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Posts Tagged ‘ covid19antibodytesting ’

CMO Covid Orange County Blog- Shares his story

By editor
January 26, 2021

It was 3 PM on my second day in the hospital--Christmas Eve- and was due to have a half hour IV infusion of Remdesivir for my Covid pneumonia. 

I looked up at the IV bottle.

It was a dark glass container, looking identical to an upside down Kahlua bottle. More bothersome - there were three heads coming off the bottle, each looking like a Satanic face.

Scared, I assumed I was dreaming. But squeezing myself, I knew I was totally awake. I closed my eyes, and looked up again at the bottle being hung. Same vile image. I noted one of the faces looked identical to the character "Anonymous.”

As a physician I knew I was hallucinating.  I knew hypoxia or high flow oxygen, of which I was having both, can cause hallucinations.

Yet it was as surreal as it comes, physician or not.

I decided to not look up until the infusion was done, and not ask my nurse about the unorthodox IV she hung.

The next day on Christmas, at 3 PM it was time for my second dose. The nurse came in to hang the IV bag. It took all I could do to look up as she hung it. It was a small clear vinyl bag, used for all IV meds. I was relieved the devilish Kahlua bottle was nowhere in sight.

I summoned the courage to ask my nurse, “was yesterday’s dose put in a different bottle?” “No,” she said, “it was the exact same small clear IV bag.”

I asked her if I had been napping when she hung the first dose. “No,” she said, “you were wide awake; why?”

I decided if I ever wanted to get released, I’d best keep my hallucinations to myself. “Just wondering,” I answered.

This falls into the category of "you know you are sick when.”

I can boil my experience into three unexpected memories. That bottle was obviously number one.

The second was my activities during my nine day stay. I had brought some books to read, planned on watching classic movies, brought a shaver and toothbrush, and some shampoo if I had a shower in my room.

Ok, I had never been hospitalized before. What did I know?

I spent eight days laying on my right side-flat, which produced the best oxygen readings.  Flat on my right side, 24/7.
 
Realize all of my adult life, I was a multi-tasker. Running a busy practice.... Running a business.... Working as a Medical Director.... Husband and raising three boys into men.... Cooking and wine tasting.... And recently I took up gardening and boating, weaving those into the hours I had in a week. The idea of lying down in my bed for even 30 minutes during the day would be my biggest nightmare.

Yet here I was, lying flat for 200 consecutive hours. This wasn't a bad dream;  it was torture.

There were a few exceptions. I could sit up to eat. But that dropped my oxygen so it had to be done quickly. One day physical therapy visited and stood me up. To achieve that, they had to crank my high flow oxygen even higher. I had one quick sponge bath. No shower, no shaving, no reading, no TV, and no visitors. My only view was of the nurse’s call button on the rail next to my face.

I knew that position was the only way my oxygen number would stay in the 90’s, allowing the nurses to try to wean the high flow oxygen from the 100% they started me on to the 30% goal-- when they could convert me from high flow to regular low flow.  They had mentioned if they couldn't wean me in two weeks, I may be transferred to a "higher level of care". I knew what that meant-- the ICU for possible intubation.

To keep from going crazy, I tried to think of as many bad doctor jokes as I could ...you know, like-

“I’m sorry,” said the doctor to his patient. “You have Covid.  We must quarantine you, and you’ll only be fed sliced cheese and bologna.”

“Will that cure me?” the patient asked.

“Well, no,” the doctor replied, “but it’s the only food that will fit under the door.”

OR

“Doctor, there’s a patient in room one who says he’s invisible.”

“Well, tell him I can’t see him right now.”

OR

How did the doctor cure the invisible man?

He took him to the ICU.

That took up about half hour before I realized I’d rather be hallucinating than thinking up bad jokes.

By day eight, they finally managed to wean me from high flow to low flow, but I was still confined to lying flat on the right side position. On day nine, they tried to sit me up. My numbers held in the 90’s. Not only could I read, eat, and watch TV from a sitting up position, but also they said they were sending me home. There were too many people in the ER as sick as I was the week earlier with no beds available. My Italian guilt took over as I realized I was glad there were enough sick people to force them to kick me out of my prison.
 
That leads to the third unexpected experience being home.

I imagined sitting on the couch watching Netflix, catching up on my medical reading, chatting on the phone with friends and family, and being back to normal in a week or so.

You can stop grinning now.

I was still on 24/7 oxygen, so my nurse/wife Mary was in charge of the slow steady wean. I am still on oxygen now, so I learned this will be a long-term project.

I was given exercises to help build up my strength. Problem is they drop my oxygen numbers plus they exhaust me. I need to use an incentive spirometer every 10-15 minutes to expand my lungs.

So I found recovering from Covid pneumonia is a lot of work. I should have believed my doctors who warned me to measure my recovery month to month, not week to week.

Yet as I recover, I find myself wanting to resume previous activities. When I was first came home, I told my staff I was retiring from blogging. Yet three weeks later, I know I want to go back to some sense of normalcy.

Believe me, writing this blog today is much more therapeutic for me than you.

One of our patients in Laguna Beach is the glass blower from the Sawdust Festival. 

He isn't going to believe the special commission I have for him this summer.

I just need to empty out a bottle of Kahlua.
 
Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group, PDQ Urgent Care and More, PDQ Telehealth 
 
P.S.  It is an understatement to say I am overwhelmed by the hundreds of cards, emails, and calls from our amazing patients and skilled staff wishing me healing. I tried answering everyone personally, then realized it was an impossible goal.

Reading these well wishes was stronger healing than the Remdesivir. I am truly humbled. Reading them made me realize I have had a career blessed by the heavens and the very best patients in the universe. Believe me the love goes both ways.
 
Remember to get tested with ANY symptoms and stay home as much as possible. I have been asked where I contracted Covid and I am sure it was from some asymptomatic person I came in contact with at work. I was still seeing patients in the office four days a week and masks are only 80-95% effective. It was a matter of time that a Covid particle sneaked around the masks we were wearing.

In retrospect, I should have stayed home doing video visits only when the numbers exploded after Thanksgiving. Do not repeat my mistake.

Caduceus will not be receiving the vaccine soon, so make best efforts to get vaccinated where you can. If you have had Covid, we advise a monthly antibody test through 2021.

We are now researching what a 2021 check up should entail and will be publishing that in a future blog.


CMO Corner- Orange County Covid Updates for December

By editor
December 1, 2020

Did you know Flintstone Vitamin D is only sold in one city in the United Arab Emirates?

Citizens in other cities refuse to eat them.

But Abu Dhabi Do!
 

As the Covid numbers spike, I feel it may be time for a little humor…yes, I know what you're saying…very little!
 
There are three questions I am continually asked, so feel it’s worth addressing in this blog.
 
1. "Check my Vitamin D level. If it’s low will I have a bad case of Covid?”
 
ANSWER: Yes and No.
 
Yes: some studies, most sources quote one from Spain---show a poorer prognosis in Vitamin D deficient people. Vitamin D may help with macrophage activity to destroy the virus. It may help fight the cytokine storm responsible for many Covid deaths.  It helps "modulate" the immune system, so important in fighting off a bad viral infection. So start taking Vitamin D, right?
 
Well......wait.
 
No: Vitamin D deficiency is more common in older age groups, smokers, obesity, and in those with chronic diseases such as diabetes, hypertension, and also some racial and ethnic groups are more predisposed to deficiencies including African Americans.

The high-risk groups that have more complications and higher mortality rates in COVID-19 coincide with groups that have a high incidence of vitamin D deficiency. So we may just be saying "If you are an older diabetic smoker you will have a poorer prognosis from Covid,” without bothering to check a Vitamin D level.

Will correcting a low Vitamin D level help with Covid? No study shows that, since you should also correct the blood sugar, blood pressure, etc. at the same time.
 
The venerable Mayo Clinic, in a bulletin to physicians, concludes, "To the best of our knowledge, there is no data on the effects of vitamin D in SARS-CoV-2 infection.”  They then opine, “we suggest it would be reasonable to supplement vitamin D in sub-populations at risk of vitamin D deficiency and unfavorable COVID-19 outcomes.” 
 
In other words, those patients we mentioned in the preceding paragraph. I could not find studies controlling for high risk Vitamin D deficient patients.
 
Our interpretation?
 
We do not have good evidence Vitamin D will help, but it’s safe so what the heck; give it to seniors, smokers, diabetics, and any other high risk groups just in case.
 
Another issue is what constitutes Vitamin D deficiency?
 
Most labs list the lower limit as a level of 30. But most experts define true deficiency as under 15. It makes a difference since most articles quote “80% of severe symptoms with Covid are Vitamin D deficient.”

But when we check Vitamin D levels as part of a yearly checkup, I'd estimate 80% of all our patients are under a level of 30, not 15. Despite heavy research, I couldn't find studies on Vitamin D levels under 15 and percentages of a Covid prognosis.
 
Our conclusion?

Taking 2000 units of Vitamin D3 a day will not hurt. If you are a senior, smoker, obese, diabetic, African American, or have hypertension, it may help but be aware evidence is weak.
 
 
What's ultraviolet light’s favorite animal?
 
A lamb, duh!
 

Geesh! Tough crowd!
 
2. Should I use ultraviolet germicidal lighting?
 
If you own a large building, yes. In your home....read on.
 
UVC units look like your mosquito zapper on the patio in the summer, but these rays zap viruses. They have been used to fight viruses since a measles epidemic in Philadelphia in 1937. Numerous studies show when used correctly, UVC produces the same result as replacing the air in a large room 10 times in an hour. It is safe and effective to add a layer of protection against most viruses.
 
Cost? For large buildings, where it is most useful, about $6 a square foot. So for the Yorba Linda packing house at 77,000 square feet, about a half a million dollars. They are already in use in many colleges, as well as certain high traffic areas of LAX.  They definitely add a effective layer of protection.
 
Go on Amazon, you will find portable UVC wands for about $50. You wave it over your body and your friends and family. They have room sanitizing UVC lights for under $100. Perfect right?
 
Well… in fact there are no studies revealing how much or how long to use these devices, or that they even work.
 
The biggest issue is that these zap viruses IN THE AIR floating around, just waiting to zip into your nose and infect you. They have NO effect for viruses already in your body, or if they aren't floating around.
 
Our conclusion?

Installing UVC devices in indoor public spaces would cost a fraction of the budget our elected officials have spent to mitigate the economic impact of this virus. As far as buying a wand or a room unit for your family room? Might be better to open a window....
 
The lab report said I had blood Type A.

But it was a Type-O.

 
Hey, these are the jokes!
 
3. Will knowing my blood type predict the severity of a Covid infection?
 
From a study recently published at Harvard Medical School and Massachusetts General,
"Blood type is not associated with a severe worsening of symptoms in people who have tested positive for COVID-19."
 
When you try to research this in the medical literature, there are two different searches.
 
First, studies that look at IF you have Type O blood. Then perhaps you may have a lower risk of getting infected.  The data is very anecdotal. And weak. Most of it falls into what doctors call the "letter to the editor" category. Interesting to read, but not nearly enough data to substantiate the claim.
 
Then there are the studies that look into IF you have Type O blood.  Then  you're less likely to get very sick and less likely to need a ventilator in the ICU than if you have Type A blood.  Same; interesting theory but the data is just weak.
 
For both categories they are retrospective studies. They look back, and analyze the cases after the fact.  Much preferred would be prospective, randomized clinical trials. Those are lacking, in fact, I could not find even one.
 
Our conclusion?

We are not at the point where we can say, "You have Type O blood so don't wear a mask," or, "even though your oxygen level is low, you don't have to stay in bed with Covid, since you are Type O." It is possible a certain blood type makes better antibodies. We just need more--and better --data.
 
Questions I cannot address yet are the multitude of rumors about the upcoming vaccine.
 

•   Most insurances will not cover
•   It will be free
•   It will be given to seniors first
•   It will be given to hospitals first
•   It may wear off after three months
•   It will have few side effects
•   It will have many side effects
•    It will only be given to certain assigned centers in each county
•    It will not stop the pandemic
•    It will get things back to normal

 
Those are all possible scenarios. We need a month or two to find the answers.
 
I also have a vaccine joke.
 
But a lot of people won’t get it.
 
I’m here all week.

 
Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group


CMO and Caduceus Covid-19 Coronavirus Team August Updates

By editor
August 13, 2020


I’m not looking to fight with you
Frighten you or tighten you
Drag you down
Chain you down
Or bring you down
All I really want to do
Is discuss Covid with you
 
Ok, so we took some liberty with Mr. Dylan’s poetry.  It’s time to look at the path we have traveled the last five months. 
 
We began Covid testing March 11, and enrolled Covid patients in our program immediately. We published our observations a couple months ago, and a lot has changed since then. Let’s revisit what we have learned.
 
We have tested over 7,500 patients for Covid- both the swab for the virus and the blood for the antibodies. We have diagnosed or been referred roughly 750 cases as of this writing.  That corresponds well to the national average of a 10% positive rate with broad scale testing.
 
Our false positives have been under 1%--as advertised by the literature.
 
False negatives? Around 5-9%- again, as expected. 
 
So any speculation by pundits on social and mainstream media stating the tests are inaccurate is hooey. At least in our admittedly limited practice the tests are reliable.
 
What is noteworthy is in May we had just passed the 100 mark of cases. So the other 650 cases have been found in the last three months. This is partially explained by our ability to procure sufficient tests to allow testing five days a week at multiple sites, as well as a corporate program that brings us company employees to test. Admittedly we have been aggressive in encouraging our patients to test, and obtained more innovative tests that allow earlier detection of antibodies. The new moderate complexity antibody tests we offer have been very impressive indeed. 
 
Nonetheless, the number of new cases exploded.  In June our new cases per week doubled. July? Quadrupled! Why?
Yes, we reopened perhaps too soon, and definitely not smart. Beach weekends, protests, church services, BBQ’s, and parties all contributed their part to the deluge in cases. 
 
At one get together in a beach town, ONE unmasked person with not-yet-diagnosed Covid, caused the infections in EIGHT other party goers. Remember, we said the 14 day incubation period combined with being very contagious was a perfect storm? Well, there ya have it.
 
Of the 750 cases, about 100 never showed symptoms.
400 have recovered totally.
250 are under active care.
Only nine needed hospitalization--yes a 1.2% rate. This compares to a 4.6% rate nationally. 
And yes, still no deaths (insert sign of the cross being made).
 
More stats that may be of interest---
85% of those that swab positive formed IgM antibodies--again just as the biologists would predict based on other viral diseases.
 
Even better, after eight weeks, 95% form IgG--the antibody that theoretically confers immunity. This is in line with SARS 1 in 2005, another Coronavirus mutation. 
 
More evidence that the doom-and-gloom of the non-experts is baloney. These numbers are exactly what the immunology textbooks would have predicted.
 
We have seen the virus change though, at first, fatigue, fever, and cough were the three most common symptoms.  Now fatigue is still #1, but headache and diarrhea have replaced cough and fever. That's right, in April 80% of new cases had a fever. Now it’s just over 50%. So much for the temperature-at-the-door test huh?
 
At first, we were treating primarily a respiratory illness. Now we need to look for--and we have seen- blood clots, cardiac and muscle inflammation, strokes, kidney failure, and major depression.
 
Covid appears in some patients to cause a cascading inflammatory response that can affect literally every major organ system. 
 
The lungs still require the most attention. We still give the double Z’s (Zpak and Zinc) but have recently seen a better response to Augmentin and Doxycycline to the Zpak. 
 
We still push aggressive pulmonary hygiene...we obsess over keeping the lungs free of mucus to avoid a life threatening pneumonia...perhaps a factor in our low hospitalization rate. 
 
I'm sure we would get emails if I failed to mention Plaquenil.  We used it successfully until Lancet and New England Journal published articles showing no effect. Within weeks of publishing these two previously respected journals were forced to retract those studies for faulty data. The political backlash regarding using Plaquenil was unlike anything I have seen in over 40 years of practice. I’ll simply leave it at Plaquenil being in our tool box and our decision to use it is between our patients and our doctors, on a case by case basis.
 
We have found a couple of new treatments more effective than Plaquenil.
 
One is Decadron, the steroid. The studies are using it on in-patients to prevent intubation. But we found using it early in patients with obvious inflammation turns the corner quickly. Decadron helps to reduce inflammation and calms down an overactive immune system.
 
The other is Symbicort--a steroid inhaler (Budesonide) with a dilator (formoterol), used with almost any respiratory symptom.  There is no doubt to us that Decadron with or without Symbicort is a game changer. 
 
There IS one "magic bullet" for Covid cases that are very sick...convalescent plasma. Yes, they take the plasma from patients who have shown IgG, and infuse it into the sicker patients. So far, a 100% IMMEDIATE SUCCESS. Well, in fairness, we have had it used in six of the nine hospitalizations, and it worked every time. Yes, more evidence that IgG DOES bind to the Covid antigen and will prevent a second case.
 
Even more evidence: How many cases of a positive swab that converted to an IgG antibody have we seen?  Around 150.  How many of these have contracted Covid for a second time? That’s right...Zip. Zero. 
 
The problem lies in how long the IgG will hang around. We had one patient lose it in a month. In another case it only lasted two months. Using SARS 1, Chinese, and European data, it should last four-six months in most people. So to get herd immunity, we will need an effective vaccine. We cannot count on our natural IgG to protect us for years as it does against measles.
 
 
Other observations:


Smokers, vapers, diabetics, and obese patients are a much higher risk of a severe case and hospitalizations. The patients we encouraged to purchase a pulse oximeter as well as an incentive spirometer had a much easier time managing their Covid.
 
Since June, Covid in our practice is a disease of the YOUNG. Our average age is 36 for a new diagnosis. How many cases are diagnosed in seniors over 65 in our population? Would you believe less than 10%? Good, because it’s lower---UNDER 5%!
 
We respectfully and strongly disagree with the CDC and our own Health Department that the quarantine may end after a week of no fever or symptoms, with no re-swab necessary.  There is simply no evidence that a positive swab with no symptoms is not contagious. I have a challenge for the CDC/Health Department--take off your mask and let one of my Covid cases that swabbed positive but have no symptoms for a week cough in your face. Case closed. 
 
We have seen a change in behavior by the Covid patients as the summer dragged on. Now, only 15% of our cases agree to be re-swabbed.  That may relate to the young age of these patients, the seniors tend to be more compliant. 
 
Only 25% of newly diagnosed agree to quarantine---that’s not a typo.  Many may agree to stay at home for a week, but do not avoid household contacts; many even go to work. I’m not making this up. They travel, go out to eat, go grocery shopping. They use how sick they feel to guide them. But they are very contagious until they swab negative. 
 
If we want to look at why our August numbers are still high, we need to look no further than the poor compliance on re-swabbing and quarantining. 
 
Overall, we have learned a lot about treating Covid since March.  Meds have changed, symptoms have changed, and patient compliance has changed. Early bedrest, use of steroids-oral and inhaled, and aggressive surveillance via telehealth all play a part in keeping our patients out of the hospital and ventilators. And we are encouraged by the immediate improvement of all patients receiving convalescent plasma.
 
Conclusions?
1. Test Test Test. Know if you’re contagious. Know if you’re immune. If you're contagious, QUARANTINE. If you’re not immune, wear your mask, stay at home, social distance and hunker down. It may save your life.
2. If you are positive, QUARANTINE and RE-SWAB! Do not risk infecting others by spreading your Covid particles.
3. If you have IgM or are recovering from Covid, have your antibody checked every 4-6 weeks until your IgG is positive. Then you may want to still check your antibody every 4-6 week to see how long it will last.
4. If you must come into contact with people (job) or elderly (visiting grandparents) we advise a monthly swab. Yours truly has a swab every 10 days, to reassure my patients, and come to think of it, to reassure ME.
5. To help those who need convalescent plasma, contact the local blood bank directly if you are IgG positive. You may save someone's life.
 
To paraphrase Mr. Dylan:
 
I do want to straight face you
Chase you, track you, and trace you
Disgrace you and confine you
All I really want to do
Is have you die of something OTHER than Covid
After many years pass through
 
Sorry Bob.  I guess it’s time for my boot heels to be wanderin'…
 
Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group


NOW OFFERING ORANGE COUNTY MODERATE/HIGH COMPLEXITY COVID-19 CORONAVIRUS ANTIBODY TEST-

By editor
July 30, 2020

OK, another game....Let’s pick something "low" complexity, and then counter with the first "high" complexity thing we think of...Ready??

Low complexity........floating in your pool on a rubber raft.
High complexity...taking on Class V rapids in the Grand Canyon.
 
Got it? Easy huh? OK OK let’s do a few more...
 
Low complexity...driving a Kia to the grocery store.
High complexity...driving auto pilot in a Tesla X in Downtown LA.
 
Low Complexity....making a grilled cheese sandwich from the Betty Crocker cookbook.
High Complexity...making a grilled cheese sandwich from James Beard winner Nancy Silverton’s cookbook.
 
Low complexity...binge watching "Breaking Bad" on Netflix.
High complexity…binge watching "Northern Exposure" from old video cassettes.
 
Alright.. so.. how does this tie into Covid? Well, the drive-thru tests for antibody offered throughout Southern California are "point of care,”meaning the test is run right then and there from a finger stick. It does NOT require government approval since it is "CLIA" waived. 

CLIA stands for "Clinical Laboratory Improvement Amendments.” CLIA is federal agency that mandates their approval for a lab to run tests and charge for them. And to get CLIA approved is quite a process...we have gone through the process and it would have been easier to get approval to launch a spaceship a la Elon Musk. 

To allow some tests to be done in old fashioned physician offices, like urinalyses, pregnancy tests, and strep screens, CLIA "waives" the tests they feel are "low complexity.” The current generation of antibody tests are low complexity and thus CLIA waived and able to be done at the "point-of-service" instead of having to be couriered to a clinical lab.
 
Are moderate/high complexity tests more accurate? Kinda…Maybe. Depends on how you define "accurate.”
 
In general, they can pick up cases earlier or with a lower "count.” They are more complex to design and run, hence the term "moderate/high complexity.” And, of course more expensive. (You saw that coming right?)
 
Let’s illustrate with an example I know a lot about...food!

The grilled cheese from Betty Crocker IS a legit grilled cheese. And decent too. No false advertising there.

On the other hand- Nancy Silverton's grilled cheese? OMG. I mean just the ingredients are high complexity....here they are verbatim:
 
•    1/3 Cup Olive Oil, Extra Virgin
•    2 ½ Tbsp. White Wine Vinegar
•    2 Tbsp. Kosher Salt
•    1 Tbsp. Freshly Cracked Black Pepper
•    2 Medium Yellow Onions, Sliced into 1/8-Inch-Thick Slices
•    ¼ Cup Whole Grain Mustard
•    8 oz. Gruyere cheese, sliced into 24-32 1/16 inch-thick slices
•    Whole country sourdough loaf

I could go thru the actual process but it would be easier to explain how to split an atom. Nevertheless at the end of the process, you also have a grilled cheese sandwich. Just unlike any you've ever had. 

The point is; both are grilled cheese. One is just high complexity. (Full disclosure-I do not receive a kickback from Nancy-but if you want to enjoy the best grilled cheese you've ever had I highly recommend her sandwich cookbook, Nancy Silverton's Sandwich Book: The Best Sandwiches Ever--from Thursday Nights at Campanile.) 

Now we can compare that to the office pregnancy test. It is accurate and picks up the pregnancy a day or two after the missed menses. The OTC test from the drugstore may need you to be 3-5 days late. Both are low complexity. But the moderate/high complexity CLIA approved test can pick it up a bit earlier than either of those that are CLIA waived. It isn't technically more accurate; just more sensitive. It picks up the hormones at a lower level.
 
You can see where this is going with Covid antibodies. The usual test available in the past through Caduceus and PDQ Urgent Care and More (and other facilities) is CLIA waived. It gives us two antibodies.. IgM -which tells us if you have had Covid, and also IgG which implies immunity. Despite what I read on both social media and mainstream media, it IS accurate. But it requires a decent antibody load to pick up the antibodies.

What is antibody load? It’s like having a single shot latte to wake up mid-day compared to a triple shot espresso. It’s easier to pick up caffeine if you are analyzing the triple shot compared to the single shot. A moderate/high complexity "caffeine test" can pick up the single shot, the low complexity just the triple shot.
 
We have partnered with KOS labs here in Orange County and Healgen Labs in Houston for a "New Improved" antibody test that is moderate/high complexity and thus requires CLIA approval. 

There are some differences between the new test and the current one being offered.
 
*The current test uses a finger stick, the new one needs a blood draw.
*The current test gives a same day answer, the new one takes overnight. 
*The current test has about a 10% false negative rate, the new one less than 5%.
*The current test picks up the antibodies 4-16 weeks out, the new one weeks earlier. 
*We of course bill insurance, but if you need to pay cash the current one costs $75, the new one is $85. 
 
As CMO I endorse the newer test if you are having the antibody test. 

We have been searching for the most accurate antibody test to offer our patients and this appears to be the gold standard.  It can still be drawn curbside. And of course, the sooner you find out if you are immune the better for all involved.

The better sensitivity and accuracy outweigh the overnight wait and the $10 price bump. We will now be using the "moderate/high complexity" test as the default. If you prefer the finger stick/same day/low complexity test we of course will honor that. We will keep both tests available.

And because I know I’ll get emails inquiring, I am not aware of this test being offered by other Orange County groups, but it may be. If they require a blood draw and an overnight wait, good chance they are offering the moderate/high complexity test. To be legal they would need to be partnering with a CLIA approved lab.
 
And of course the video visits are from the privacy of your home and the testing is from the comfort of your car.
 
Conclusions? 
1. If you want to know if you've had Covid, you need an antibody test looking for IGM.

2. If you want to know if you are immune, you need an antibody tests looking for IgG.

3. If possible have a "moderate/high complexity antibody test" in lieu of the low complexity version. We work hard to not run low on inventory, and I still ask EVERY Caduceus patient to have an antibody test.

4. So far, there has not been a reported new positive Covid test in a patient with a positive IgG--at least that I can find. A positive IgG should reassure that you are immune.

5. KNOW IF YOU'RE CONTAGIOUS (Swab)
    KNOW IF YOU'RE IMMUNE (Antibody via blood)
    Test.Test.Test.

 
Ok; let’s do one more…
 
Low Complexity....Reading this blog eating a bologna sandwich.
High Complexity...Reading this blog eating a Nancy Silverton grilled cheese...no way you'll pay attention to the blog!


Gregg Denicola MD
Chief Medical Officer 
Caduceus Medical Group


 


Covid 19 Universal Antibody Testing

By editor
May 28, 2020

An Important Message from Our CMO
 

If you have been following our blogs since the Covid-19 pandemic started, you know our mantra:
 
Test.Test.Test.
 
If you are concerned you have Covid-19, it’s the swab. If you think you've had it, it’s the antibody blood test. For possible proof of immunity, it’s the antibody.
 
In doing over 1,500 antibody tests over the last few weeks, we have found good accuracy-over 95%. But will a positive IgG antibody really translate into immunity going forth?
 
We should know in the next 90 days, as our cities reopen. 
 
Unfortunately, we are seeing only a 4% positive rate from all we test. The vision that the antibody tests would unveil a large population immune from the virus has been a delusion, and only by knowing the antibody status of everyone going out in the community will we collect the data necessary to plan the next steps of this devastating pandemic.
 
Therefore, as Chief Medical Officer, I am calling on ALL Caduceus patients to consent to having an antibody test.
 
To assist in this undertaking, we will be requesting you to agree to a test and our medical staff will add this test at the time of each blood draw done at a Caduceus location. 
 
Results take 15 minutes, and you will be offered to wait, or to go home and we can message you back same day in your secure patient portal account the results.  If you prefer us to contact you by phone or email instead we can do that too. 
 
Whether you choose to have the test or not, please keep directing your Covid-19 questions, comments, kudos, and critiques to us.
 
For medical questions about this blog post you can email mousecalls@caduceusmedicalgroup.com.
 
To make an appointment for a video visit from your phone for Covid-19 antibody or any other medical needs, please email our appointments team at videovisits@caduceusmedicalgroup.com.
 
For any other general questions or assistance please email us at support@caduceusmedicalgroup.com.
 
 
We take every email seriously and foresee the current advice to be a small portion of this saga - as we evolve in these uncharted waters.

Gregg DeNicola MD
Chief Medical Officer
Caduceus Medical Group 


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.