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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

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