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Posts Tagged ‘ covidfaqsorangecounty ’

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


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

By editor
October 15, 2020

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

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

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

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

Explanation?

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

Caduceus patients really know how to party. 

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

We are in the midst of a SURGE in cases. 

We are NOT near a safe level of positive cases. 

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

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

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

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

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

Masks work. Just not 100%.

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

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

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

KNOW IF YOU ARE CONTAGIOUS.

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

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

We cannot assume people with no symptoms are not contagious.

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

No.

Not the answer you wanted to hear right? 

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

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

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

3.  How long will my antibodies last?

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

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

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

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

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

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

For example, let’s look at #4…

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

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

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

The evidence for that advice is weak.

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

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

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

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

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

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

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

If you live with roommate or family that IS infected:

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

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

It’s only three weeks.

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

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

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

Five stand out as being especially effective:

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

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

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

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

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

In Summary:

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

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

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

Gregg DeNicola MD 
Chief Medical Officer
Caduceus Medical Group