Posts Tagged ‘ coronavirustesting ’

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

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

MEET YOUR ORANGE COUNTY COVID TEAM

By editor
July 1, 2020

A Message from our CMO-

With movie theaters being closed, I’ve found- like many of you-the magic of Netflix. And since I do not have sports to follow, I gravitated towards sports movies. 

I found that no matter what era or sport, the main characters varied little. It appears that success of a team is predicated on a stereotyped group of defined roles.

It reminded me of the Caduceus Covid Team we assembled in mid-March to objectively diagnose and treat the wave of cases we were diagnosing.  The characters were eerily similar. There are many advantages to treating some conditions with a team approach, and a new serious one like Covid has been best fought with just such a team. 

Like an old sports movie, there is always a head coach who is tough but fair. In the older movies, he wore a fedora and chomped on an unlit cigar. His game plan appeared to yelling things like "GO GO GO" and "FIGHT FIGHT FIGHT!!”
“Yours truly” is the Covid Team’s "head coach.” I actually do have a fedora, and when gatherings were allowable, was known to enjoy a cigar at a summer BBQ. And with the volume our team has with Covid cases, the strategy of yelling GO! and FIGHT! has been effective.

Then there is the quarterback- good looking, popular, and pulls off the winning score by overruling the head coach and calling some creative off the wall plays.
Our quarterback Is Dr. Mary DeNicola (Doctor of Nursing Practice).  I hope to avoid political backlash by divulging Mary is my wife of 44 years, as I say she is good looking and popular. And she has consistently pulled off one win after another, fighting off this unpredictable and deadly bug. We form the game- I mean treatment -plan together, but she is on the iPad over 12 hours a day making creative and life-saving decisions on our Covid patients. I know with her “play calling” our patients are in excellent hands.

Of course, every winning team has excellent Special Teams. 

Our OBGYN Covid consultant is Dr. Nathaniel DeNicola, Senior Fellow on Health Economics and Chair of the ACOG Department of Telehealth. Yes, you do see a trend--to be a member of the team it does help to be named DeNicola--and in Nathaniel’s case, my first born son. As a board certified OBGYN, we refer him cases involving GYN issues and all Covid patients that are pregnant.  Yes, they have special needs that require a specialist with Covid knowledge and experience.

Our pediatric Covid consultant is Dr. Cyndy Krepps-Hoffer (another Dr. of Nursing Practice) with the most beautiful South Carolinian accent on Earth.  And astonishingly, she is NOT a DeNicola! She is an excellent clinician with extraordinary diagnostic skills, which is so important with pediatric Covid cases. All Covid related kids issues are referred to Cyndy, under the auspices of the team. Recently, Cyndy diagnosed a MultiSystem Inflammatory Syndrome in a child that previous doctors had missed. This condition hits kids with Covid exposure, yet they do not test positive. A few days in the ICU and -thanks to Cyndy--a life saved.

One roll in all sports movies is the “play by play’ guy. He keeps the audience up to date on the goings-on, and despite trying to be objective always roots for the home team. When they win the big game, he beats up the announcer on his left with a rolled up program, who coincidentally always was for the other team. Our play by play person is Talia Wright. Whew! Another non-DeNicola. Actually Talia's maiden name IS DeNicola, and yes -full disclosure--is my sister. 
Acting as a concierge, she keeps all the patients and providers informed, of appointments and results, late into the night if necessary.  I do not believe she has ever beaten anyone with a program, she can get quite irate when labs delay test results.

Another essential character is the water boy (water person in 21st century jargon). He offers comic relief, always smiling and joking around. He has the uniforms clean, Gatorade handy, helmets painted, and talks the star player into playing in the Big Game despite his girlfriend dumping him.
Our water person is Pam Dukes. Pam is not related by blood, however has been in the DeNicola family almost 50 years and has a permanent smile painted on her face. She keeps the team in good spirits and does whatever it takes to oversee 200 patients with Covid and related conditions. Phone calls, getting the video visits working, tracking down labs, and even making daily runs to TruBru coffee house next door to keep everyone awake. Without Pam, there is no team.

I understand  nepotism invites criticism . But I counter with an iron clad argument--using pizza of course (the Covid Team’s theme). You have all had Pizza Hut--and it is a competent pizza. They are a big pizza system, and have many resources available to them. 

Now compare with the pizza at Tony’s Little Italy in Placentia. Tony’s is family owned and run by Tony Manzella since 1978, with his wife and son (also named Tony).  They aren't part of a big company. Yet you taste the care and passion the Manzella family brings to their pizza--the best I have ever tasted. And I admit to tasting a LOT of pizzas!
I pray our Covid team matches Tony’s results with Covid instead of Pizza.

The team enrolls patients from positive swabs or antibody tests, and referral from friends and other doctors. All visits are conducted by telemedicine, varying from daily to weekly appointments. Treatment protocols are followed and change frequently, depending on what we see working and not working.

We prescribe total isolation while infected. 

And total bedrest. 

We trace close contacts--which we define as being within five feet for at least 15 minutes the 15 days prior to symptoms or a positive test. Yes, we know the two week incubation period and six feet rule. But 5-15-15 is easier to remember. 

Depending on details of the case, we prescribe the "Double Z's" and the Covid Cocktail. (Further described in a previous blog).

Our #1 goal is to have Covid patients die far in the future of something OTHER than Covid. #2 goal is to keep them off of a ventilator. So far, we are batting a thousand on both goals. 

ADVICE?
1.  If you test positive, self-isolate. Do not leave your room. Get under the care of a doctor or team. It doesn't need to be ours. But do NOT attempt to ride it out our on your own. That could be a fatal mistake.

2. If you test antibody positive, prepare to repeat it every few months to ensure the immunity is working.

3. If you have Covid, call all your contacts you were within 5 feet of for over 15 minutes within the past 15 days. Get them tested.

4. If you have Covid and are pregnant or are post-operative from a gynecological surgery, you need a specialist.  If you are positive and are under 18, you need a pediatric specialist.   It does not have to be our special teams but you do need special treatment.

5. Know if you're contagious. Know if you’re immune. Test.Test.Test

This is our Covid Team. We will expand it as the virus grows. We treat aggressively, and change protocols frequently. And we work very hard- no hunkering down for the TEAM.

To end with a word from the coach to the team (with apologies to Herb Brooks)-- Covid Team, great moments are born from great opportunity. You were meant to be here. This is your time. Now go out there and BEAT COVID!!!

Gregg Denicola MD
Chief Medical Officer 
Caduceus Medical Group

COVID 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

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

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