31 March 2020 Blog Post: COVID-19 Update – Santa Monica Primary Care Experience

31 March 2020 Blog Post: COVID-19 Update - Santa Monica Primary Care Experience

At this writing, we have a COVID-19 prevalence rate of 13.6% among the samples that we have tested. Our first positive sample was obtained on 3/18/20.
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Our daily prevalence rate peaked on 3/25/20 with 15.5% of tested samples returning a positive result. Shelter in place in California began Thursday night, 3/19/20.
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The only worrisome bit of data that I see is the percentage of total positive cases that our clinic accounts for in Santa Monica. We currently account for 8.5% of all positive tests in our community. If positive test results were distributed equally across providers, that would lead to us taking care of 7,855 Santa Monica residents. As a solo physician practice such a census is physically impossible.
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What this indicates is that far more testing needs to be done in our community. Specifically large outpatient provider groups are lagging. We all need to be doing our part in case identification, contact tracing and emphasis of quarantine / physical distancing.

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

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30 March 2020 Blog Post: COVID-19 Recovery: What Do We Know?

30 March 2020 Blog Post: COVID-19 Recovery: What Do We Know?

One of Dr. Fauci’s quotes that may have been lost in yet another week of CDC mixed messaging and more Dr. Birx shuffling, is the following:

“But I feel really confident that if this virus acts like every other virus that we know, once you get infected, get better, clear the virus, then you’ll have immunity that will protect you against re-infection.” He continued, “So it’s never 100 percent, but I’d be willing to bet anything that people who recover are really protected against re-infection.”

At this writing, there are a number of patients both in our practice as well as around the country who have tested positive for coronavirus and have recovered or are on the road to doing so. This is good news, not only for them to have survived this infection, but also for our community as we now are blessed with individuals who are, for intent and purposes, immune. As Dr. Fauci said above, we cannot say that immunity is 100% but if #COVID-19 functions like other viruses (and evidence thus far shows that is does), then we can expect functional immunity. In fact, a study in monkeys that had been reexposed to COVID-19 after initial infection showed with no recurrence of COVID-19. (Link: https://www.biorxiv.org/…/2020.03.13.990226v1.full.pdf).

According to the CDC, the decision to discontinue home isolation, “should be made in the context of local circumstances. Options now include both 1) a time-since-illness-onset and time-since-recovery (non-test-based) strategy, and 2) a test-based strategy.” Obviously it would be hypocritical of me to at once criticize the CDC for their wavering guidance and then look to them for, well, guidance.

Fortunately there are other sources with more expertise and proven outcomes in reducing coronavirus spread and disease burden. The paragon of COVID-19 response thus far has been South Korea. They have had, to date, 9583 cases, 152 deaths (1.6%), 5033 released from isolation and 4398 remaining in isolation. They have performed 39141 tests with a 2.5% positive rate (to compare – at Santa Monica Primary Care we are at nearly 15% positive tests).

The following criteria clinical and testing are used by the Centers for Disease Control and Prevention of South Korea to release a confirmed patient from quarantine:

1. A person should not have a fever without the help of medicine and clinical symptoms should improve.
2. A person’s PCR tests – two tests performed with a 24 hour interval – should both display negative results to meet the testing criteria.
3. Confirmed patients who do not display symptoms are released from quarantine IF two tests performed on the seventh day after COVID-19 confirmation with a 24 hour interval both display negative results.
4. If the patient tests positive, another set of two tests with a 24 hour intervals at dates to be determined by physicians (e.g. day 10 or day 14 after testing positive) is performed. Quarantine will be lifted if the test results are both negative.
5. However, if a patient continues to be asymptomatic, quarantine will be lifted after three weeks of self-quarantine or isolation in a quarantine facility from the date of confirmation.
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OK so how do we practically then lift quarantine restrictions for those who have had positive tests? The answer, as always, is testing. This means that every case of COVID-19 should have at least three tests and, at Santa Monica Primary Care, this is precisely what we intend to do. Test, test, test. There is no reason to create a new system when we can rely on the experience and expertise of others. We are an international community (in Los Angeles particularly) and should take stock in what our colleagues around the world are doing to effectively stop this pandemic in its tracks.

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

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28 March 2020 Blog Post: COVID-19, An Update in a Week of Confusion

28 March 2020 Blog Post: COVID-19, An Update in a Week of Confusion

As we complete our first full week of ‘shelter in place’, now would be a good time to take stock in where we stand nationally and locally. As I have pointed out in previous posts (and have been hearing more and more from patients), the lack of consistent messaging from the CDC has made it difficult to understand the contours of this outbreak. Part of the reason that we are hearing mixed messaging is because, currently, #COVID-19 is highly regional, with some areas being heavily impacted (NYC Metro area), others about to be impacted (New Orleans, Los Angeles, Chicago, Detroit) and some areas with less burden of disease (North Dakota, USVI, Hawaii).

This regionality has led President Trump and Dr. Deborah Birx to begin a discussion of high, medium and low risk areas. Such would “help states make decisions about relaxing or enhancing the measures they have put in place to stop the spread of the coronavirus.” This is faulty thinking and stems from Dr. Birx’s HIV experience, which she has attempted to shoehorn into our response to coronavirus. This is classic ‘to a person with a hammer, everything looks like a nail.’ In HIV, early work focused on a small number of risk groups which, although oversimplifications, were effective in communicating risk reduction techniques intended to slow its spread.

Unlike HIV, coronavirus is spread primarily through respiratory droplets and is incredibly infectious. This makes the entire population is susceptible, unless actively infected, hospitalized or recovered.

In a recent press briefing, Birx stated, β€œWhen people start talking about 20% of a population getting infected, it’s very scary. But we don’t have data that matches that based on our experience.”

This is factually incorrect. In the NYC metro area, 30% of coronavirus tests are positive. Ah, Dr. Birx would counter argue, but we are only testing ‘high risk’ patients, not the general population so of course that number exceeds 20%.

At Santa Monica Primary Care, we have been testing patients in whom a positive test or a negative test would have some consequence. As I outlined before, we may test a patient with vague symptoms but is caring for a susceptible elderly parent. Or we may not test a patient with more typical symptoms who is already quarantined and doing well.

Cumulative percent of positive tests in our clinic have been as follows (date is the sample submission date):
3/11/2020: 0%
3/12/2020: 0%
3/13/2020: 0%
3/16/2020: 0%
3/17/2020: 0%
3/18/2020: 0%
3/19/2020: 14.2%
3/20/2020: 10.8%
3/23/2020: 12.1%
3/24/2020: 11.3%
3/25/2020: 14.8%
3/26/2020: 14.2%
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Shelter in place for California began Thursday night 3/19/2020. Note what has happened to our clinic rates between 3/19/2020 and now – nothing. They are identical (I hadn’t noticed that until I wrote the sentence). Although we are not yet at 20%, we are not that far off.
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So now is not the time to categorize regions as high, medium, or low risk. We are all at high risk. Now is not the time to relax social distancing and shelter in place orders. Now is the time to keep our prevalence rates stable so we can manage those patients who need Emergency care or who need ICU care without overwhelming our medical providers and hospital capacity. We need to all be doing this.

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

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25 March 2020 Blog Post: COVID-19 Update

25 March 2020 Blog Post: COVID-19 Update

At this writing there are 441,187 confirmed coronavirus cases with 55,568 occurring in the United States. In the US there have been 809 deaths (1.45% mortality rate) and 354 recoveries.

In my previous posts I have tried to outline the basic epidemiologic concepts of control measures which seek to reduce the average amount of transmission between infectious and susceptible individuals. Any control strategy (or mixture thereof) will depend on the disease, the population and the scale of the epidemic. The key to understanding the effectiveness of a control strategy is case identification and reporting.

One concept that is rarely talked about outside of epidemiology circles is one of study bias. Similar to the standard definition, epidemiologic bias is defined systematic errors in research methods. There are a myriad of sources of bias (more than 50, and I’m pleased that I no longer need to remember them). One example is recall bias. When comparing patients with a disease (cases) to those without a disease (controls), cases may remember possible exposures in a manner systematically different than those without a disease. As you might imagine, if you have a disease you would begin to suspect a number of potential culprits and report these to a researcher. Without the disease, you have no reason to suspect much of anything, so report nothing or very little. Therefore, it becomes difficult (or impossible) to discover the historical difference between cases and controls – missing the true cause.

Introducing testing with an economic requirement as detailed in the attached LA Times article introduces a type of bias termed selection bias in which some individuals within a target population are more likely to be selected for inclusion than others. This limits application of results to the general community.

Additionally concerning is the description of the testing protocol which involves a ‘cheek swab’. For initial diagnostic testing for COVID-19, CDC recommends collecting and testing upper respiratory tract specimens. These can include nasopharyngeal or oropharyngeal swabs.

The source of these tests, Korva Labs, does not list any experience on their website in regard to viral PCR assays. Granted this technology is not novel and has been employed since the 1980s (invented by Dr. Kary Mullis, the Nobel Prize-winning technique uses cycles of heating and cooling to make millions of copies of a very small amount of genetic material). The CDC recommends COVID-19 diagnostic testing through clinical laboratories authorized by the FDA under an Emergency Use Authorization (EUA).

So to selection bias, we can now add the potential instrument bias which occurs when an inadequately calibrated measuring instrument systematically over/underestimates measurement.

The magnitude of bias is generally difficult to quantify and, mathematically there are few tools to adjust for bias at the analysis stage. As a result, careful consideration and control of the ways in which bias may be introduced during the design and conduct of a study is essential in order to limit the effects on its validity. It is disheartening and perplexing to see physician scientists willingly introduce bias as we attempt to understand the contours, transmission patterns and effects of #COVID-19 in the community.

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

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23 March 2020 Blog Post: COVID-19 Update

23 March 2020 Blog Post: COVID-19 Update

As readers are probably all well aware at this point, COVID-19 cases have skyrocketed in the United States and now stand at 42,839 with 522 deaths (1.21% mortality rate but likely an underestimate given where we are in the epidemic) and 295 recovered. As I have expressed in previous posts, this total caseload is undoubtedly an underestimate and remains so now. More likely 40-80,000 cases was the total disease burden in the US a week ago, not currently.

At Santa Monica Primary Care we have begun to receive coronavirus test results back from our commercial lab provider, LabCorp. The amount of time for test returns has been widely variable ranging from 24 hours to 9 days to obtain results. We have had positive tests (indicating active coronavirus infection) in about 15% of the tests we have run to date. This is significantly higher than the the 10% positive testing rate that our Surgeon General has discussed among patients tested with a “high likelihood” of positive results.

In Los Angeles County, public health officials have, for all practical purposes, given up any attempt for viral containment. This is documented in The Los Angeles TimesΒ article. In addition to lack of testing, the County also lacks staff to trace the source of a positive test and to inform close contacts who may have been exposed.

I think we can do better. The key to doing better can be found in the basic principles of Epidemiology and outbreak containment. At its core there are two strategies: #1 – Therapeutic countermeasures (e.g., vaccines and antiviral medications) and #2 – Public Health interventions (e.g., infection control, social separation, and quarantine). Given that we have no proven therapeutic countermeasures against coronavirus, we must rely exclusively on Public Health interventions. But the key to infection control… is disease surveillance. In other words: test, test, test.

Simply because the Public Health infrastructure around us has given up on their core mission does not mean that we need to suffer the same. So in our clinic, we have continued to test. Maybe not test, test, test given the lack of kits but at least test. I’ve been asked, ‘how did you get test kits?’ I did not ‘get’ them. Two and a half months ago anybody who had even audited a first year Epidemiology class could tell that this pandemic was coming. So first I asked our LabCorp representative to set aside some viral test kits for our office. After much cajoling, phone calls and persistence – we got a handful of kits.

But our office tests for other viruses in our usual clinical practice. We have point of care flu tests and we send throat and nasal swabs out for viral PCR testing all the time. We compared the swabs sent by LabCorp to what we had in the office, looked at old papers on Middle Eastern Respiratory virus surveillance techniques and concluded that we could fashion our own test kits. LabCorp, to their immense credit, told us to send what we could and, if usable, they would run it. The kits work, as evidenced by positive results exceeding the national average.

I believe a negative coronavirus test is an immensely important result. It allows somebody to care for an elderly parent, neighbor or dependent. It reassures the patient themselves that the cough and slight fever they have may indeed be the common cold, or influenza, or something else – but not coronavirus. Could it be a false negative? Of course it could be. Is it likely to be a false negative? Not likely. Equally important, a negative test also tells an individual that they have NOT had the infection, and remain susceptible and should remain vigilant since there is no vaccine, no treatment.

Similarly, a positive coronavirus test is also critical information. An infected patient can double down on their quarantine knowing definitively that they could very well spread this infection to others. They can inform close contacts and do their own disease surveillance, even if only among a small group. They can act as ambassadors of the efficacy of restrictive interventions: social distancing, travel restriction, quarantine, and case isolation. Could it be a false positive? Of course but this too is not likely. But exception handling in the middle of an outbreak should not be our focus.

In 2007, Lawrence Gostin and Benjamin Berkman of Georgetown University Law Center wrote the following during the H5N1 pandemic threat:

“Surveillance is the backbone of public health, providing the data necessary to understand an epidemic threat and to inform the public, provide early warning, describe transmission characteristics and incidence and prevalence, and assist a targeted response. Surveillance strategies include rapid diagnosis, screening, reporting, case management reporting, contact investigations, and the monitoring of trends.”

And, if a physician is quoting two lawyers, it is probably now clear that we are rudderless in an extraordinary time.

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

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18 March 2020 Blog Post: COVID-19 Update

18 March 2020 Blog Post: COVID-19 Update

It has been a bit of time since my last update. At this writing there are now 217,031 worldwide #COVID-19 cases, 8,911 deaths and 84,383 recoveries. In the United States the total number of cases is now at 8,055 with 127 deaths and 106 recoveries. As I outlined in a previous post, the US case number, while rising rapidly, is undoubtedly a significant under representation of true cases. More likely there are 40,000-80,000 true cases.

At Santa Monica Primary Care we are now in our third full day of exclusive use of telephone and video conferencing with patients. I have found the video conferencing via Facetime to be most useful in the evaluation of specific concerns.

Unfortunately, we have not had a much success in obtaining COVID-19 testing results through our commercial partner LabCorp. We began sending samples last Wednesday (one week ago) and thus far have only had two results (both negative) return. The initial 3-4 day turnaround time is now listed as 6-7 days. The lack of availability of testing and the slow turn around time will continue to be major barriers to any hope for effective containment of coronavirus in the United States.

In terms of what to expect moving forward, a recent study from the Imperial College UK evaluated the effectiveness of the following five interventions – alone and in combination:

1. Home isolation of cases – whereby those with symptoms of the disease (cough and/or fever) remain at home for 7 days following the onset of symptoms
2. Home quarantine – whereby all household members of those with symptoms of the disease remain at home for 14 days following the onset of symptoms
3. Social distancing – a broad policy that aims to reduce overall contacts that people make outside the household, school or workplace by three-quarters.
4. Social distancing of those over 70 years – as for social distancing but just for those over 70 years of age who are at highest risk of severe disease
5. Closure of schools and universities
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By fitting the projected effects of these scenarios on available COVID-19 data, one of two scenarios occur:
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Scenario #1: Three specific interventions (home isolation of cases, home quarantine of household members of cases and social distancing of those over 70 years) slow down but do not completely interrupt the spread of COVID-19. This would reduce the demand on the healthcare system by 66% while protecting those most at risk by reducing mortality by 50%. This pandemic would then peak over a three to four-month period during the spring/summer.
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Scenario #2: Employing all 5 of the above intensive interventions could interrupt transmission and reduce case numbers to low levels. However, once these interventions are relaxed, case numbers are predicted to rise. While there are initially lower case numbers, there remains risk of a later epidemic in the winter months unless the interventions can be sustained.

At Santa Monica Primary Care we intend to continue our current virtual clinic stance until at least March 27th and will reassess at that time. I will be making some house calls next week (forgive the full protective gear) to perform evaluations or procedures (such as suture removal or medication delivery by injection) to those that remain in necessitated self isolation.

Also today we have begun to proactively call our patients who have been asked to self-isolate due to age or a compromised immune systems. The goal of these calls is to ensure that each patient has adequate medication supplies as well as access to medical equipment, food and any other necessities that they may be lacking. We remain available 24/7 for any concerns and Dr. Bretsky will remain on call again through this upcoming weekend at (310) 828-4411.

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

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15 March 2020 Blog Post: COVID-19 Update

15 March 2020 Blog Post: COVID-19 Update

Sunday morning March 15th and total worldwide confirmed #COVID-19 cases stand at 156,400 of which 2,952 are in the US. Of these, we have had 57 deaths (1.9% mortality rate) and 12 confirmed recoveries. Please note that the mortality rate is unlikely to be accurate for several reasons including the lack of accurate case acertainment (due to lack of test kits primarily) as well as where we are in the epidemic. A true case fatality rate (CFR) cannot be calculated until towards end of an epidemic. However, given that the CFR in China has been estimated at 2.3% and thus far in South Korea it stands at 0.5% looking at a moving average of our CFR may provide some insights.

In this post I would like to highlight data we have thus far on the role of medications in interrupting either infectivity (acquisition) of the virus, or in modifying its severity (i.e. making it more or less lethal). Olivier Veran, the Secretary of Social Affairs and Health in France, tweeted this morning the following;

Taking anti-inflammatory drugs (ibuprofen, cortisone, …) could be a factor in worsening the infection. If you have a fever, take paracetamol [Tylenol/acetaminophen]. If you are already on anti-inflammatory drugs or in doubt, ask your doctor for advice.

France is now advising all people to stop taking NSAIDs like Motrin, Aleve, Ibuprofen altogether to avoid side-effects in case of a potential COVID-19 infection. Instead of Ibuprofen, they are suggesting Tylenol. Why? Their supposition is that NSAIDs prevent the inflammatory responses of the body, a natural reaction that happens to fight the coronavirus after infection. By preventing inflammation, these drugs could mask the severity of a disease, and reduce the capacity of the immune system to deal with the pathogen.

A similar discussion has emerged regarding the role of two classes of medications commonly used to treat hypertension:
ACE inhibitors (identifiable by their suffix -pril) and ARBs (suffix -sartan). The angiotensin converting enzyme (ACE) controls blood pressure by regulating the volume of fluids in the body. Some research has shown that the ACE2 protein was the main receptor for the SARS virus and therefore advocacy for stopping these effect medications has begun. However, European Society for Cardiology did not agree and noted that in stable patients with COVID-19 infections or at risk for COVID-19 infections, treatment with ACEIs and ARBs should be continued.
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Best summed up by Dr. Mohammad Majiid (UTHealth; Houston who has studied the links between influenza and cardiovascular disease: β€œThere is a lot of misinformation out there,” he said. β€œThe ACE inhibitors and ARBs do not act on this receptor directly so they are not going to affect the activity of the virus for these cells. The proposed interactions of ACE inhibitors and ARBs with the virus is purely hypothetical with no reliable data to justify any deviation from current practice guidelines.”
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Three medications in particular have generated interest (and questions from my patients!) as all three are currently in early phase COVID-19 treatment trials in China. These are: Kaletra / Aluvia (a combination lopinavir and ritonavir), the generic drug chloroquine phosphate and the generic drug hydroxychloroquine.
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Kaletra is an ntiretroviral agents for human immunodeficiency virus (HIV). It is under investigation in 16 ongoing or planned clinical trials for Covid-19 in China.
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Chloroquine is a generic anti-malarial medication that is believed to have broad-spectrum antiviral activities. Note that it it is not approved as an antiviral agent but there remains a strong rationality for the use of chloroquine to treat infections with intracellular micro-organisms. It has been used to treat Coxiella burnetii, the agent of Q fever as well as Tropheryma whipplei, the agent of Whipple’s disease. Data from China has shown that chloroquine could reduce the length of hospital stay and improve the evolution of COVID-19 pneumonia leading to recommendation for administration of 500 mg of chloroquine twice a day in patients with mild, moderate and severe forms of COVID-19 pneumonia (click here).
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Hydroxychloroquine is structurally related to Chloroquine (as the name implies) but is less toxic. It too acts an anti-infective and antirheumatic agent. It is used for rheumatoid arthritis, discoid and systemic lupus erythematosus and juvenile idiopathic arthritis
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Another medication (not on this list) that is further along in clinical trials is Remdesivir, initially developed to treat Ebola virus (and, unfortunately, ineffective in Ebola) and developed by Gilead Sciences. It is now being tested on 761 patients in a study at multiple hospitals in Wuhan. The results from the trials are expected to be available over the next few weeks.
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Lastly, I would add to this list Favilavir (Favipiravir). The National Medical Products Administration of China has approved the use of Favilavir, an anti-viral drug, as a treatment for coronavirus. The drug has reportedly shown efficacy in treating the disease with minimal side effects in a clinical trial involving 70 patients.
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There’s emerging evidence that some medications may have the potential to treat the symptoms of COVID-19. More large-scale testing is needed to determine if these treatments are safe and clinical trials for these drugs could take several months.
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At this point in time, at Santa Monica Primary Care we are not recommending any change to patient’s current medications. Over the next weeks, however, we will be actively checking in with our patients to ensure that they have adequate supplies of vital medications. Based on data from France, we will begin to recommend Tylenol instead of Ibuprofen for supportive care of potential coronavirus infections. In the meantime, should you have questions or concerns, please feel free to call our office at (310) 828-4411. We are available 24/7 for our patients.

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

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15 March 2020 Blog Post: Important Notice To Our Patients

15 March 2020 Blog Post: Important Notice To Our Patients

At Santa Monica Primary Care our mission is to provide for your health and safety in the best manner that we can. To this end, I have made the difficult but necessary decision to suspend all of our in-office operations beginning Monday March 16th, 2020 and into the foreseeable future. We will move our clinical care to a telehealth and video conferencing platform.

For those of you already scheduled for a face-to-face in office visit, you will be able to keep your current appointment but that will become a telehealth consultation. In the case of those awaiting their routine annual evaluation, that can take place over video conferencing. Laboratories that need to be drawn can be performed at an outside contracted LabCorp site – although I would recommend that you call first to find times when there are few other patients likely to be there.

As those of you who have followed my regular #COVID-19 updates, you will know that we are in the midst of a dynamic pandemic. Our goal is to minimize the exposure risk to our patients, the community and in particular to protect the most vulnerable.

While our in office operations will be closed to patients, we will remain fully staffed to respond to your needs. Although the manner in which you receive care will be different, be assured that you will continue to get the high quality, serious, and considered care that you have come to expect from our office.

Please understand that we will not be scheduling any face-to-face appointments until further notice. We simply cannot estimate when we will be able to accommodate face-to-face visits. As we learn more, please follow us on social media (Facebook, Instagram and/or Twitter). When we signal that we have resumed normal operations, you will then be able to call to schedule an in office appointment.

We sincerely apologize for the further disruption we may have caused. We very much appreciate your patience and understanding. We look forward to inviting you back into the office as soon as possible.

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

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14 March 2020 Blog Post: Where Are We Going Based On Where Have We Been?

14 March 2020 Blog Post: Where Are We Going Based On Where Have We Been?

This seems to be the most common question I have been getting, particularly of late. Where is this all going? We have all been impacted now by school closures, “social distancing”, travel disruption, working from home and increasing isolation from friends and family. So what can we expect in the upcoming days and weeks?
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At this writing there are 155,423 total confirmed worldwide cases of which 2,572 are in the United States. I think we all agree that the US numbers are a massive underestimate of the true burden of infection but what does that mean practically? We are also clearly on the upswing, both in terms of case identification and as #COVID-19 spreads (see Figure 1 below). As Dr. Anthony Fauci stated, “I can say we will see more cases, and things will get worse than they are right now.”
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So how many more cases and how much worse? For those of you who are fans of Chris Cuomo – let’s get after it!
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Agreeing that 2,572 identified cases is an underestimate, where do we suppose that the actual number of current infections in the US stand? Trevor Bedford, who is a scientist Fred Hutch and is well worth following on Twitter has studied the King County Washington COVID-19 data in incredible detail. His analysis based on that flare suggests that we are currently operating at a 1:10 to 1:20 case to infection reporting rate. That would indacted that we have anywhere between 25,000 and 50,000 cases already in the US.
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Thus far, a 5-6 day doubling time has been an accurate model for growth as the “appearance of outbreaks across the US are not due to a sudden influx of cases but instead transmission chains that have been percolating for 4-8 weeks now.” We are just now starting to see the exponential growth “pick up steam.” (Quotes are Dr. Bedford’s words – giving credit where credit is due).
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This is an important time in the epidemic curve for, if you look at Figure 2 from the coronavirus outbreak in China, you can see that cases rose rapidly just after 40,000 infections. The line is nearly vertical at one point before flattening.
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Laurie Garrett (who is a scientific journalist and known for her reporting on the Ebola virus outbreak in Zaire and also worth following on Twitter), estimated 30,000 cases in 10 days. This, however, I believe is a significant underestimate. Given what China reported between mid February and early March, I would estimate that the US should prepare for 80,000-100,000 cases. Note too that the number of cases in Figure 2 flattens dramatically towards the end of February – this from aggressive containment measures by Chinese public health officials.
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Doubling time varies dramatically by country. The US, Germany, France and Spain have a 3 day doubling time (now some of this in the US may be due to case detection as testing has not been widely available), In Italy it is 4 days. Iran 6 days. South Korea – 12 days. Currently in China – 32 days.
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“Hope is not a strategy,” says Mike Ryan, who is an epidemiologist and the World Health Organization’s head of emergencies. “We are still very much in the up cycle of this epidemic.”
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At Santa Monica Primary Care we continue to be available for any questions and concerns you may have. We can be reached 24/7 by phone at (310) 828-4411. While the major bottleneck we have faced thus far is the availability of any testing, we hope that changes soon allowing us to identify both cases and those who remain unaffected.

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

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13 March 2020 Blog Post: COVID-19 and Increasing Reliance on Telemedicine

13 March 2020 Blog Post: COVID-19 and Increasing Reliance on Telemedicine

As regular readers of these ongoing posts will know, Santa Monica Primary Care responded to #COVID-19 by employing telemedicine and video consultations early in the epidemic. At this point in time, about 50% of our patient encounters are via one of these modalities. The CDC has further recommended leveraging telemedicine technologies and self-assessment tools as a way to protect patients.

The initial intent of a telemedicine encounter is to assess a patient’s risk based on known exposure or travel. Further, it permits us to quickly identify high risk patients or those who are sick enough to need hospital care.

Given evidence in Los Angeles County of person-to-person spread we now have moved to identifying those patients with milder symptoms who can be monitored at home so as to limit the spread of this disease and not overwhelm our healthcare facilities.

Specifically, through telehealth:
1. We can increase access to care.
2. We can offer care that is commensurate with the acuity and nature of the symptoms and make referrals as needed.
3. We can help with coronavirus prevention and control.
4. We can allow patients to receive their care in the home without exposing themselves to further illness.
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Lastly, there is additional potential for telehealth to help in providing routine care for other conditions (although we have seen less of this thus far). Patients have other healthcare needs unrelated to coronavirus, but may afraid to go to healthcare settings for fear of catching the virus.
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I am sympathetic to patients who feel that telemedicine may be inadequate and not their preferred modality of receiving care. Yet, it is important to reiterate the two central points above. By effective telehealth based risk stratification, we can limit the spread of coronavirus (particularly to those most vulnerable populations) and also not overwhelm our Emergency Departments and Hospitals.
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This is an extraordinary time and requires novel approaches. Widespread application of telehealth is one such strategy

𝗦𝗢𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 π—’π˜‚π—Ώ π—‘π—²π˜„π˜€π—Ήπ—²π˜π˜π—²π—Ώ

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