CEO BLOG- Matthew Perry's Untimely Death

What Lessons Can We Learn to Avoid the Same Fate?

Last night I forgot to ask my wife to join me in the Jacuzzi. I was really in hot water.

Ok, perhaps it isn't the best idea to start a blog about Matthews Perry's death with a Jacuzzi joke.

Yet I feel Chandler Bing would have approved. "If meeting my maker can be used to bring a smile to thousands of people, I say go for it- plus I wish I had thought of that joke!" This is what I suspect he would say.

By now, we have all heard the news; Matthew Perry-AKA Chandler Bing- drowned while in his Jacuzzi at age 54. 

With no evidence of drug or alcohol ingestion as the cause, the world awaits the toxicology results and the final autopsy findings. 

Assuming it wasn't due to those factors, what could cause someone to drown taking a dip in their hot tub? How likely is this a possibility for you and me?

A year ago, a 57-year-old acquaintance of mine died swimming in the ocean. Autopsy - acute heart attack- that allowed her to drown. The death was from the drowning, not the heart attack itself.

In fact, drowning after a cardiac event or by substance use is not rare. Last year there were 4000 deaths from drowning, and about half were related to cardiovascular factors. 15% were due to alcohol or drug use, and the remaining third were accidental--maybe a boat accident. And let’s not forget riptides. 

A couple of years ago, another 50- year- old acquaintance suffered a drowning while snorkeling. Autopsy? An acute stroke that caused a loss of consciousness and subsequent drowning

Was there something Mr. Perry could have done to prevent this tragedy? And perhaps more important-are there steps WE can take to avert an avoidable drowning?

To determine this, we should look at the top three probable causes of loss consciousness while in a pool or Jacuzzi, or even snorkeling in the ocean. 

1. Mr. Perry may have suffered a stroke or heart attack, which caused a temporary loss of consciousnesses. If it had occurred out of the water, it may not have been fatal. But going underwater while unconscious is pretty much a game ender. 

Mr. Perry was a former smoker, and of course a known drug abuser.  It is reasonable to think he was at a higher risk than a person who never took up those habits.  He may have had warning signs such as angina or TIA’s but not necessarily. 

Actor Joe Flynn - a heavy smoker- died at age 49 while doing laps in his pool. Baby Boomers may know him as Captain Binghamton on McHale’s Navy in the 60's. By the time he was pulled from the pool, he had drowned. He had been swimming alone. Autopsy- Heart Attack. But the cause of death was drowning.

2. Mr. Perry may have experienced an arrhythmia---an issue with his heartbeat. This is statistically more likely, and falls in three categories:

a) He may have had a "Sick Sinus Syndrome" (SSS) where an issue with his internal pacemaker slows the heart down--even into the 20's . It usually will speed up with consciousness regained. But after a minute underwater, death is probable.

b) He may have suffered with A Fib-where the heartbeat is irregular and fast- which can lead to a fainting spell. 

It is possible to have A Fib and not be aware- until it goes into a fast rhythm. Both SSS and A Fib are not uncommon after 50, and more common in smokers or with enlarged hearts, which Mr. Perry was likely to have. Both conditions are relatively easy to diagnose if we are looking for them.

c) He may have been faced with ventricular arrhythmia, AKA PVC’s. If he had several in a row, a fainting spell was likely. 

Orville Redenbacher also drowned in his Jacuzzi. He was 88--a victim of a heart attack. He was a shrewd agricultural scientist who experimented with different strains of popcorn and became a millionaire in the process of revolutionizing the popcorn industry. Although an octogenarian, he had shown no signs of ill health or cardiac disease prior to this Jacuzzi incident.

3.  A third possibility is that Mr. Perry simply fainted as he was entering the Jacuzzi or while sitting in it. With the hot temps of Jacuzzis and saunas, your blood vessels become larger.  Blood falls from the brain via gravity, and you faint. If he were already hot and possibly dehydrated from playing two hours of pickleball, add the 104-degree temps of the Jacuzzi, and a loss of consciousness that proved fatal is certainly possible. This can happen to almost anybody at any age, but people over 50 do not tolerate temperature extremes as well as the youth. 

Of course, we also recall singer-actress-diva Whitney Houston too was a victim of drowning- albeit in her bathtub. Her toxicology results revealed cocaine and Xanax that most likely led to her losing consciousness while soaking in her tub, and then drowning. 

So, what conclusions can we make about Mr. Perrys' death? Was it preventable?

Almost assuredly. 

If you feel you may be at risk, here are some steps you can take to avoid a premature death thru drowning:

1. If you smoke, stop. If you are hypertensive or diabetic, see your doctor to get them under tight control. If there is any doubt about you having hardening of the arteries (thus leading to heart attacks and strokes), consider a treadmill stress test. We do several types here at Caduceus and insurance will probably cover them. If not, the cash price is $205. Mention this blog, we will do it for a flat $200. 

2. If you get palpitations, or have a personal or family history of arrhythmia, see your doctor. Or self-order an event monitor-there are a few different types. Insurance usually covers, but if not, the cash price is less than $500. These monitors will track every heartbeat over days or weeks and analyze them. If you are prone to SSS, A Fib, or PVC’s this test should help pick it up.

3. If you have a history of fainting spells, even from seeing a snake, do not use a sauna or Jacuzzi alone. Especially if you are over 50.  (Please see joke that began this blog, ha ha!). 

Be sure you are hydrated beforehand. Dip in a pool or lukewarm shower before entering the sauna/Jacuzzi. There is a reason most hotels post signs warning against using the sauna/Jacuzzi alone, especially with a cardiac or diabetic history. 

Oh, and a trivia question-Who named the band the Rolling Stones, and was their uncontested leader in the early/mid 60's? 

If you said Mick Jagger----WRONGGGGGGG!

Brian Jones (No not the Monkey--that was Davey)-a multi-instrumental musician- would be the right answer---which if you are a Baby Boomer Rock and Roller, you knew. 

Brian was a musical genius whose alcohol and drug abuse turned the band against him, and on June 9, 1969, was kicked out. Three weeks later, he partied at his house with some friends, and enjoyed large amounts of alcohol and other illicit substances and decided to go for a midnight swim. His friends pulled him out when he appeared unconscious; his girlfriend felt a pulse. He died in the ambulance on the way to the hospital. Coroners labeled the drowning "Death by Misadventure"- thus going down in history as one of the most creative descriptions of a drowning caused by drugs and alcohol. 

In Summary, let’s revisit a scene from Friends-

Rachel: "Guess what, guess what, guess what!!??"

Chandler: "The fifth dentist caved and now they ALL recommend Trident?"

Ummm, not exactly-

1. If you haven't had your annual checkup, get one.
2. Ask about a treadmill or event monitor -it may prevent fainting in the water. 
3. Do not use a sauna or Jacuzzi alone, especially if you are over 50 or have a history of fainting.

As Chandler Bing would say: “Could the advice BE any more obvious?

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

Self-book your annual check-up, and/or request a consult with your primary care provider to review your options for either a treadmill test or event monitor. You can also request directly by live chat from our website, through your patient portal, or call our dedicated appointment line at 844-807-8558.
Gregg DeNicola MD
Caduceus Medical Group

PDQ Urgent Care & More

CEO Blog- Allergies... A Silent Killer

Many of you know I love to eat. And being Italian by heritage, I also love to cook, especially Italian food. I'm proud to have raised two doctors, one is a hemopathologist and the other an ob-gyn & Caduceus CMO. I'm equally proud that my love of cooking also spawned an executive chef. 

Although I love making up my own recipes, I admit I also love to play around with cookbooks and now possess a modest collection. I especially treasure those books signed by the author/chef.

In my collection, I have two cookbooks by the Napa chef, Michael Chiarello. One is called Casual Cooking, my favorite recipe in it is Spuma Di Tonno - a bread spread that is life- changing, and a go-to opener for any meal. (If you want the recipe, just email me and I’ll gladly share!)

The other book of his is called Flavored Oils, teaching the art of making infused olive oils. This book in my collection was autographed when Mr. Chiarello met my chef son, Ryan. It says, 
"Ryan- Infuse your cooking with passion!" 

Ryan left the book in our kitchen when he moved out, so I am claiming ownership--at least until he reads this blog and comes home to reclaim it.

Earlier this month, the culinary world was shocked by Mr. Chiarello's sudden death from an anaphylactic allergy reaction while home in Napa. He was only 61. As a physician, my first thought was, could this have been prevented?

To help solve this, a word about allergies.

Allergies may be environmental- bee stings come to mind. Or food based. The "big three" in the US are cow’s milk, eggs, and nuts. Surprisingly, shellfish is down the list aways, but definitely a player. 

When most people eat shrimp, the proteins are harmlessly digested, and all is well. But in shrimp-allergic people, there is an overreaction of the immune system to the protein--we call allergens. With a little luck, this manifests only as hives, a stuffy nose, or watery eyes. A little Benadryl, maybe a Medrol dose pack in a more severe case, and all is back to normal. 

But with enough sensitization, true anaphylaxis can occur. Once you've witnessed this, you'll never forget. It may start with the just mentioned symptoms. But it rapidly may move on to on e or more of the following:

  • feeling lightheaded or faint
  • swelling of the mouth, throat or tongue, which can cause breathing and swallowing difficulties
  • wheezing
  • collapse and unconsciousness
  • respiratory and cardiac arrest

Even scarier, in severe cases, this cascade can unfold in minutes.

To make matters worse, the prevalence of food allergies is increasing worldwide, approaching an epidemic level in some regions. In the U.S. alone, approximately 10% of children and adults suffer from food allergies.

People who know they are allergic are encouraged to carry EpiPens which usually work immediately. But what if you don't know if you’re allergic?

Luckily, people with nut or shrimp allergies have had hives or wheezing from eating these in the past, saw a doctor, were tested, and know to avoid them and also carry the EpiPen. And it is true that with each peanut or bee sting the reactions are worse, so they have a warning they may be predisposed to anaphylaxis.

However, we are now finding out is it possible to have a true allergy and not be aware of it because they are asymptomatic allergies (such as Mr. Chiarello).

This condition is sometimes referred to as asymptomatic sensitization. In many cases, people with this condition may not even be aware that they have a food or bee sting hypersensitivity. 

So yes, your body becomes sensitized with each exposure but does not cause a hive break out or wheezing attack which would alert you. You could eat shrimp many times before the anaphylactic attack manifests itself.

In Mr. Chiarello’s case, most people (including yours truly) thought--well he must have accidentally eaten something cooked in a pan that had previously been used with shellfish, or the kitchen had peanuts in it, where small grains got into his dish. If only he had an EpiPen!

But his family has gone public with the facts to encourage people to look into what allergens they may have. Mr. Chiarello had no known allergies. He had never exhibited any allergic symptoms previously.  As a chef, he enjoyed almost all foods, with no previous issues. 

He was apparently not eating at the time of his attack. There was no bee sting or contact with pets or plants. No antibiotics or other medications.  He was simply at home when the attack occurred. Even a prompt response by 911 was not in time. His doctors have told the family they will probably never know the cause of the allergic attack. 

This is not an isolated case. Anaphylaxis in people with no known allergies is one of these horror stories that make doctors shake their head. When there is no obvious or apparent cause of a reaction, it is termed idiopathic anaphylaxis.

In a recent AAFA study - one of the most accurate studies done on life-threatening reactions- found that almost 1 in 50 Americans is at risk for severe reactions. This study also found that many patients are not ready for this type of reaction.

To answer the question we posed at the start---is this preventable?  Perhaps. If you feel you may be at risk or are looking for reassurance, here are a few steps you may consider.

1. Arrange a consultation with an allergist. They may want to do testing, or just give general advice.

2. Contact us for RAST testing--a blood test. This test checks for specific IgE antibodies to determine the substances that a person may be allergic to. It is an alternative to a skin prick test; it is not often recommended because of the high number of false positives. But it is fairly easy since it is a simple blood draw.

3. The most accurate would-be a skin test, usually starting with skin pricks. We have these here at Caduceus and they test for both environmental and food allergies. It should pick up most allergies that could lead to anaphylaxis, but of course there is no guarantee.

The RAST tests and allergy tests both run $400-500 depending on the exact order and patient. If it is not covered by your health plan, due to the large number of requests we have had recently, Caduceus is discounting its usual $400 price for the skin tests to $275 until November 30th. This would include both food and environmental allergens. You may arrange a Zoom call or in-person visit with your doctor, or you can also order it yourself, and the results will go to your doctor. 

You may not feel a 2% chance of anaphylaxis is worth worrying about--or you may want reassurance you should have an EpiPen that may have saved Mr. Chiarello’s life. Either way, pay close attention to hives, wheezing, and watery eyes/nose. They are the first clues that you are at risk.

Oh, by the way, the 'tonno" in the dish of Mr. Chiarello’s that I love, is Italian for “tuna.” It is basically tuna mousse. In tuna, beta (β) parvalbumin allergen is found in the muscle. I am thinking I need the testing for that allergen for sure!

I do know that if I don't get tested, the next time I am in a restaurant, and they ask me "Do you have any food allergies?” --my answer is "How do I know?!!!

Self-book a consult with your provider to review your treatment options, request a consult with your primary care provider to discuss or book allergy testing directly by live chat from our website, request through your patient portal, or call our dedicated appointment line at 844-807-8558.
If you are experiencing hives, wheezing, and/or watery eyes or nose, seek same day treatment with a Zoom call or in-office visit at our urgent care partner, PDQ Urgent Care & More.  
Email for my recipe.
Gregg DeNicola MD
Caduceus Medical Group

PDQ Urgent Care & More

CMO Patient Blog- Toxic-Free Advice for Halloween

This Halloween while you’re carving ghoulish characters in your jack-o-lantern, spinning webs around the house in eerie decorations, or perhaps rummaging through the closet for last minute costume ideas, there’s one thing that shouldn’t haunt you: toxic chemicals in hair and makeup.
If you’re not careful these ghostly ingredients can sneak up on you – and worse yet seep into you – whether it’s for your adult costume party, preparing kids for trick-or-treating, or just in your daily routine.  For example, did you know chemicals like lead, arsenic, and even formaldehyde are commonly found in makeup for both kids and adults?
So don’t get spooked – Caduceus is here to guide you through the maze of mysterious ingredients and deliver you to the other side toxic-free.
The first thing to know is a few common toxic chemicals or groups of chemicals to avoid if you can find them on the label.  These chemicals can not only irritate the skin, but some have been linked to cancer, and others to developmental disorders like ADHD and autism.  Where possible avoid:

  • Asbestos: can be found in talc-based makeup
  • Benzene: found in colored hairsprays
  • PFAS: a category of “forever chemicals” in many cosmetics
  • Lead: can be found in lipstick
  • Other heavy metals Arsenic, Cadmium, Mercury: can be found in children’s face paint
  • Formaldehyde: found in preservatives like DMDM hydantoin

You never knew Halloween could be so scary??  So what can you do?

Well the second thing to do is look for labels that, generally speaking, are more protective against these chemicals. 

  • “Parabens-free” products can reduce exposure to hormone-disrupting chemicals. 
  • “Fragrance-free” products typically have fewer phthalates that also interfere with hormone function.  Don’t get fooled by “unscented”!  These products actually contain more fragrances all mixed together to cancel each other out. 
  • And for other reasons animal-lovers may look for “cruelty-free” testing.

What if all this seems like too much work?  Like the perfect sheet-turned-Casper costume, we’ve got you covered there too.  Here are some apps you can use to scan the barcode of products and get a quick snapshot of possible toxicity:

  • Yuka

  • Chemical maze

  • Detox me
Finally, don’t downplay the truest Halloween tradition of all: finding something around the house that works and saves money.  Like the collared shirt tucked into jeans that suddenly counts as “Chandler from Friends.” Especially for kid's face paint there are a number of Do-It-Yourself recipes with household ingredients such as cornstarch, sunscreen, and colorful foods.
For more tips from the pros, check out my interview with professional makeup artist Sonya Talamentes talking about how she makes environmental safety part of her service to her clients.  For herself she is using toxic-free makeup to get into character for Dia de los Muertos.  We’ll remember her.
And remember this – these toxic chemicals don’t disappear like Halloween candy on November 1.  They stick around for years (or longer!) and have implications for things like pregnancy health, protecting fetal development, children’s brain health, even women’s health conditions like uterine fibroids and PCOS.

Use the button below to self-book an appointment, call our dedicated appointment line at 844-807-8558, or request an appointment through your patient portal account. 

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

Patient Blog- Protecting Our Community: Seasonal Vaccines for Influenza, COVID-19, and RSV

As we enter autumn, we have many fall highlights ahead: Halloween costume planning, all variety of food and drink dipped in pumpkin spice magic, and even our southern California version of sweater weather. Not to mention football! So the one thing we don’t want to have to worry about is getting sick – or worse yet ending up in the hospital.

So this year we have a triple-protection vaccine schedule to keep you healthy, happy, and haunt-free.

The Significance of Seasonal Vaccination

Vaccination is one of the most effective tools we have to prevent and control infectious diseases. The benefits of seasonal vaccines are substantial, both on an individual and community level. By getting vaccinated against influenza, COVID-19, and RSV, we can significantly reduce the spread of these illnesses, ease the burden on our healthcare system, and save lives.

Influenza (Flu) Vaccine

This one is easy, basically everyone should get it: age 6 months and older. It is especially crucial for the elderly, young children, pregnant women, and individuals with underlying health conditions. Influenza, a common respiratory illness, can have severe consequences, especially for vulnerable populations. The flu vaccine is updated annually to target the specific strains expected to circulate during the flu season. Of note, pregnant women should not receive the nasal spray version of the vaccine.

The influenza vaccine is available now at all Caduceus locations while supplies last.

COVID-19 Vaccine

This vaccine is also broadly recommended: at least one dose for every age 5 years and older. Seniors, pregnant women, and those with respiratory disease or have a compromised immune system are most at risk. It is important to remember that this dose is no longer a booster to the original COVID-19 virus and is really a new, updated vaccine. Multiple doses may be indicated for children age 6 months - 4 years and people who are immunocompromised.

The COVID-19 pandemic brought to light the importance of vaccination. The COVID-19 vaccines have been rigorously tested and authorized initially for emergency use, and now for preventative health maintenance, proving highly effective in preventing severe illness, hospitalizations, and death. Achieving high vaccination rates within our community is vital to curbing the spread of this novel coronavirus.

Check with your Caduceus physician or advanced care practitioner through your patient portal or live chat from our website to confirm availability of the COVID-19 vaccine at Caduceus locations.

Respiratory Syncytial Virus (RSV) Vaccine

This vaccine has some special considerations: it is advised for people 60 years and older, and for pregnant women 32 - 36 weeks, and children 8 months and younger who are entering their first RSV season. It can be received at the same time as the Influenza and COVID-19 vaccines, but due to timing during the third trimester of pregnancy it may make sense to schedule it separately for prenatal patients.

RSV primarily affects young children and older adults, causing respiratory tract infections. While many people will recover within one to two weeks, it can create serious complications for susceptible people, especially with respiratory disease or who are immunocompromised.

Check with your Caduceus physician or advanced care practitioner through your patient portal to confirm availability of the RSV vaccine at Caduceus locations.

At Caduceus, we are dedicated to promoting a culture of health and wellness within our community. As part of this commitment, we strongly advocate for seasonal vaccinations against influenza and COVID-19, and discuss with your doctor if you are eligible for RSV vaccine. All vaccines can be received at the same time. Together we can create more treats, less tricks this sweater weather season.

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

CEO BLOG- Long Covid FAQ's... From the Frying Pan into the Fire!

One pill makes you larger
And one pill makes you small
And the ones that mother gives you
Don't do anything at all

This could describe doctors during the Covid pandemic. We had no studies, concept of what to give, or what to treat with. In the final analysis, only Paxlovid was approved orally for treatment.

For music buffs you will recall White Rabbit (the song above) was written in 1967 by Grace Slick, a true matriarch of American rock.

Grace's story is interesting. A major force in American rock 'n roll for 20 years, she became disillusioned with her situation. As lead singer, songwriter, and spokesperson for the Jefferson Airplane/Starship, she became fed up with record company execs, fellow band members’ poor work ethic, and the overall commercialization of the American music scene.

So in 1988, she left--to be on her own.

And failed miserably.

Relegated to singing some backup vocals and finding no success with her music away from her old band, she retired from the music industry in 1990.

Hers is a good example of the saying "out of the frying pan into the fire."

It is commonly used as a metaphor describing moving from a bad situation into one that is worse.

Which we can use now on a very frustrating medical issue facing us--Long Covid.

It's not bad enough you may have used masks, socially distanced, contracted Covid anyway, took the meds given, quarantined yourself for weeks, possibly spent time in the hospital, missed work---but now you find yourself with a strong possibility of fighting Long Covid.

In other words, going from the frying pan into the fire.

In early 2020, we had no idea how to treat Covid, let alone that it can morph into a true monster even AFTER the antibodies did their job.

Even 3 1/2 years later, we can't agree on a true definition of Long Covid.

Most authorities use four weeks after recovery (some use 12 weeks) as the time the Long Covid symptoms start--they are sometimes unrelated to the symptoms of the Covid you started out with.
To make matters worse, the symptoms can appear and disappear during the course of Long Covid. So, you're never really sure when you are out of the woods.

So are you or a loved one affected?

Here are the major symptoms-

-Fatigue (the most common and frustrating one)
-Memory Loss
-Breathing issues
-Sleep issues
-Autonomic nervous system issues, especially with POTS -just think dizziness and unsteady gait

Minor symptoms (experts’ terms, not mine)

-Loss of taste /smell persisting
-Extremity weakness
-Cognitive issues, especially anxiety/anger/depression

In addition, there are three criteria:

1. Documentation of prior Covid infection over four weeks from onset
2. Presence of any of the above symptoms
3. Alternate explanations are ruled out

Higher risk or more serious cases are linked to:

1. The unvaccinated
2. Women
3. Over age 50
4. Covid needing hospitalization, especially ICU care

If you had a mild case, you have a 20% chance of contracting Long Covid and it lasting over four months
If you had a serious case, it goes up to an 80% chance and it may have not yet cleared even three years later. The CDC estimates there are currently NINE MILLION cases of Long Covid in the US now.

Authorities now are calling Long Covid a "post-viral syndrome,” which usually implies an autoimmune basis, persistent inflammation, and continued Antigen resistance to the Antibodies produced.

So---why bring up Covid again when it seems the pandemic is over and normalcy has returned?

Well don't tell that to the nine million cases of Long Covid--not counting the millions who have not yet been diagnosed. They have truly gone from the frying pan into the fire-and until now did not have a good handle on what to order or use to treat.

The news came out a couple of weeks ago- Long Covid patients show a change in immunity and hormone function- per a study in the respected journal Nature.

Moreover, there are now specific biomarkers that can be tested to assist in diagnosing and possibly treating this resistive condition.

The study also showed lower morning cortisol levels in Long Covid, something relatively easy to check.

Hopefully this is the tip of the iceberg and more studies will show biomarkers and other blood tests to assist in diagnosing and treating Long Covid.

What if you decide to be tested and all the evidence points to you having Long Covid?

Still no treatments are approved. Only anecdotal reports.

Almost all authorities advise more Paxlovid which has shown some promise. Trying to boost the immune system through IV Hydration with Immune Boosting formulas has helped in small numbers.

Using antihistamines is under trial in the university settings--Benadryl and Famotidine specifically.
HIV drug Maraviroc and the cholesterol medication Pravastatin have been helpful in some clinical trials.

Being able to better identify Long Covid victims will allow us to better find which of these--or yet unthought of -treatments may help.

In summary:

1. If you had Covid and now have any of the major or minor symptoms, please consider you may be suffering from the post viral syndrome Long Covid. Consider contacting us for an evaluation for this not-rare condition.

2. Via an office visit (possibly virtual by Zoom) and blood work, a severity determination may be possible, new data confirms.

3.Treaments for Long Covid are being researched and may possibly achieve off label use.
Incidentally, some celebrities have gone public with the Long Covid to encourage more research--Colin Farrell and Alyssa Milano come to mind.

Having navigated over 8,000 patients through the gnarly rapids of Covid-19, we are well positioned to help you if you have Long Covid. The same team of Covid providers that followed and cared for you through Covid, is ready and willing to help you through Long Covid.

Remember, you won the war, however the battleground can take longer to heal.

What about our Rock Queen Grace Slick? She feels her frequent masking has prevented a Covid infection. In fact, she was prophetic about our lack of sanity and scale with the whole pandemic-as she ended the song White Rabbit with-
When logic and proportion
Have fallen sloppy dead
Remember what the dormouse said
Feed your head!

Gregg DeNicola MD
Caduceus Medical Group
PDQ Urgent Care & More

CMO Patient Blog- Hurricane Hilary Safety Tips

August 18, 2023

To Caduceus patients and the community:

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

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

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

-Phone and computer chargers plus pre-charged battery packs

-Drinking water

-Non-perishable food and snacks

-Games that don’t require electricity

-First-aid kit

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

-Facebook, Instagram, or Twitter

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

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

CMO BLOG- UV Safety Awareness Month Orange County

Summertime and the livin’ is easy…

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

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

First, let’s talk sunscreen.

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

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

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

Whichever sunscreen you choose there are a few common rules:

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

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

Second, we’ll review overall summer health.

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

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

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

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

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

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

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

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

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

CMO BLOG- Tis' the Season- Allergy Testing 

New Allergy Testing: Scratch and No-Sniff


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

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

So, who should be tested?  

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

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

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

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

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

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

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

In summary:

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

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


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

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

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

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

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

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

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

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

It doesn't. 

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

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

In Summary:

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

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

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

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

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

PATIENT BLOG ORANGE COUNTY Colorectal Cancer Awareness

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

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

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

Others who should be screened earlier are people with:

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

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

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

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

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

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

In the end, trust your gut.

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

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

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

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