Latest Patient Center Updates

CMO Perspective on Covid-19 over the Last Two Months

By editor

May 21, 2020

COVID-19….the first 60 days from the Caduceus perspective.

Caduceus started testing for Covid in mid-March. We began treating patients within days and started accepting referrals in early April. Overall we have tested over 2000 patients in our three OC testing sites and have actively treated over 85 cases with a "Covid Team" approach. Approximately half have recovered; the other half are receiving regular ongoing treatment.

Around half are previous Caduceus patients, the other half came under our care once diagnosed. The distribution is split between North, Central and South OC 33% each. In general, most of the early cases were in South OC, and the more recent cases were based up North. Half the cases were diagnosed the first three weeks of testing, with a slowdown after April 7. Since that time, we have still had a steady flow of new cases new weekly. From the start we began meticulous record keeping.

We have heard in other areas more cases are diagnosed in men. Not with us, the gender split is 50/50. As for seniors having more cases- that has not been our experience. Over half of our cases are under 40. Only 10% are seniors over 65.

Two hospitalizations have been recorded from our patient population, both to the ICU, ages 62 and 69, both healthy, both recovered.

No deaths have been reported.

As for many cases being asymptomatic, nope. Less than 10% of our cases are diagnosed symptom free.

As for what we hear about the most common presenting symptom being fever or cough? Guess again. 90% present with fatigue as the biggest symptom. Only 80% have fever at all, and almost half have parageusia (loss of taste and smell).

Early on, we saw the need for an aggressive strategy for treating even mild cases. The pattern was actually frightening with the first dozen cases.

A typical case-

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

One patient suffered significant illness for 25 days. No; not a senior.

We find a regimen of "Double Z's" helps a few...Zinc and Zithromycin.

A "Covid Cocktail" is very helpful once a positive swab was found. ... Sudafed, Promethazine, and Albuterol inhaler. This is designed to combat mucus and open the airways.

Once a cough or air hunger develops we teach aggressive "Pulmonary Toilet" AKA Hygiene.

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

As many times a day as could be tolerated, at least three.

We see them via telemedicine frequently and daily if necessary.

One severe case in March was given Plaquenil AKA Hydroxycholoquine, almost as a last resort. There was immediate improvement so we used it again. And again. Every case improved. No cardiac issues. In fairness, we have been using Plaquenil in our practice for many years for connective tissue diseases, so felt comfortable with its use. Plus it was a five day course, whereas most lupus patients are on it a lifetime. The risk/reward ratio seemed to favor its use. In all we prescribed it 15 times; all 15 reported improvement.

We are aware this does not match scenarios from other centers, even the CDC, but as they say in sports – “we gotta call ‘em as we see ‘em.”

Severe cases are the hardest to treat, simply because there was no playbook for their treatment. They universally report an air hunger, feeling of drowning, copious mucus, and the sensation of not enough oxygen even with a deep breath. Several informed us of a near-death sensation. The look in their eyes - even over a video visit on their phone -was haunting. Would they all have recovered without the aggressive treatment we described? No one knows. Yet as victims recovered, we had the comforting feeling the “Big Guy” was guiding things.

Despite all measures we mentioned, the #1 factor in improvement is bed rest- complete and total.
Bed. Couch. Recliner.

Almost 25% suffered a relapse after recovery, and the number one factor in those cases was discontinuing bed rest.

We attempt to check a test-of-cure on all of our cases. On average it takes 30 days to turn "swab-positive" to "swab negative." Almost all swab positive cases are showing antibodies, but it’s taking 30-60 days to do that. Whether the antibodies will prevent a re-infection via immunity still needs to be established. Theoretically it should.

Mysteriously, there are another 25 patients--taking us to over 100 cases--that have identical courses to our Covid-19 cases, right down to the air hunger, copious mucus, near drowning and parageusia. However, they are swab negative. Multiple times.

False negatives? Doubtful given the well established PCR technique. A Covid mutation unrecognized by the PCR test? That’s our hypothesis. We are treating them identically to swab positive patients, with the exception of withholding Plaquenil. Perhaps because of withholding it, these patients are sicker longer and have a tougher road to recovery.

As the city, county and state begin to re-open, we must prepare for a "second wave."

Our advice based on what we have learned?

1. Avoid proximity to ANYONE sick. Do NOT forget how easy it is to catch Covid-19 and the long 14 day incubation period.
2. If you feel fatigued or have a fever, get to bed and get tested ASAP. DO NOT attempt to fight this off by yourself. Stay under the care of a physician.
3. Social distancing, masks, hand washing, AND avoiding unnecessary travel are still wise, although unpopular. At least until the numbers fall more.
4. If you test swab-negative Do NOT become complacent and assume it’s a common cold. You know the saying "If it quacks like a duck...."
5. Test. Test. Test. Either for the swab or antibody depending on your individual needs.

If you are a patient, we share this so you may avoid the virus and hopefully resume some type of normalcy.

If you are a physician, we share this information as part of the Hippocratic Oath we all took......"I will remember there is art to medicine as well as science. I will respect the hard won scientific gains of those physicians in whose steps I walk in, and gladly share knowledge as is mine with those who are to follow…”

Gregg DeNicola MD
CMO
Caduceus Medical Group

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

Antibody Testing.. Fact or Schiznick??

By editor

May 14, 2020

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

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

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

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

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

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

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

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

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

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

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

Gregg DeNicola MD
Chief Medical Officer

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

COVID 19 ANTIBODY TESTING- WHAT YOU NEED TO KNOW

By editor

April 29, 2020

Since March 1st, we have evolved—

-First there was no test available for Covid 19.
- Then came the nasal PCR swab PCR to show us evidence of the live virus.
-And now, antibody testing has arrived.

Depending on your age, you can hear Roseanne Roseannadanna in the distance.
I know a lot of you are asking, what is an antibody test? Do I need one? Where do I get this test? Do I have to pay for it or is it free? Do I come to you or do you come to me? Can you do it from my car curbside or do I have to go into the office? Do I see a doctor first? If I have had Covid 19 do I get one? If I haven’t do I get one?

Well dear patients; you sure ask a lot of stupid questions! God bless Gilda Radner looking down with a smile...

Of course these are not stupid questions at all. Let’s answer succinctly.

This is a perfect time to bring up the old adage LET THE BUYER BEWARE…

The WHO has put out many cautions that the antibody test may not actually predict your immunity. Many experts are also cautioning that the antibody test may not actually predict immunity since COVID-19 is such a new virus; it would be dangerous to rely on a test that has no track record.

At Caduceus, we completely agree. On the other hand, it’s “the best we got.” It appears clear that if you need a high degree of assurance of your immunity, you should pass on the antibody test for now.

However only by doing antibody tests on a large population of people will we be able to find out if it’s accurate. A true catch 22.

Covid 19 is a virus and when it is in your body acts as an antigen. Your body forms antibodies to fight off the virus. You need a test to find out if you've had Covid 19 and to check for immunity.

Some health plans are paying for it; others will not tell us yet. You may be asked to pay $75 if it’s unclear your health plan will reimburse for it. We are also offering a cash price for those uninsured of $99 which includes the video visit screening and curbside antibody test from your car.

Caduceus is only doing testing curbside. The staff will be bundled up well in PPE. We advise against having the test inside a medical office or hospital. At Caduceus, a physician’s order is required, and the doctor will help you interpret the test. It is NOT a simple positive/negative as with the PCR nasal swab.

You SHOULD consider having one no matter if you've had Covid 19 or not.

Two cautionary tales…
1. In our opinion, antibody tests available prior to April 20th are very suspect. Distributors were frankly “shady” and prices were all over the map, there were high false negative rates, and no FDA emergency blessing. We searched high and low to find one that we are comfortable with recommending for our patients and the community at large. All antibody tests are NOT the same. Before having one vetted, stay away from sites that charge over $125, do not require a doctor’s order, give you results in two minutes, require you to enter a lobby with other possibly sick patients, or in general appears sketchy. This is one test you may want to avoid the “Motel 6 variety.” Hold out for the “Four Seasons” version. 2. Studies are showing it may take up to 90 days for the antibody to “show up” on the tests. If you were exposed in early March that means ideally you'd be tested in June. Realizing most patients will not want to wait, be prepared to be re-tested in the summer if you test negative now.

Let’s have a little fun....and play doctor....NO not that game! Instead I’ll give you FOUR short cases and you guess which is the right test; nasal PCR swab or blood antibody?

Case 1-
Suzy is 44 and has a fever, cough, and loss of taste for the last week. Two weeks ago she went to the grocery without a mask and the deli worker did sneeze a couple of times near her. What test should she have? ANSWER- Nasal swab. It will show active Covid 19 virus accurately. The antibody test will be negative for weeks more.

Case 2-
Sam is 55 and went to a New Year’s Eve party where a couple were coughing and saying they were “getting over a flu bug.” A week later, he spiked a high temperature, started coughing, and had chills and body aches. He went to an urgent care where they diagnosed the flu and gave him Tamiflu. It took two weeks to recover, and Sam now believes he may have actually had Covid 19 since the couple at the party was hosting a Chinese exchange student over holiday break. What test for Sam? ANSWER - antibody test. The virus is most likely out of his body but the antibody test will reveal if he has antibodies against Covid 19, thus confirming that was his proper diagnosis in January.

Case 3-
Tammy is 26 with an active social life and who also cares for her frail 79 year old grandfather. A month ago, a close friend tested positive for Covid 19. A week later, Tammy had a mild sore throat and low grade fever for two days. She did not get tested. She wants to be sure she is not a carrier so she does not spread Covid 19 to her friends or grandfather. Which test to order? ANSWER- A PCR nasal swab will rule out her being contagious. An antibody test does not test for active virus but would tell Tammy if she indeed had Covid 19 but NOT if she’s a contagious carrier.

Case 4-
Joe is 50 and has been furloughed from his job for a month now. He has been well, with no symptoms or known exposure. His boss has announced his intent to reopen the office and resume operations sometime in May, but he is requiring all staff to show whether they have had Covid 19 and if they are immune. What test does Joe ask for? Answer- An antibody test will actually give Joe TWO results on antibodies; IgM will tell us if he has had Covid 19 recently. IgG will confirm immunity. A PCR nasal swab fails on these criteria.

Did you have a perfect score at FOUR for FOUR? If so we may want to deputize you! I mean every Sheriff Taylor needs his Barney right?

Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group

Please follow these directions to request an antibody test:

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

Covid 19- Our CMO Answers Your Questions

By editor

April 14, 2020

AN IMPORTANT MESSAGE FROM OUR CHIEF MEDICAL OFFICER GREGG DENICOLA MD

Is this the real life?

Is this just fantasy?

Caught in a landslide; no escape from reality.

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

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

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

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

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

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

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

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

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

Our answer?

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

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

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

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

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

Our answer?

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

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

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

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

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

So ending the quarantine?

Our answer?

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

Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group

Covid19 Treatment- What You Need to Know

By editor

April 7, 2020

As more of our patients test positive for COVID19, it’s a good time to look at treatment options.

Caduceus is actively managing a case load of over 50 cases, all accumulated over the last three weeks. There will be more by the time you read this; we take on additional cases every day. Most are diagnosed through our own testing program, and we also accept referrals from patients unable to find doctors to treat them. Our cases stretch from LA to Riverside.

We have developed a treatment protocol based on available research and old fashioned “trial and error.” By spreading the word, we hope current and future COVID-19 positive patients may find it useful.

STEP 1---It seems obvious, yet we insist on COMPLETE AND TOTAL BED REST. Multiple studies over the years show the beneficial effect on our immune system to minimize stress on your body while fighting infections. That means bed, couch, or recliner. Patients can get up to use the bathroom and shower and eat at the dinner table. Alone.

The idea of exercising the virus away or keeping the body in shape will certainly prolong the symptoms. You feel fatigued with the virus for a reason- your body is asking for rest. Listen to it.

STEP 2--- Have a Covid cocktail. NO, not that kind. (We named it, but feel free to steal it.) Sudafed, Promethazine DM, and an albuterol inhaler. A twist is optional.

The idea is simple; we need to keep the mucus and fluids out of your lungs. That is where the serious cases have problems.

The Sudafed shrinks the blood vessels in the nasal passages, reducing congestion. The Promethazine Dm (by prescription only) helps with the cough, thins the mucus, helps keep the lungs clear and helps you rest.

The inhaler (also a prescription) opens up the airways. It’s like removing the cones from a two lane highway, making it a four lane highway. We want a path for the fluids to get out of your lungs.

Not everyone needs all three. We grade all of our cases as asymptomatic, mild, moderate or severe. The exact ingredients of the cocktail and the frequency varies on severity of the case.

Results? Unquestionable improvement.

STEP 3---Finding a medication that fights the virus. We have been putting all symptomatic cases on the "Double Z’s"- a Zpack and Zinc. For the Zpack, it is more than just preventing a secondary bacterial infection. Azithromycin appears to have activity over "atypical" bacteria, which have some elements of a virus. It was used in Asia with fair success.

Zinc makes sense. We know there is activity using Zinc versus the common cold. It’s safe, cheap, and readily available.

Unfortunately, neither has been especially impressive.

Hydroxychloroquine -aka Plaquenil - has been our go to for moderate to severe cases. The results so far ARE impressive. Despite media reports that millions of doses are flooding the pharmacies, it is still a challenge to find it. The pharmacies want to see proof of a positive result. Most deny having it.

So far we have been able to find it for every patient we feel has needed it. But it takes a lot of calling around. We have had to send patients out of the OC to get it. Our advice- if you are positive and are sick, let us find it for you. Our goal is to keep you out of the hospital.

Both Proteus inhibitors (used for HIV) and Ivermectin (used for scabies) have promising reports- we will advise those in certain cases if Plaquenil is not available or fails.

That's about it. No other meds appear to be worth using at this time. (Convalescent serum is being developed, but will be reserved for inpatient usage)

STEP 4--As a medical student in the ‘70's at the VA Hospital, I would need to get up at 3 AM to perform an order for "Pulmonary Toilet.” In the 21st Century, political correctness renamed the process “Pulmonary Hygiene.” Either way, it’s getting the yucky mucus out of the lungs.

The premise is simple- put a glass of water on your front porch. In a few days, it turns brown, and has little things swimming around in it. But a garden hose trickling for days stays clear. Stagnant fluid in the lungs turns badly infected, and needs to be removed. Here are the three processes we teach--they should be done 3-4 times a day.

TURN, COUGH, AND DEEP BREATHE- Lie in bed on your right side, cough hard, take a deep breath, and turn to your left side and repeat. Do this for 5 minutes. Imagine trying to get honey from the bottom of a jar to the sides. Same idea.

INCENTIVE SPIROMETRY- If you have one of those gadgets with balls that rise as you take a deep breath; perfect. Otherwise, improvise by exhaling totally, take as deep a breath as deeply as possible, hold it for 5-10 seconds, exhale, and repeat the process for 5 minutes. We need the airways open, and this accomplishes that.

PERCUSSION AND DRAINAGE- Again we improvise for home use. You'll need a partner wearing PPE (protective personal equipment). They cup each hand and begin playing the bongos on your back as you lie over a table with your shirt off. They should pound fairly hard. After about a minute, they should leave the room as you cough deeply to remove as much fluid as possible. Repeat the process for five minutes or more. (As a medical student I would sing “BABA LOU” as I played bongos on my patient’s back- it kept me awake and sometimes they'd even sing along.)

As part of the protocol, we schedule video visits every one to five days depending on the severity. Per CDC criteria, this protocol is complete once the patient is without fever or symptoms for three days, and at least one week after the original diagnosis (although we advise two weeks in most cases).

At this point we can do a test. A nasal PCR will tell us if the virus is still there. An ACCURATE antibody test will tell us if your immune and recovered. To date there is no test to see if you are an asymptomatic carrier other than repeated PCR swabs. We currently advise a PCR nasal swab done at our curbside locations. By the time your home we will have an answer. Keep in mind both the antibody tests and nasal swabs are still in short supply.

Results?

50 cases are hardly sufficient for a statistical analysis. What our records show is two patients that tested positive needed hospitalization -4% compared to a 12% national rate.

Of course we began testing earlier than most of the country and were able to start treating with milder cases. No deaths of our patients have occurred, compared to a 3% national mortality rate. As we head to 100 cases under our protocol, we must brace ourselves for that possibility.

The three most effective treatments?

Total bedrest.
Plaquenil.
Aggressive Pulmonary Toilet- I mean Hygiene.

We share this with you hoping you will share this with others. If you know someone with COVID19 and is not doing well, perhaps this data will assist. If you are a medical professional, please feel free to critique and/or use the info here. If you have successful treatments we didn't mention, please let us know. It will be awhile before the peer reviewed journals can give us strong data. By then it may be too late for some victims.

Gregg DeNicola MD, Chief Medical Officer

See the doctor from your phone and schedule your next visit from the comfort of your own home.

COVID-19 TESTING 101

By editor

March 31, 2020

AN IMPORTANT MESSAGE FROM OUR CHIEF MEDICAL OFFICER GREGG DENICOLA MD

One of the most heated topics when reviewing patient feedback on our blog involves COVID-19 testing and the length of time to receive results as well as the availability of tests. We sympathize on the turn-around time complaints as we are as anxious to get these results back as our patients are. When the lab machine can handle 250 tests a day and they are getting 750, things back up as one may expect. Hopefully between lower demand and more machines we will see this be less of a problem soon.

So let’s do a “Testing 101” and emphasize three major issues:

1. Who should get tested?
2. What are the different type of tests now coming out?
3. When should a negative test be rechecked and a positive test as well?

Who Should Get Tested-

In the first blog post we went over the five major criteria- personal exposure, recent high risk travel, fever, upper and lower respiratory symptoms. What makes it confusing is that the CDC is leaving it up to each provider to determine the need for a test. One group may be very "tight" in their approvals, while others very "loose.” The wild card is the chronic lack of availability of the tests. Some days Caduceus starts the day with only 25 tests that would typically last a half day. Other days we wake up to 250 tests at our three swabbing centers.

Calling the local OC health department was of little help; they suggested a common sense solution. Save the tests for the highest risk patients- seniors, smokers, and those with impaired immune systems. So the days we are low, as CMO, I have had to tighten the approvals to those groups only. Other days, we are much more liberal in who we can screen.

Is this a form of rationing? Absolutely. It goes against everything we stand for as a medical group. Fortunately, we have never run out of tests since we started after they first became available. At this time we appear to have sufficient tests to keep our current testing capacity. We have done well over 500 tests, with a 6% positive rate. We commit to our patients- as long as we have it within our power –that we will have enough tests to continue testing daily as long as necessary.

We continue to insist that everyone who even THINKS they meet criteria, attempt to get tested. Otherwise, one may compare it to off-roading in a Jeep at night without headlights. Yes, one MAY be fine- until coming to a cliff.

Caduceus must give HUGE accolades to our Senior VP’s of Operations, Monique Wusstig and Katie Franklin. Their focus and determination to keep us fully stocked with swabs has been inspirational and life-saving.

The take home message?

If you have a fever or are sick, DO NOT IGNORE IT. Don't "watch" it. Ask your physician or provider a medical question at mousecalls@caduceusmedicalgroup.com. Schedule a video visit on our app or email our team at videovisits@caduceusmedicalgroup.com. Get swabbed. We will figure out a way to get you tested.

Let’s discuss the different type of tests now coming to the market-

The gold standard--the only test Caduceus has used--is the "PCR" test on a nasal swab. This can detect as little as one virus particle in swabs taken from inside the nose. For Covid-19, the exact accuracy of PCR is unclear but PCR’s in general for other conditions are usually over 95% accurate.

The MOST important statistic is the "false negative.”
To be told you don’t have Covid-19 could be a disaster if you go back home and continue normal daily activities and sleeping habits with your spouse or partner and you really do have it.

A false positive is no picnic either; to stay quarantined alone and pray you do not contract life- threatening pneumonia when you don’t have Covid-19 at all is also not ideal.

The PCR nasal swab has very rare false positives or negatives.

The two problems with the PCR test are the lack of availability and the turnaround time on results, which should be three days, but has been over a week in some cases.

Enter the new antibody test. It’s a blood test and may be easier to find. Most only take 15 minutes, so you can get the result while you wait. Problem solved?

You guessed it; nope. The false negative rate is at least 10%. If we do 200 tests this week on that machine, 20 people will be told they are negative when they are actually positive. Also, there are different types of antibody tests with varying time for results and accuracy.

Some are even "fake" with reports that clinics charging are $250 for the test. My advice is NEVER to pay for a Covid-19 test. It’s against the law to charge the patient for the test. A doctor “on the level” will bill your insurance. As tempting as this test is, I’m afraid I MUST advise you to pass on the blood antibody test. One disclaimer- If we run out of PCR swabs for the long term, we WILL revisit using the antibody test.

A third player will enter the game in the next few weeks. Abbott Labs has a small machine intended for private medical and urgent cares. Called Abbott ID Now, it is a swab, not blood, and gives results in 5-10 minutes. They envision tens of thousands of these machines being utilized around the country through the month of April. Now we are “cooking with gas” right? Not so fast. Although Abbott hasn’t released exact data yet, one study shows a whopping 40% false negative rate!

Extreme caution must be used NOT to follow the temptation of a rapid test readily available. Time will tell if they are adequate for accuracy. If you’re skeptical of my cynicism, just Google “Theranos.”

The take home message?

I do NOT advise rapid "point of care" antibody blood tests or swabs on small machines at this time. The current PCR test is the gold standard for a reason. It’s accurate. The Covid-19 virus is not the time to be experimenting and risking a false negative or positive .Your life and the lives of your loved ones may depend on it.

Testing re-checks for both negative and positive-

Even though the PCR is accurate, are there times to re-swab? Yes. If you test negative, but you just landed from New York and then develop a fever, you need to be swabbed again. If you have a productive cough, test negative, but the cough worsens with trouble catching your breath, do a re-swab. If your partner tests positive, and you test negative, but you later spike a fever---you guessed it... re-swab. You could have another video visit to discuss things and confirm with the doctor but they WILL advise a re-swab.

What about those that have tested positive? When do they get swabbed again? Ahhh, this question is a bit trickier.

We call that a "test of cure" and it is very controversial. Mainly because it’s possible to stay positive for an extended period of time but we aren’t sure you're really contagious if symptoms have resolved. The CDC has gone on record as leaving it up to the treating physician or care provider whether to test a positive case until we receive a negative result. At first it was standard to re-swab once feeling better, but the trend now is swinging away from re- testing.

It is possible once the quarantine is over employers will require a “test of cure.” Bed partners may request one. Those seeking peace of mind will ask for one. At Caduceus we are taking this on a case by case basis. Surprisingly, most of our victims of Covid-19 have declined the “test of cure.” Most say they feel great and to save the swab for those that really need them. In times of crisis, we see that people really DO care.

The take home message?

If you test negative, don’t be bashful if your symptoms are new or persisting. We will re-swab you if there is any doubt. If you are recovering, you should discuss re-swab with your physician. We feel everyone who has any reason to be tested, should be.

After all, shouldn't we follow the lead of that great troubadour, Bob Dylan, who, in the song Rainy Day Women, sang "Everybody must get swabbed"?

Gregg DeNicola MD
Caduceus Medical Group
Chief Medical Officer

COVID-19 IMPORTANT UPDATES FROM OUR CMO

By editor

March 24, 2020

AN IMPORTANT MESSAGE FROM OUR CMO (CHIEF MEDICAL OFFICER) GREGG DENICOLA MD

There is a new phrase I've noticed being used regularly. It used to be when discussing travel plans and logistics, we would refer to a time frame.

“Want to plan a vacation?” Maybe in the fall!
“Try the new sushi place?” Let’s go next month!
“Go wine tasting?” Next weekend!

Now the answer to all of those ideas is the same - "After all of this is over.” Six short words that express simultaneously both despair AND hope.

I want to discuss 3 important--and possibly life-saving topics:

1. A plea to not ignore your normal health care needs.
2. Our take on the new therapies being touted.
3. The need to test---real or overblown?

I noticed about 10 days ago a patient I am treating for an irregular heartbeat had cancelled his appointment. He normally sees me to check-in every six months. He has been stable for years. Concerned, I called him. He said-you guessed it-he wanted to "hunker down,” and he would reschedule after “ALL OF THIS IS OVER."

I convinced him to convert the office visit to a video visit. He needed blood drawn, since he was also on thyroid medication, which could affect his heart rate and his blood sugar was always in the pre-diabetic range. We arranged a curbside blood draw a few days before the video visit.

Sure enough his thyroid level was elevated and required a reduction of his thyroid medication. Unchecked, it easily could have led to a serious arrhythmia. His blood sugar was also higher than usual, which he admitted was due to increased snacking and poor dietary choices during his "hunkering.”

It is obvious that high cholesterol stays high during a pandemic. Fatty livers are still fatty and those patients need their blood tests to check them. Moles do not stop their progression to melanoma just because Mr. Newsom tells us to stay home.

With video visits and curbside lab draws, all of these can be evaluated and managed via telemedicine. We have been doing telemedicine at Caduceus for over six years with excellent results. Of course there are situations where the patient must be seen in person. Since our lobbies and rooms have been infection-free for some time; it is still safer to be seen by your doctor than letting your non-COVID health suffer.

The moral of the story?

Keep your appointments.
Convert them to Video Visits.
Have your blood drawn curbside.
Do NOT wait until "all of this is over" and this message is even more important than preventing the spread of the virus. And it is even more essential than a trip to Costco.

I have examined the evidence to use Hydroxychloroquine for COVID-19 cases and it is promising. We have been using it at Caduceus to treat swab positive cases, but it is very hard to find. Some pharmacies are concerned about supply depletion which will lead to lupus patients unable able to refill their prescriptions. Others say they don't agree with the indication. Yet others simply deny having any. There is little question the risk/benefit curve points in favor of the liberal use of it in positive cases. If there are no symptoms (e.g. the patient was returning from Europe and tested positive but had no symptoms) it is NOT indicated.

For any physicians and other care providers reading this, the dose is 400 mg. BID x 1 day, then 200 mg bid x 4 days. Warning-you will need to call around and be prepared to beg.

Also, Proteus Inhibitors have shown activity against COVID. You may have heard of them as HIV medications. Current COVID-19 guidelines reserve their use for cases admitted to the hospital. Both WHO and CDC are advising us AGAINST the use of Tamiflu for COVID, as well as NSAID’s like Ibuprofen. More importantly, they also now advise against the use of steroids, such as Prednisone or a Medrol dosepak.

The moral of the story?

Although there is no consensus from the specialists on this, as CMO I advise the routine use of Hydroxychloroquine for all swab positive Covid cases with symptoms.
It is NOT to be used preventively.
No other drug therapy is currently advised unless admitted to the hospital.

I am sure most of you know Caduceus and PDQ and More Urgent Care has been testing for over a week now. The first day we allowed in-office testing but soon saw the need to screen/test
patients in the comfort of their homes and cars. A video visit is required to receive the order from the provider then the patients are directed to one of our three curbside locations in Orange County to be swabbed. Results currently take a minimum of 2-4 days. Unfortunately supply of tests being distributed to physicians is not matching the demand for testing. The number of test kits being made available is not enough. We need to test everyone with symptoms or at risk due to exposure. Caduceus has done over 350 swabs so far but could have done thousands more if we had them.

I must respectfully disagree with Washington officials who say if you don't have symptoms, you do not need to be tested. It is very easy to spread this virus without symptoms. Not every COVID patient knows how they were exposed. The problem with comparing this to the flu or to almost any other virus is that it has such a long incubation period. For non-nerds that means you can spread it without knowing you have it. And its penetrance is quite high; for non-nerds that means it is VERY easy to catch it, no matter how good your immunity is. To our immune systems COVID is a new enemy, never seen before, which makes fighting it very difficult.
These are the reasons we are seeing it spread like a wildfire and why officials demand quarantining of everyone to control it.

Worse, it is NOT true that only the old and infirmed are at risk for dying. The last two deaths I am aware of were a 35 year old and a 24 year old. It appears COVID is a "lung eater.”

If it stops at a sore throat or bronchitis there is a full recovery. But 10-20 % of the time it goes into a full pneumonia, causing a SARS situation. This is more common in vapers. It makes more and more mucus and fluids, which doctors cannot always successfully manage. These victims literally drown while in ICU.

Despite this plea for more tests, I want to caution AGAINST the new "at-home" test kits. User error is one issue and the accuracy is suspect. There are already knock-offs that are not FDA sanctioned. They may be perfected soon, but as of now, I'd avoid them.

The medical board of California is investigating concierge physicians selling at-home test kits for up to $400. Besides probably being inaccurate, it is also both illegal and unethical. Current law waives any patient responsibility for COVID-19 screening and swabbing. Do NOT agree to pay cash for any type of screening or swab test.

The moral of the story?

If you are sick or have been exposed get tested. We will help.
Don’t count on your immunity to save you.
Don’t use the new at-home tests quite yet.

Only by testing as many people as possible can we get our lives back....
"After all of this is over."

Gregg DeNicola MD
Caduceus Medical Group
Chief Medical Officer

Reserve your next visit from the comfort of your home at videovisits@caduceusmedicalgroup.com.

COVID-19 CORONAVIRUS LATEST UPDATES AND FAQ'S

By editor

March 16, 2020

AN IMPORTANT MESSAGE FROM OUR CHIEF MEDICAL OFFICER GREGG DENICOLA MD

Published 3-16-2020

It is impossible to turn on TV or engage on any social media platforms without being informed about the Covid-19 crisis, thus we felt it best to use the newest update in an “FAQ format.”

Q: Are things getting better at all? How do we know if all the measures are working?

A: We advise you to follow us on Facebook and Instagram where we post the number of new cases globally every morning. It has been suggested we post U.S. numbers but this is a global pandemic. As long as the number of global cases are increasing, we are at risk.
About a month ago, it was 1000 new cases a day. Then at the end of March, 3000. A week ago, 5,000. Today 10,000.That is because each new case has infected numerous others. The biggest difference between Covid-19 and the flu is that we know the flu season ends each March historically. We have no end in sight to this virus.

Q: I understand the need for self-quarantine to limit the spread. But what CAN I leave the house for?

There are always special situations, e.g. a loved one who lives apart from you and needs assistance, your pharmacy doesn't deliver and you need your meds, etc. In reality there are only two essential reasons to leave quarantine.
1. Food. You need to eat and drink. As the shelves get restocked you need to buy your provisions.
BUT--consider learning to use delivery services (Instacart, etc.) to get your groceries without leaving your home. Especially if you are a senior or not in perfect health.

2. Health. You should still take care of your health which means keeping your medical appointments. It makes no sense to isolate to prevent this virus yet have your diabetes run out of control, your blood pressure become elevated, or your tension headaches go without treatment, which could indicate something more serious.

BUT --consider using video/virtual visits aka “telehealth” or “telemedicine.” Over 80% of visits can be done via face to face video from the comfort of your home. It’s easy to set up and is used with your mobile device or tablet (ex. iPad)

Q: Are Caduceus' offices open?
A: We are taking it day by day and yes we are open for normal business. We STRONGLY encourage all of our patients to use the Caduceus or the PDQ Urgent Care and More app and seek out care via a video visit from your mobile device during this crisis.
IF YOU ALREADY HAVE AN APPT, please change it to a video visit. Please DO NOT CALL THE OFFICE during this time. You can email patient support at mobile@caduceusmedicalgroup.com or use the “Live Chat” feature on our website at caduceusmedicalgroup.com. Our staff will be calling all patients with appointments to ask them to change it to a video visit.

IF YOU DO NOT HAVE AN APPT BUT WANT TO MAKE ONE, start off by scheduling a video visit. It is easy to request by email at either mobile@caduceusmedicalgroup.com or by “Live Chat” on the website. If your doctor doesn't currently offer video visits we can have you see a provider that does temporarily until you can come in the office to be seen.

IF YOU ONLY WANT TO BE SEEN IN PERSON, we are open for you. We have not allowed suspected infections into our lobbies for almost a week. There will be no one infected near you during the visit. Of course that doesn't guarantee the people you will come in contact with are not infected. Any staff member who has any signs of infection is not allowed to work.

Q: Is Caduceus still doing Covid-19 swabs?
Yes. We have a limited number of swabs still available and are awaiting word on having the labs sending more. If we do not have a new shipment soon, we will run out mid-week.
We are now announcing a new protocol for Covid-19 testing.
-All patients wanting COVID-19 testing must first be screened by a provider through a video visit. You can book that through the PDQ Urgent Care and More app. If you have trouble, please use “Live Chat” on pdqurgentcareandmore.com . We have been doing video visits since 2012 and have the technology and systems set up to handle the volume assuming the PDQ app is used on an iOS or Android mobile device or tablet.
-Once the screening is done, you can be directed to one of our THREE curbside testing centers.

We cover all of Orange County
- North County- Caduceus Yorba Linda Family Practice and Urgent Care Ste 201 and 203
- Central– PDQ Urgent Care and More in Orange
- South County- Caduceus on Thalia in Laguna Beach

For Covid-19 screening, we are using video visits and curbside swabbing only. This allows for evaluation from the comfort of your home and car.

For ANY infection that presents to one of our urgent cares including ANY FEVER, you will be directed back to your car for a video visit. Our staff will assist in setting up the video visit for you.
If a fever is discovered after performing vital signs prior to your actual visit with the provider in ANY Caduceus office, you will also be directed to your car for a video visit. Patients with fevers will not be roomed in any Caduceus office.

-Once screened, you MUST return home for self-quarantine until the result is in, usually 3-5 days.

This is a daily evolving situation. Please monitor our social media, e-newsletter, and website for updates. Since we are sending any staff home that are even possibly sick, including our doctors, we ask your understanding as we mobilize our resources to best handle the Covid-19 pandemic.
It is best to NOT cancel any visit, including annual check-ups, with the idea of rescheduling in the summer. We anticipate our provider schedules to be full so it is advised to keep your appointments. We can do a lot to treat you via a video visit, so please give some thought to changing your appointment to see the doctor from your phone. We can always reschedule your in-person appointments once the crisis allows.

Q: Anything new with prevention or treatment?

A vaccine is being tested but not available for community use. There are anecdotal reports of various anti-viral antibiotics being successful, but the data has not yet been published.
I have read reports on social media and even mainstream media supporting ginger tea, vitamin c, turmeric, garlic, and CBD drops being successful treatments. There is NO evidence for ANY of these, although they may be harmless to try.

In Summary:

Stay home except for essential reasons
Use delivery services for food
Use video visits for your health care in lieu of rescheduling in person appointments
Do NOT ignore a fever or signs of infection. Ask a medical question to your physician at mousecalls@caduceusmedicalgroup.com or schedule a video visit ASAP
Follow us on social media to keep current on the numbers and our latest recommendations

Gregg DeNicola MD
Caduceus Medical Group
Chief Medical Officer

COVID-19 (CORONAVIRUS) TESTING NOW AVAILABLE

By editor

March 12, 2020

BREAKING NEWS FOR LA/OC/RIVERSIDE county residents – Caduceus Medical Group will now be offering Coronavirus COVID-19 curbside testing and medical travel clearances.

A few COVID-19 facts:

• The virus is NOT slowing down. A month ago the WHO (World Health Organization) was publishing 1000 new cases a day. Two weeks ago, 2000. As of this morning, WHO announced 4627 NEW cases in the last 24 hours..

• Please ignore posts on social and news media comparing Covid-19 to the "flu" which had more cases and deaths this year. There are 3-4 strains of the flu, all lumped into one statistic. Covid-19 is ONE strain of coronavirus and appears to be a very different strain.

• Also the seasonal flu season is over and generally ends of February. Covid-19 appears to be just getting started, unless, as we are all hoping, the warmer spring weather kills it off.

• The biggest difference is that it is easy to test for the flu. Standard swabs are available at most urgent cares and emergency rooms across the country and the world. Since patients typically feel sicker with the flu, they are more likely to be seen and get a diagnosis. Covid-19 can start with milder symptoms and until very recently there was NO easy way to test for it; we are seeing a definitive UNDER-reporting as to the number of new cases and fatalities. Some authorities are estimating the number may be being miscalculated by at least TEN fold; in other words, the total may have actually been 39,000 in NEW cases today alone.

What makes this virus so different?

• During the 14 day incubation period an infected person can spread it even exhibiting NO symptoms. That is very unusual for most viruses.

• It appears to be VERY easy to "catch.” Very casual contact can spread Covid-19 where as most other viruses need a form of closer contact.

As CMO, I am taking this opportunity to announce two new initiatives.

1. Clearance letter for airline travel-

Many airlines and resorts are requiring a "clearance letter". A swab is unnecessary. The clearance letter requested asks the medical provider attest the patient is healthy, asymptomatic, and has experienced no recent fevers. The patient should have no known exposure to viral diseases and a normal physical exam. Caduceus will do these clearances on a walk-in basis at two locations- PDQ Orange and Caduceus on Thalia in Laguna Beach. Since clearances are not covered by third parties, Caduceus will charge an affordable cash price of $69 for this visit. If a blood test, such as a CBC (complete blood count) is needed, a $20 charge may be assessed.

2. COVID-19 (coronavirus) curbside testing-

Local labs such as LabCorp and Quest are now offering the kits for testing for Covid-19. As you can imagine, they have been swamped with calls, but here is what we can report as of Thursday, March 12th.

• Caduceus has ordered and received swab kits from both Labcorp and Quest. These kits are in short supply and being rationed; we will reorder when the stock has been depleted and cannot guarantee delivery dates. Priority will be given to those patients determined by the provider that are good candidates for the COVID-19 swab that arrange for a video visit in lieu of coming in to an office location.

• The labs do NOT want patients to come to their draw stations. They will run tests only ordered by a physician, physician assistant, or nurse practitioner.

• Governor Gavin Newsom has announced these tests will be free of any cost sharing. In other words, FREE. There will be no co-pay, co-insurance, or applied to a deductible for running the test.

• This new rule applies to all commercial insurance plans, both HMO and PPO, as well as MediCal. It does not apply to Medicare patients.

• The labs do not know the cost but will bill your insurance. Any payment billed to the patient will be from the lab, not Caduceus. The patient should NOT receive a bill. Any dispute on the "free" testing should be directed to the Department of Insurance or Managed Health Care. Caduceus only performs the swab.

• The labs and health department will NOT run tests for patients without symptoms; there are simply insufficient kits. Caduceus providers will also abide by this protocol and will only do the swab on patients with symptoms or findings consistent with a viral illness.

• We are directing ALL patients WITH SYMPTOMS (fever, coughing, sneezing, and shortness of breath) to our PDQ Orange urgent care for North County patients and Caduceus on Thalia in Laguna Beach for South County patients. NO appointment necessary.

• A curbside video visit from your mobile device in your vehicle will be required to be swabbed for Covid-19. This will be billed as a standard office visit, subject to co-pays and/or deductibles, and we also offer a cash price option.

• If you are doing a walk-in, please text or call PDQ Orange (714-287-0459) or the Laguna Beach office (949-482-9699) and let the staff know you are in the parking lot and are wanting the Covid-19 swab. A staff member will be out to assist you. If you prefer to do the visit in-office, let the staff know and they will escort you to a room.

• The estimated time for results is 3-4 days. They will be emailed to you directly through the secure patient portal.

Since we can only provide the Covid-19 to swab patients with symptoms and we feel ALL patients with symptoms should stay home, the swab is not useful for the clearance letter. These are two separate and distinctive initiatives we are offering for our patients and the community.

If you aren't sure you qualify for the Covid- 19 swab, consider doing a same day video visit from the comfort of your home, office, or other location. You can message your physician through the patient portal or email your physician a medical question via mousecalls@caduceusmedicalgroup.com.

Follow us on Facebook@caduceusmedical and also make sure you are on our email list for regular coronavirus updates. If you are not receiving our emails, request patient support to be added at mobile@caduceusmedicalgroup.com.