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Top Five Covid FAQ's- Just the Facts for Orange County

By editor
October 15, 2020

Mark Twain once said there were three types of lies... “Lies, Damned Lies, and Statistics”...meaning we can bend statistics into verifying wrong conclusions. 

Mr. Twain actually modified a quote by T.H. Huxley---"There are three types of liars- Liars, Damned Liars, and Experts.”  

The more I research Covid and its physiology and treatment, this quote takes on great meaning--and accuracy. For once, as a previous blog pointed out---even our experts are usually flat out wrong.

An example is the fact that our new Covid cases from testing at our three centers shows a significant spike, as we reported two weeks ago. They have not yet come down. This is despite reports from the OC Health Department showing new cases are flat. 

Explanation?

Clearly either Caduceus encourages more testing, giving us more cases- or –

Caduceus patients really know how to party. 

I’m going with the former.  I pray a third possibility, cases through the health department are being under reported, is out of the question.

We are in the midst of a SURGE in cases. 

We are NOT near a safe level of positive cases. 

As tired of this as we all are, we cannot let down our guard and assume the worst is over.

Using the tenet that “you can only believe what your eyes see,” let’s use actual scientific data to answer the five most common FAQ’s we are receiving.

1. If masks and distancing work, why get tested?
2. Is it now safe to eat at restaurants?  Bars? To fly?
3. How long will my antibodies last?
4. When I hear I should quarantine, what exactly does that entail?
5. With all the cases Caduceus has treated, what are the most effective therapies?

1.  If masks and distancing work, why get tested?

Even the N95 masks fail 5% of the time. Typical cloth masks seen everywhere are 85% effective in blocking the virus, meaning if you are near someone Covid positive there is a 15% chance the virus gets past the masks.

Masks work. Just not 100%.

Many studies confirm that while social distancing at six feet apart prevents transmission of 80% of the virus, the combination of a sneeze, a cough, singing, or a slight breeze in the air can aerosolize the virus and allow it to travel 40 feet or more. 

So the X’s on the floor six feet apart do work. Just not 100%.

Hence the need for regular testing- preferably a PCR nasal swab. It adds one more layer of protection. It's arguably safer to be at a Sunday BBQ with ten people who all tested negative that week, than at a restaurant table with three people untested. 

KNOW IF YOU ARE CONTAGIOUS.

Wear masks, distance six feet apart and avoid super-spreader events. Regular frequent testing is literally a life-saving strategy.

In the past three weeks 40% of our positive cases had no symptoms. That’s right. They were spreading the virus and did not know they were contagious.  

We cannot assume people with no symptoms are not contagious.

2.  Is it now safe to eat at restaurants?  Bars? To fly?

No.

Not the answer you wanted to hear right? 

A study recently published in Morbidity and Mortality Weekly Report, a respected journal, found adults with positive SARS-CoV-2 test results were twice as likely to have reported dining at a restaurant as those with negative SARS-CoV-2 test results. That went for indoor OR outdoor dining. 

The reason? When eating at a restaurant, patrons take off their masks. They sit closer than six feet apart. And most diners do not know if they are carrying Covid. Fortunately, the restaurants that have contracted with Caduceus for testing do test their chefs and wait staff on a regular basis. When they do test positive, it’s almost always from an infected diner; remember the statistic 40 % of our positive cases are with NO symptoms. A diner with Covid that has not yet shown symptoms will infect the waiters- despite the mask worn by the waiter -15 % of the time.  This applies to bars as well.

The same science applies to air travel. Despite filtered air, and meticulous cleaning, there are just too many people in a confined area. Some flights do require a negative PCR nasal swab, which is reassuring. Until that is standard procedure, “ix-nay on anes-play.”

3.  How long will my antibodies last?

If you are one of the lucky ones to test positive for the Holy Grail of antibodies -IgG-it is likely you are immune from Covid 19. But how long does that immunity last?

We have had 2 patients where it only lasted four weeks. We have had many patients where it is still showing up after six months (which is as long as we have been able to test for it). In Asia and Europe, data tells us to expect IgG to stay active for 2-12 months--a huge variance. 

That's why we advise a monthly antibody test if you are antibody positive. If you are immune, you still need to wear a mask, social distance, and avoid super-spreader events. But you can breathe a little easier knowing you're IgG positive. 

For example, we have had ZERO cases of Covid in people IgG positive. And this comprises a sample of hundreds of patients. IgG appears to be performing as advertised.

Another Mark Twain quote is “If you don’t read the newspaper, you’re uninformed. If you read the newspaper, you’re misinformed.”

Never has a century-old saying been more accurate. Our team spends hours a day reading, researching, and surfing dozens of publications, and are incredulous at the misinformation floating out there. 

For example, let’s look at #4…

When I hear I should quarantine, what exactly does that entail?

There are two times to quarantine:
-When you test positive
-When you are tested because you had close contact 

In both cases, you need to quarantine until you swab negative. Yes, we are aware the local health department and the CDC do not require a test of cure. That is the misinformation we are talking about. 

The evidence for that advice is weak.

Let’s look at the White House saga. The President was "cleared" of Covid using CDC guidelines of 10 days without symptoms. But many infectious disease centers advocate for a 20 day quarantine. Other academic centers match our advice, insisting on weekly swabs until negative.

Our experience tells us the average time to swab negative after a positive swab is three weeks, confirming the 20 day recommendation. The weekly swabs until negative rule is valid and should be the standard.

Why does the CDC stick with the 10 day rule? Admittedly there is data suggesting the virus is most contagious the first week of the infection. And that only a small number of patients stay infectious longer.  Yet they also admit they stopped advising the test-of-cure (re-swab) due to a shortage of tests.

At Caduceus, we have no shortage of tests. We want our patients to be SURE they are not contagious .A positive swab means there is active virus and that virus should be quarantined until gone.

What's the saying about “the proof being in the pudding?” Under the CDC guidance, numbers are spiking across the country. Clearly we need a more aggressive pudding...I mean strategy.

A larger problem is how people are quarantining. Very reasonable people are balking at standard quarantine protocol. This is one of the biggest issues comparing the flat curve of Asia and Italy. We simply aren't being smart about our quarantine protocol.

Pushing aside the patients that shockingly refuse to stay home and even go to work after a positive swab, we need better education on how to quarantine. 

If you live with roommate or family that IS infected:

-Stay in your own room.
-Use a dedicated bathroom.
-Food delivery contact-less is left at door.
-To move about the house or go into the yard, the house should be empty, or the residents should be out of sight of the infected person. That means NOT watching TV in the same room as the family, NOT eating at the same dinner table, NOT "hanging around" other household members. 

I know it is very difficult. Do NOT be misinformed. Quarantine correctly.

It’s only three weeks.

We desperately need to get the number of new cases down to lower the death and hospitalization rate until a vaccine is available.

5.  With all the cases Caduceus has treated, what are the most effective therapies?

This is straightforward, having used dozens of different therapies on our 500 cases we have actively treated. 

Five stand out as being especially effective:

-REST; yes it’s that simple. People who stay in bed, on the couch, or recliner and rest get better faster than those that get about and try to exercise. This is a great time to binge The Sopranos complete series.

-Pulmonary hygiene---ideally buy a pulse ox (drugstore/Amazon), nebulizer, spirometer, and find a partner with a mask to pound your chest.  Mucous is our nemesis; we are aggressive in getting the mucous out of your chest. It has kept many of our patients out of the hospital.

-Budesonide (Pulmicort) daily as a preventive med to keep airways open, and Albuterol as an abortive inhaler when cough or shortness of breath hits. It has worked in nearly everyone with lung symptoms.

-Decadron orally in patients who are not improving or worsening despite best practices. Initially meant for inpatient use, we have found excellent results safely to help prevent the hospital in the first place.

-For those few patients who have needed to be admitted to hospital, both Remdesivir and convalescent plasma have been very effective to neutralize the virus.

In Summary:

-Test. Test. Test.
-Know if you're contagious (get swabbed regularly).
-Know if you're immune (get antibody tested regularly).
-If you have been exposed or are positive, self-quarantine by the book.
-Read the newspapers, but be skeptical.

Mr. Twain had another saying worth modifying---
“The two most important days in your life are the day you are born and the day you find out why.”

We can take some poetic license and say:
The two most important days in 2020 are the day you test Covid positive...and the day you test negative.

Gregg DeNicola MD 
Chief Medical Officer
Caduceus Medical Group


Now Offering Covid Rapid Antigen Testing Orange County

By editor
October 1, 2020

There's something happening here…
What it is ain't exactly clear…

Stephen Stills had it right in the 80's. We’ve been dealing with Covid for over six months now, and how do we deal with it? Well- it’s not exactly clear.

We will address these issues today:

• The newer trends and what Covid has told us
• Announcing new testing policy at Caduceus
• A call to action to our patients and the public on how to curb the spread

If there is one thing we have learned this year is that we have run out of patience.

At first, we all were united. We saw the horror of China. The devastation of Europe. The ambulances lined up with bodies in New York.

So we quarantined. Locked down. Hunkered.

And the numbers in California dropped from April through late May.

So we reopened. But not smartly. We were ready for returning to some type of normalcy. Going out to restaurants. Memorial Day gatherings. Protests. But Covid plays by ITS rules, not ours and the June, July, and August numbers skyrocketed.

We became divided. Maskers vs. Anti-maskers. Social distancers vs. life as normal. Sadly, it became political. Even Right vs. Left managed to somehow arm wrestle over what should have been a unifying crisis.

Fortunately, as masks and distancing became the "new normal,” the numbers began to fall in the first half of September. So much that in Orange County we were allowed to open back up- restaurants, theatres, gyms, and churches. And at the same time, here came the Labor Day weekend.

We warned our patients about gatherings, parties, and BBQ’s. About frequenting restaurants and hanging out downtown instead of our living rooms.

We've all heard Albert Einstein's famous line, "Insanity is doing the same thing over and over again and expecting different results.”

You guessed it; we are seeing another spike in cases- apparently learning little from our Memorial Day experience.

We shouldn't be surprised. Covid has now told us exactly how it works.

• It has a two week incubation period where it is spreads even if no symptoms.
• It can spread by micro droplets, far beyond our arbitrary six foot boundary.
• It has a high penetrance rate---i.e. it doesn't take a lot of Covid to spread; it’s very "catchy."
• It doesn't care about the age of its victims.

At Caduceus we have been tenacious on our position.

As CSNY would say,

We, who have a Covid load
Must have a code
That we can live by…

And here is ours….

Know if you’re contagious.
Know if you’re immune.

In Europe, the caseloads are also rising quickly. Where they had been using universal testing with good results and lowering the numbers, they took their eye off the ball when the numbers fell. The European view is shifting toward individual responsibility, and not government action. Instead of locking down and pushing for universal testing, European governments note that many Europeans are tired of the whole thing. Testing, masks, and distancing are less common now, and the rising European numbers are proof that as tired as we all may be, we will not start to see blue skies until we know who is contagious, and who is immune.

Caduceus and PDQ Urgent Care and More are now offering improved PCR swab testing for Covid. At this time, we are no longer using LabCorp or Quest for our testing. (Except on patient request).

This was not punitive or political. We simply could not rely on the results being timely, and our calls to check on the results on behalf of our patients went unanswered.

We have made arrangements with smaller labs that have the same machines, but can meet our needs regarding turnaround time.

We now offer our patients with insurance NO OUT OF POCKET PCR Covid testing with a 2-3 day turnaround.

This allows us to further advise our patients to set up a REGULAR testing schedule without worrying about out of pocket payments.

If you need a 24 hour turnaround,
We can offer you an expedited test for a cash price of $189.

In addition, I recall an old ad campaign for Toyota that said, "You asked for it, you got it.”

If you have no insurance, we can offer you the antigen test with a physician’s order for $66. Results while you wait or we will follow up with you same day if you prefer not to wait curbside.

That’s the deal with swabs for presence of virus. How about immunity?

We continue to use "moderate complexity,” a more sensitive antibody test to help determine if you are immune. We alert you that some insurance plans are not covering antibody testing, so in that case we offer a cash rate of $85 for moderate complexity and $75 for low complexity antibody testing.

One example of how testing may help bring down the numbers…

A family we are caring for wanted to have a family gathering of 10 people over the Labor Day weekend. Of course, I discouraged it, but there were mitigating circumstances that made it essential. The ages ranged from 20 to 80 and many had jobs serving the public.

We ordered PCR testing the day before the gathering. Results were back the next day. All 10 were PCR swab negative. (Antibodies were also negative so no immunity.) They still practiced precautions, but it was reassuring all 10 were Covid free at the same time. It has been over 14 days, and no Covid came from that gathering.

Testing works.

Let’s look at a gathering without testing---

65 people attended an August 7th reception at the Big Moose Inn Cabins in Maine. By August 25th, 53 cases were tied to the wedding. A week later, 147 people who attended the wedding or got the virus second-hand as a result of someone who attended the wedding tested positive for Covid.

Even worse?

Three of those people have died. None of the fatalities had even attended the wedding.

Testing works.

In addition to offering improved testing choices, I also encourage setting up a regular testing schedule for ALL of our patients.

If you serve the public (health care, restaurants, retail workers),
Test every two weeks (Caduceus and PDQ test their staff at least every two weeks.)

If you are usually home or in a small office, but do go out and about,
Test monthly.

If you hunker down at home and rarely go out,
Test quarterly and on demand when you must go to a gathering or meeting.

All patients should consider an antibody test every 1-3 months to detect immunity. If it is negative, take extra precautions.

And as always, all of our testing is done by video from your phone and curbside so you never leave the security of your home or car.

For both swabs and antibody tests, you do not need a physician's order if you have had a telehealth visit (or office visit) in the previous 12 weeks and were negative.

In summary:
• Learn from this summer… Mask. Distance. Avoid gatherings. Don’t give in to impatience.
• Get tested regularly. If you are contagious, self-quarantine. and if you are not immune, take extra precautions.
• Don’t succumb to peer pressure or your own impatience to socialize unnecessarily or go without a mask. Covid has told us its rules. Listen to them.

If David Crosby could write a song about Covid now, it might go…

Must be because I’m worried I'll get Covid at Christmas
And I'm not feelin' up to par
It increases my paranoia
Like not wearing my mask then seein’ a police car
But I'm not givin' in an inch to fear
‘Cause I promised myself this year
I feel like I owe it to someone
To be tested
Hoping my Covid swab shows none

Gregg DeNicola MD, Chief Medical Officer


CMO Covid Corner

By editor
September 27, 2020

URGENT ALERT-

As CMO I want to report to our patients a dramatic upswing in POSITIVE Covid19 PCR cases.

After seeing a drifting downward of new cases between late August and early September, we are experiencing large numbers of new cases similar to our dark days of April.  We are in the middle of another surge.

I cannot speak for numbers put out for LA or Orange County now. This alert is based on OUR swab results in the last week.  About 33% of our new cases are without symptoms. Those with symptoms have become very ill, very fast. Average age is 35, with most cases between 20-40.

We have noted good response to Budesonide and Decadron given early, so I encourage being tested immediately for ANY Covid symptoms, especially:

-Fever
-Fatigue
-Loss of taste/smell
-Nausea/diarrhea
-Muscle aches
-Upper or lower respiratory symptoms including sinus pain and sore throat

We want to keep our patients out of the hospital and prevent the horror stories that have become common with Covid infections, even in younger patients.

The current siege started on September 21st, exactly 14 days after the Labor Day activities we were concerned about. Recall the incubation period for Covid is 14 days. Many of our new cases trace their contact to that weekend, others to the recently reopened restaurants, gyms, and salons. One common denominator--none of our new cases suspected their contacts were contagious.  Because no one knew they were.

We DO NOT advocate more closures.
We DO advocate more testing.

CADUCEUS and PDQ URGENT CARE AND MORE NOW OFFER NO OUT OF POCKET COST PCR SWAB COVID TESTING WITH A 48 HOUR RESULT TIME (with valid insurance).

Of course the physician order is via a telehealth video visit from your home, and the swab is curbside from your car. We have reasonable cash prices if you are uninsured.

We have worked hard to arrange this service for you, please consider taking advantage of it.

If you test PCR positive -STAY HOME AND QUARANTINE!
If you are antibody negative, STAY HOME AS MUCH AS POSSIBLE.

Understandably, the new siege has stressed our systems, and we are adapting. You can help us by--

-Avoid the phones, use email or LIVE CHAT instead, available from the home page of our website or app.
-Use our telehealth platform, if appropriate, in lieu of office visits or walking in.
-Keep your appointments, and let us know if you must cancel or no show. This makes room for more patients.

We are all weary of the masks, the X's on the floor, the elbow bumps, and the binge watching on the couch.

We will beat this.

But it requires you to:

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

Our lifestyles, and lives, depend on it.

Gregg DeNicola MD
Chief Medical Officer


September Newsletter

By editor
September 15, 2020

Get Your Flu Vaccine While Supplies Last

Fall is almost here and with the change of seasons also means the flu season is just around the corner.  Flu season generally runs between October-April with peak season December-February.  The Centers for Disease Control and Prevention (CDC) recommends that everyone 6 months and older get immunized.

There’s no vaccine for Covid-19, but there’s one for influenza. Getting your flu shot now could blunt the effect of two potential respiratory infections and minimize the risk of a more severe case.

Also, flu vaccines are generally covered for anyone with health insurance.  We also offer an affordable cash price of $35 for 6 months-64 years and $69 for seniors for those that are uninsured. 

Come curbside NO APPOINTMENT NECESSARY WHILE SUPPLIES LAST. Email us to confirm we have stock prior to driving to your preferred location.

Hours for curbside testing:

  • Yorba Linda- Mon-Fri 8-4
  • PDQ Orange- Mon-Fri 8-4
  • Irvine- Tues/Thurs 9-11, 2-4
  • Laguna Beach- Mon/Wed/Fri 9-11, 2-4

In addition to flu vaccines, we will continue to offer Covid-19 diagnostic and antibody testing*, rapid flu and strep swabs*, and any other lab draws curbside from your car.

* Telehealth video visit from your phone required to testing

Reserve a telehealth video visit screening for Covid-19 testing and/or rapid flu/strep.  

Open Enrollment is Almost Here

Medicare open enrollment, also known as Medicare’s annual election period, runs from October 15 through December 7 each year. During this annual window, Medicare plan enrollees can reevaluate their coverage – whether it’s Original Medicare with supplemental drug coverage or Medicare Advantage – and make changes or purchase new policies if you want to do so.

During the Medicare open enrollment period, you can:

  • Switch from Original Medicare to Medicare Advantage (as long as you’re enrolled in both Medicare Part A and Part B, and you live in the Medicare Advantage plan’s service area).
  • Switch from Medicare Advantage to Original Medicare (plus a Medicare Part D plan, and possibly a Medigap plan).
  • Switch from one Medicare Advantage plan to another.
  • Switch from one Medicare Part D prescription drug plan to another.
  • Enroll in a Medicare Part D plan if you didn’t enroll when you were first eligible for Medicare.

We offer complimentary Medicare consultations at our offices and email us if you wish to meet with a Medicare specialist.  

Watch our Medicare 101 video to understand your options.  

Covered California/Medi-Cal Open Enrollment Period is November 1 – January 31. Open enrollment is the period during which you can purchase health insurance and apply for Medi-Cal coverage for the upcoming year. During open enrollment you can apply without a Qualifying Life Event.  Learn more about your options.  

More Providers Now Available for Online Booking

We have added two more providers to our online appointment booking feature from the appointments tab of our website; you pick the time and date for either an in-office visit or a telehealth video visit from your phone.

Dr. John Sanguedolce joined our family practice team in August and provides primary services at Yorba Linda family practice and Caduceus on Thalia in Laguna Beach.

Dr. Kim Kirton-Fusilier is our Director of Physical Therapy at Back in Motion and you can now book new patient consultations directly from our appointments page. 


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