickie tests are those that feel great but the airline, Hawaii, or job wants a test that was done in the last three days.  If you hear about a new test that is very accurate and results take less than a day, avoid it. That test does not yet exist.

IMMUNE? 

To find out if you are immune, you need the antibody test. For both IgM and IgG. 

IgM=you've had it. 

IgG=you’re immune.

IgM comes first, about 4-12 weeks after you are infected. It does NOT confer immunity.

IgG DOES confer immunity, but takes months to turn positive. We do not know how long the IgG stays on to protect you.  Maybe three months. Maybe three years. IgG from SARS 1 (in 2002) only hung around 4-6 months. The hope is your IgG will protect you until early 2021 when a vaccine is available.
 
So why do people on social and mainstream media keep insisting they are not accurate? If you are one of them and read this, PLEASE send me your source. If they aren't accurate I need to know NOW!!  Because all respected data says IgG confers Covid immunity.

Our tests come from labs in the USA. They are ready the same day. Almost no false positives and about 5% false negatives. Uses a finger stick.

We will soon announce we have obtained for our patients a newer more sensitive, moderate/high complexity, laboratory grade antibody test.  It is not necessarily more accurate, but does pick up the antibody earlier. 
 
We have had one patient IgG positive and then swabbed positive, but he had swabbed positive a month earlier. So far no one has been IgG positive and THEN contracted Covid. Not only in our practice, but in the literature. Again -if you read of anyone IgG positive later contracting Covid, please email me; that would be big news to the medical community. Good news...so far ALL of our Covid positive patients eventually turn antibody positive, confirming the accuracy.
 
Caduceus Medical Group/PDQ Urgent Care and More strives to be the best partner we can be to our loyal patients. We are honored to be helping blaze the trail in providing the newest and most accurate tests available. Soon, we will offer two types of antibody-(quickie/accurate and overnight/more accurate.) We are planning to offer two types of diagnostic swabs...both the PCR (very accurate, seven day turnaround) as well as a type of quickie (one day turnaround, less accurate).
 
As far as who needs what, and how often, here are the current Caduceus guidelines:
 

  • You have never had it, and no symptoms- do both swab and antibody.  We advise repeating monthly (no video visit required for repeat testing) if you are working, going out, or traveling.  It is less essential for regular testing if you are homebound. 
  • You recently swabbed positive for Covid---retest weekly until clear.  Then test monthly for antibody until IgG positive.
  • IgM positive, IgG negative...test monthly until IgG positive.
  • IgG positive…test every three months to ensure immunity. Stop when vaccine available. 

 
What about the posts stating "only test if you have symptoms?"  
 
Hooey. Poppycock. Horsefeathers.
 
Caduceus/PDQ does NOT require symptoms to be tested. We advocate EVERYONE should know if they are contagious and immune. By frequent testing, we will all know just that.
 
Why? 

How did China, Spain, New Zealand, Denmark finally reopen? Bingo! Universal testing. 

In some provinces of China, the government went door-to-door offering free tests. 

Denmark had a policy to test every willing citizen at no charge--and THEN offered them a digital "passport" to show they were free of the virus as of the date of their test. This was used to allow travel, certain jobs, and general reassurance of friends and family. 

And Spain? This is a quote from an article from Reuters on APRIL 6---at the peak of the high death rate:  "Spain is planning to widen coronavirus testing to include people without symptoms as a first step towards slowly easing a lockdown in the nation with the second highest death toll from the global pandemic." Guess what happened to the number of cases? Exactly!
 
Recently, with employers and traveling requiring swabs, we are finding up to 30% of our positive swabs show NO symptoms. So to require symptoms to be tested is missing a large reservoir of contagious people. It is a common-and deadly policy.
 
Our diligent staff work tirelessly to commit to our patients we will not run out of either swabs or antibody tests, and will test curbside daily as many people that can squeezed into one day. We do not require only Caduceus patients to be tested by us. We gladly swab all people, even from Kaiser, St. Jude, St. Joes, Memorial Care, and Hoag. 

How do we keep acquiring enough tests to have done this for four months now?

Sometimes it involves putting unmarked bills in a paper bag behind the palm tree in exchange for enough swabs...well ok, not exactly (but close to it). It shouldn't be that hard. Whatever the cost to produce adequate testing, it is less expensive than the devastation of closing down our economy.
 
Covid testing is definitely not a profit center. But -as Spike Lee would say—“it’s doing the right thing.”
 
Only by universal testing, and REPEAT testing, can we begin to tame this fast moving, lung eating, deadly virus. 
 
CONCLUSIONS 

  • If you know you are contagious, strictly quarantine yourself until you are documented not contagious.
  • If you are not immune, avoid close contacts, confined spaces, and crowds. (And wear masks, wash hands…the whole bit)
  • Staunchly consider putting yourself and your family (and workplace) on a monthly testing program until the numbers fall, or a vaccine is approved. Even….no wait...ESPECIALLY if you have no symptoms! 
  • When testing, avoid "quickie" tests and sacrifice speed for the best accuracy available.
  • If you have tested positive for Covid, or are IgM positive, antibody test monthly until your IgG becomes positive. It will.

Be aware of the massive demand for testing as cases surge. Expect a delay for a video visit, results of swabs, as well as phones and chat lines. We pledge to offer all of our patients daily video visits and curbside testing. No one will be turned away, which may intensify the delay. We thank you in advance for your understanding. 

KNOW IF YOU’RE CONTAGIOUS
KNOW IF YOU'RE IMMUNE

Let’s conclude with one more Yogi wisdom. One day at Shea stadium, streakers ran naked across the outfield. The reporters later asked Yogi (who was managing the Mets that day) if they were male or female streakers. With a puzzled look, Yogi answered....

 “I don’t know. They had bags over their heads.” 

Don't wear a bag over your head. 

Get tested.

Gregg Denicola MD
Chief Medical Officer 
Caduceus Medical Group

To make an appointment for a video visit from your phone for Covid-19 diagnostic swab and/or antibody or any other urgent or non-urgent medical needs including your annual physical, please email our appointments team at videovisits@caduceusmedicalgroup.com.
 
If you own a business and are interested in more information about our on-site corporate Covid-19 testing program for your employees, please email us at support@caduceusmedicalgroup.com.

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

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