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Our Recommedations:

If you develop fever and cough, please call your physician. Do not go to the ER unless you are very ill as most upper respiratory infections are not caused by SARS-CoV-2 (the virus responsible for the COVID-19 disease). When the disease is widespread, the ER will be a great place to find it and we don’t want that.

While community testing is becoming more readily available, we recommend testing only in the setting of fever, cough, known or suspected exposure, or for healthcare providers. The testing situation is changing very rapidly. We have had many questions about whether we are testing in our office. While we do have test kits, we do not have the appropriate equipment to protect our staff from infection (and then from spreading that infection) so at present, we are not able to test in our office. The focus on drive-thru testing is that this is the most effective way to safely test large numbers of people while limiting exposure of others to those being tested. Recent questions about the reliability of various available tests has made this issue even more complex.

For office visits:

The peak of COVID-19 has been dramatically attenuated by measures put in place to date. As we venture from our nearly three months hibernation, it is important that we do so carefully. We will update this post periodically to reflect changes in our office plans. 

For patients due for lab testing, immunizations, or office visits, we will review each upcoming appointment to assess the risk and benefit of proceeding versus delay. When lab testing is necessary, we do recommend that patients come to us as we feel we can better protect them in our building and office than at a lab draw station. We will coordinate individually with each patient based on their unique circumstances and will we may delay some routine testing. If you have questions, please reach out to us and we will discuss our plans.

Effective 06/01/20, we will return to our usual office schedule (07:00 - 16:00 weekdays). But we will continue to see patients by appointment only as we will be spacing visits to minimize interactions between patients. 

When you enter the building, we recommend using a car key to call the elevator and then to select the fourth-floor button. We are cleaning the handle on the door to our office frequently and will have alcohol hand gel available as you enter our office.

There is a significant concern about the spread of coronavirus from people who feel perfectly well, and we are making changes to minimize that risk. We will ask all patients, physicians, and office staff to wear masks for all patient encounters. Gloves are not useful in this situation, but hand washing is critical.

When you arrive in our office, we will ask you to use hand sanitizer gel and don a mask before we bring you back to an exam room. We will also wear a mask while you are in our office. The mask you are wearing is to protect us, and the masks we will wear are to protect you.

Before you leave our office, we recommend either washing your hands or using alcohol hand gel. We will then escort you out of the office, call the elevator for you and select the ground floor for the elevator so that you will not need to touch anything in the building as you leave. If you prefer, you may call the elevator and select the ground floor with a car key or other object (to avoid touching the elevator buttons).

These steps may seem excessive, but we want to do everything possible to protect our patients, staff, and physicians.

Recent Developments and Highlights:

05/27/20:

The peak of COVID-19 has been dramatically attenuated by measures put in place to date. As we venture from our nearly three months hibernation, it is important that we do so carefully. We will update this post periodically to reflect changes in our office plans.

For patients due for lab testing, immunizations, or office visits, we will review each upcoming appointment to assess the risk and benefit of proceeding versus delay. When lab testing is necessary, we do recommend that patients come to us as we feel we can better protect them in our building and office than at a lab draw station. We will coordinate individually with each patient based on their unique circumstances and will we may delay some routine testing. If you have questions, please reach out to us and we will discuss our plans.

Effective 06/01/20, we will return to our usual office schedule (07:00 - 16:00 weekdays). But we will continue to see patients by appointment only as we will be spacing visits to minimize interactions between patients.

When you enter the building, we recommend using a car key to call the elevator and then to select the fourth-floor button. We are cleaning the handle on the door to our office frequently and will have alcohol hand gel available as you enter our office.

There is a significant concern about the spread of coronavirus from people who feel perfectly well, and we are making changes to minimize that risk. We will ask all patients, physicians, and office staff to wear masks for all patient encounters. Gloves are not useful in this situation, but hand washing is critical.

When you arrive in our office, we will ask you to use hand sanitizer gel and don a mask before we bring you back to an exam room. We will also wear a mask while you are in our office. The mask you are wearing is to protect us, and the masks we will wear are to protect you.

Before you leave our office, we recommend either washing your hands or using alcohol hand gel. We will then escort you out of the office, call the elevator for you and select the ground floor for the elevator so that you will not need to touch anything in the building as you leave. If you prefer, you may call the elevator and select the ground floor with a car key or other object (to avoid touching the elevator buttons).

These steps may seem excessive, but we want to do everything possible to protect our patients, staff, and physicians.

05/07/20:

Our latest thought about COVID antibody testing at this link.

04/20/20:

The Centers for Medicare and Medicaid Services will increase the reimbursement rate for some versions of Abbott Laboratories’ tests for SARS-CoV-2 from $51 to $100 per test to increase the rate of testing. The increase applies to tests run on Abbott m2000 machines generally found in hospitals.

Abbott Tests

These machines have been running at less than 10% of capacity and the increased reimbursement is intended to encourage higher utilization of available testing facilities, particularly among residents of nursing homes.

Abbott also announced the production of antibody test kits to help determine whether an individual has been previously infected. We do not yet know that having IgG antibodies (evidence of prior infection) means that you cannot get the disease again.

“I don’t know we have enough trust in what an exposure means that it would change the way we deploy our workforce,” Kimberly Hanson, an infectious-disease physician at the University of Utah School of Medicine, said at a media briefing. “We’re still trying to figure out what detecting an antibody response means, and if it’s protective or not, we don’t know.”

At present, the primary uses of antibody testing may be to quantify the extent of asymptomatic infection and to identify potential convalescent plasma donors. Convalescent plasma is currently being used in the treatment of some patients with severe COVID-19.

04/17/20:

Great news from the NIH. The first subjects have been enrolled in a blinded, randomized, placebo-controlled trial to evaluate the efficacy of hydroxychloroquine (HCQ) in patients being admitted to the hospital for treatment of COVID-19. The ORCHID (Outcomes Related to COVID-19 treated with HCQ among In-patients with symptomatic Disease) study is being conducted by the Prevention and Early Treatment of Acute Lung Injury (PETAL) Clinical Trials Network of the National Heart, Lung, and Blood Institute (NHLBI), part of the NIH.

The Adaptive COVID-19 Treatment Trial (ACTT) is a similar blinded, randomized, placebo-controlled trial is underway to study remdesivir in the treatment of COVID-19. Subjects are being enrolled at the University of Nebraska Medical Center (UNMC) in Omaha. The study is sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), part of the NIH.

20200409-covid-19

Remdesivir, developed by Gilead Sciences Inc., is an investigational broad-spectrum antiviral treatment. It was previously tested in humans with Ebola virus disease and has shown promise in animal models for treating Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS), which are caused by other coronaviruses.

“We urgently need a safe and effective treatment for COVID-19. Although remdesivir has been administered to some patients with COVID-19, we do not have solid data to indicate it can improve clinical outcomes,” said NIAID Director and U.S. Coronavirus Task Force member Anthony S. Fauci, M.D. 

“A randomized, placebo-controlled trial is the gold standard for determining if an experimental treatment can benefit patients.”

It will be at least several weeks before data is available from either study but this is the level of evidence we desperately need.

04/16/20:

An interesting analysis of COVID-19 occupational risk from Visual Capitalist today. The green circles represent healthcare professions, blue ones non-healthcare. The size of the circle represents the number of individuals represented. Unfortunately, some of the blue circles are going to shrink rapidly as unemployment grows. Stay safe!

04/15/20:

The Infectious Diseases Society of America (IDSA) recently issued guidelines for the treatment of patients hospitalized with COVID-19. Essentially, they recommend any of several treatments, but specify that each should be used in the context of a clinical trial where possible. 

It appears that the rate of new COVID-19 diagnosis in Italy is slowing. Hopefully, this trend will continue and be duplicated elsewhere. 

04/14/20:

One of the most challenging aspects of the SARS-CoV-2 epidemic to date has been the difficulty in testing to determine the presence of infection. The currently available tests require a nasopharyngeal swab (obtained not from the front of the nose like a flu test, but much deeper). This test is uncomfortable for the patient and can only be performed by healthcare personnel with appropriate personal protective equipment (PPE) including mask and face shield. Yesterday, Rutgers University was granted emergency approval by the FDA for a newly developed test for the SARS-CoV-2 virus which uses saliva. If proven effective in trials that are underway now, this may provide a much-needed option for testing outpatients for SARS-CoV-2. Stay tuned for more on this!

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A paper published yesterday in the New England Journal of Medicine reviewed admissions testing data for 215 pregnant women admitted to Labor and Delivery units in New York, all were screened for SARS-CoV-2. At the time of admission, 1.9% had fever or other symptoms of COVID-19, and all had positive tests for the SARS-CoV-2 virus. Of those without symptoms, 13.5% tested positive for the SARS-CoV-2 virus. So, 29 of 33 (88%) patients who tested positive for the SARS-CoV-2 virus had neither fever nor symptoms. On one hand, this is reassuring (only one patient was reported to develop symptoms felt due to COVID-19) because it would suggest that young pregnant women remain at low risk. On the other hand, one in eight women who delivered a baby in New York would have returned home with a newborn. We all know that babies are a lot of work and often grandparents want to help. This could lead to a disastrous spread of the SARS-CoV-2 virus in families. 

04/13/20:

We are optimistic that the peak of COVID-19 has been somewhat attenuated by measures put in place to date. But overall risk remains high and our advice remains that all patients minimize excursions away from home to those only absolutely necessary. 

For patients due for lab testing, immunizations or office visits, we will address each upcoming appointment to assess the risk and benefit of proceeding versus delay. When lab testing is necessary, we do recommend that patients come to us as we feel we can better protect them in our building and office than at a lab draw station. We will coordinate individually with each patient based on their unique circumstances and will likely delay some testing. If you have questions, please reach out to us and we will discuss our plans.

04/12/20:

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04/11/20:

A publication in the New England Journal of Medicine reported on the use of Remdesevir in severly ill patients with COVID-19. 

“In this cohort of patients hospitalized for severe Covid-19 who were treated with compassionate-use remdesivir, clinical improvement was observed in 36 of 53 patients (68%).”

Still, 7/53 (13%) died despite remdesivir treatment.

These patients in this study look like they were sicker than the average hospitalized population but also 26% under the age of 50. 

Just one placebo-controlled trial, please! Even a small subject number should work if the effect size is large.

Another study beginning soon in Detroit will enroll more than 3,000 hospital healthcare workers and first responders in an attempt to determine whether hydroxychloroquine (HCQ) is effective in preventing SARS-CoV-2

Participants will be tested for antibodies to the virus and then receive vials of unidentified, specific pills to take for the next 8 weeks. The vials will include either a once-a-week dose of hydroxychloroquine, a once-a-day dose, or a placebo. 

Researchers will contact participants weekly and in person at weeks 4 and 8 to determine if they are experiencing any medication side effects or symptoms of COVID-19, ie, dry cough, fever, or respiratory issues. Blood will again be drawn at week 8 and results among the 3 groups compared.

If HCQ is effective in preventing COVID-19 in this high risk group, its widespread use would likely follow. Such a finding would also support the use of HCQ in treating COVID-19. First responders and healthcare workers in Detroit can learn more about enrolling in the study here:        https://www.henryford.com/whip-covid-19

We anticipate a flood of new data from this and similar studies over the coming months. For now, we have very little valid scientific evidence about what works and what does not. Many anecdotes, but in medicine, we really prefer randomized blinded trials. 

For now, it feels to many of us like we are putting together our parachute on the way down!

04/10/20:

We’ve had many questions about antibody testing for SARS-CoV-2Antibody testing is not yet available, hopefully will be soon. But we also do not yet know that having IgG antibodies (evidence of prior infection) means that you cannot get the disease again. So there are many questions we will need to answer before we know what to do with the test results when they do become available.

There’s a great article discussing this in the Wall Street Journal from 04/10/20. An excerpt:

“I don’t know we have enough trust in what an exposure means that it would change the way we deploy our workforce,” Kimberly Hanson, an infectious-disease physician at the University of Utah School of Medicine, said at a media briefing. “We’re still trying to figure out what detecting an antibody response means, and if it’s protective or not, we don’t know.”

Given the potential shortcomings, early serology tests might prove more useful as a tool for gauging the spread of the virus through communities, rather than for determining whether individuals have full immunity.

Our office will be closed on Friday 04/10/20 in observance of Good Friday.

04/09/20:

Our office will be closed on Friday 04/10/20 in observance of Good Friday. Of course, we are available by telephone as usual.

There were several reports that therapies targeting the immune respone to COVID-19 show promise (such as blocking the action of IL-6 by Actemra). Most are anecdotal or case series and much more study is needed. The application of these treatments has been limited to severely ill patients but this is encouraging. 

04/08/20:

The CDC released updates today regarding the spread of SARS-CoV-2 at family gatherings such as funerals or pot-luck meals. All gatherings should be avoided. We know it’s not the same, but have a Zoom birthday party and save lives. 

CDC also reported updated data regarding the risk of hospitalization being very clearly correlated with age.

04/07/20:

From Visual Capitalist, a nice illustration and thorough explanation of the math behind social distancing

04/06/20:

More details from CDC, including instructions for creating cloth masks at home. Now we all have homework. 

04/05/20:

Courtesy of Visual Capitalist, the latest lists of diagnostics, drug trials and vaccine development projects for COVID-19.

04/04/20:

CDC now recommends that all individuals wear fabric face coverings in public settings where other social distancing measures are difficult to maintiain (such as in pharmacies and grocery stores). The goal is to prevent transmission of virus by people who do not know that they are infected. It is important to note, the mask does not protect the wearer, it protects everyone else.

There are many bleach products available and the use of these for disinfecting household surfaces can be confusing given the variety of products and concentrations of sodium hypochlorite (the active ingredient). Michigan State University has posted a helpful page to describe the mixing ratios for various bleach products.

We have cautioned against the use of hydroxychloroquine and azithromycin (HCQ/AZ) until additional studies are completed (see our update from 03/31/20 below) as the inital case reports from France were encouraging but lacked any scientific rigor. Two recent publications reinforce our reservations about the use of HCQ/AZ at this time. Researchers in Paris found no evidence of HCQ/AZ in patients with severe COVID-19 disease. Another recent review article echoes our concerns, noting that "Data to support the use of HCQ and CQ for COVID-19 are limited and inconclusive."

04/03/20:

Dallas County commissioners have extended the coronavirus stay-at-home order until 05/20/20. 

04/02/20:

Back to some basics today. 

CDC background information on how to protect yourself from COVID-19.

What is social distancing? 

Social distancing is the strategy that we should ALL be following. This includes avoiding crowds, closing schools and working from home when possible. When we must leave home (to shop for groceries for example), careful attention to hand hygiene is critical. Staying at least six feet away from other people also lessens your chances of catching COVID-19. But to be clear, the six foot separation is not a socialization strategy. So when we see images of groups of people standing six feet apart socializing, that's not social distancing

What is self-quarantine? 

Quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick. These people may have been exposed to a disease and do not know it, or they may have the disease but do not show symptoms.

People who have been exposed to the new coronavirus and who are at risk for coming down with COVID-19 might practice self-quarantine. Health experts recommend that self-quarantine lasts 14 days. Two weeks provides enough time for them to know whether or not they will become ill and be contagious to other people.

What is isolation?

Isolation separates sick people with a contagious disease from people who are not sick. Anyone diagnosed with COVID-19 (or thought likely to have the disease) should be isolated, even from family members in the same household. More information about caring for someone sick at home.

04/01/20:

April Fools day has been canceled.

03/31/20:

Texas Governor Greg Abbott has issued an essential services order. The order would require anyone who is not considered an essential critical infrastructure worker to stay home. The order will limit everyone who lives or works within the state of Texas to only leave home for essential activity, essential business, essential government functions and critical care functions. Essential critical infrastructure workers work in the following fields:

• Chemical
• Commercial facilities
• Communications
• Critical manufacturing
• Dams
• Defense industrial base
• Emergency services
• Energy
• Financial
• Food and agriculture
• Government facilities
• Health care and public health
• Information technology
• Nuclear reactors, materials, and waste
• Transportations systems
• Water

We feel strongly that this was the best plan to protect Texans and we applaud the decision that the Governor made today.

Last evening, a group of authors published a detailed discussion of the limitations of recent data regarding the use of chloroquine (CQ) or hydroxychloroquine (HCQ), either alone or in combination with azithromycin (AZ) in treatment of COVID-19 as well as the logic leading to optimism about these medications. It’s pretty dense reading. We agree with their conclusions, and would add that while HCQ alone is generally safe for short-term use, it can be directly toxic to heart muscle cells. When administered in combination with other medications (including azithromycin), CQ and HCQ can cause an often-fatal abnormal heart rhythm called Torsades de pointes. Bottom line, we strongly recommend against taking CQ or HCQ given the lack of data to support this treatment and the potentially fatal adverse effects, particularly when combined with other medications including AZ; we recommend HCQ and CQ be reserved for hospitalized patients with severe COVID-19 illness where the hoped-for benefits are felt to outweigh the known risks.

03/30/20:

As we settle in for what may be our new normal for the foreseeable future, we need to be reminded that social distancing is a strategy to be used when making necessary trips away from home (to the grocery store, etc), not a strategy for socializing.

03/29/20:

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The basketball team at Regis High School had a 1-16 record as the players entered a rival’s gym in the winter of 1958 fully expecting to leave with yet another loss. The other team’s star was a future NBA coach who would one day run the New York Knicks. Regis was led by a diminutive future doctor who would one day run the National Institute of Allergy and Infectious Diseases.

“Nobody gave us a chance,” said John Zeman, a Regis alumnus. “Everyone figured it was going to be a blowout.”

But there was one teenager who looked at this demoralizing collection of data and came to a wildly optimistic conclusion.

“Tony said no,” he said. “We’re going to win this game. And we did.”

Tony, the team captain better known as Fauch, a short kid with a thick Brooklyn accent who led his overmatched team to a highly improbable victory in the biggest game of his life, now answers to a name that most Americans have come to recognize: Dr. Anthony Fauci.”

There’s a great article in today’s Wall Street Journal about Dr. Fauci. Definitely recommended reading. Not much else new, so we’ll leave it at that for today.

Stay home, stay safe!

03/28/20:

As of today, we have identified 75 anesthesia machines in the Plano/Frisco area. We are so proud of our awesome staff and the hard work they have done searching for these potentially life-saving machines! The Food and Drug Administration has amended its regulatory policies for ventilators, anesthesia equipment, and other devices to allow them to be used if needed during the COVID-19 crisis. If you know an office or facility that has anesthesia equipment, please let us know here.

FDA issued a warning advising against taking chloroquine intended for use in aquarium fish. Makes sense to us.

03/27/20:

Taking a break from the statistics for today. There is such an information storm that it’s overwhelming when repeated. So, two thoughts for today.

First, get outside! Take a walk with family (or alone) and find something pretty to look at. The sun makes us feel better and after ten rainy days indoors, yesterday was a nice reprieve. Let’s hope that continues.

Second, America has been challenged by SARS-CoV-2 in a way that has not happened in about 100 years. We are starting to treat this threat as a war, rather than a disease. Look at the history of our country, we win wars! Here’s how it goes:

1. America challenged.
2. America says “hold my beer.”
3. Private industry ramps up. (General Motors retools to make ventilators, etc.)
4. America wins. Always.

03/26/20:

Abbott labs submitted a request to the FDA for approval of a point of care test for SARS-CoV-2. This may allow for testing in physician offices or other settings and possibly rapid availablity of test results. We hope to have more details in the near future.

The rate of reported new cases in Europe appears to have slowed. It remains unclear whether this is the result of fewer new cases, or less testing. Let’s hope it is the former. We will likely only know more when we see a trend in the number of deaths each day.

Answers to new frequently asked questions: “Will ultraviolet (UV) light or hand dryers in public bathrooms kill SARS-CoV-2?” Neither UV light nor hand dryers are effective in killing this virus (and the latter may aerosolize any bacteria or viruses still living on wet hands being dried).  Washing hands with soap and water (thoroughly, for 20 seconds minimum) or the use of alcohol hand gel are the only safe ways to protect yourself against virus on your hands.

Among the first (of likely many) clinical trials to report no benefit in treatment of COVID-19 was published online by the New England Journal of Medicine. This study examined the utility of a combination of two anti-viral medications (lopinavir and ritonavir, sold as Kaletra do not appear to be of benefit for the treatment of HIV disease). While earlier studies had indicated a possible benefit in treatment of these drugs alone or in combination in treatment of SARS-CoV and MERS-CoV, they in treatment of COVID-19 (caused by the SARS-CoV-2 virus).

03/25/20:

There has been a significant increase in the rate of growth in cases in the United States and in Texas, we believe that this is related to increased testing availability and cannot make any conclusion abou the rate of actual disease spread.

03/24/20:

Collin County Judge Chris Hill announced that he will not issue a shelter-in-place order at this time. Moments later, Dallas Mayor Eric Johnson issued a stay at home order which seems in direct conflict with that of Collin County (some parts of the City of Dallas are in Collin County) so both confusion and conflict will certainly follow. 

We strongly disagree with Collin County’s muddled message today. Anything short of a shelter-in-place order sends signals to our community that the spread of this disease can be “handled” or negotiated with. The only thing right now that can “flatten the curve” adequately is an absolute standstill of all non-essential services, public gatherings and social interactions, the sooner the better. And the more complete the better. We have already seen areas of the world (Italy among others) and now our country (King County, WA and the NYC area) overrun with cases and demands on health care that are not sustainable. Again, we strongly advise everyone to stay home and to only leave their homes for absolutely essential necessities. There are many unknowns such as how long can this virus exist in the environment and remain infectious, as well as the ability of completely asymptomatic people (about 18% of those infected) to shed this virus and infect others.

The number of new cases in Italy overnight was again 8%. Lets hope the trend continues and is a reflection of slower disease spread and not less testing; at this point it is not clear whether one of these factors (or both) is responsible for the apparent slowing of viral spread.

A dozen physicians at the epicenter of Italy’s Covid-19 outbreak issued a plea to the rest of the world, going beyond the heartbreaking reports of overwhelmed health care workers there and a seemingly uncontrollable death toll to warn that medical practice during a pandemic may need to be turned on its head - with care delivered to many patients at home.

“Western health care systems have been built around the concept of patient-centered care,” physicians Mirco Nacoti, Luca Longhi, and their colleagues at Papa Giovanni XXIII Hospital in Bergamo urge in a paper published in NEJM Catalyst, a new peer-reviewed journal from the New England Journal of Medicine. But a pandemic requires “community-centered care.”

Most nearby hospitals in the wealthy region are “nearing collapse while medications, mechanical ventilators, oxygen, and personal protective equipment are not available,” the physicians write.

Major hospitals such as Bergamo’s “are themselves becoming sources of [coronavirus] infection,” with Covid-19 patients indirectly transmitting infections to non-Covid-19 patients. Ambulances and infected personnel, especially those without symptoms, carry the contagion both to other patients and back into the community.

03/23/20: 

We are assembling a list of anesthesia machines in the north Texas area. These are the machines used in operating rooms to ventilate (breathe for) patients during surgery. The Food and Drug Administration has amended its regulatory policies for ventilators, anesthesia equipment, and other devices to allow them to be used if needed during the COVID-19 crisis. The updated regulation also allows for nonconventional modification to the devices and procedures. This would allow ventilation of multiple patients using a single machine for example. We are contacting outpatient surgery centers and physicians' offices (for example plastic surgeons) who may have these machines. If you know an office or facility that has anesthesia equipment, please let us know here

And two bits of good news today

First, effective at 11:59 pm tonight, Judge Jenkins’ Stay Home Stay Safe Order will mandate that all Dallas County residents remain home (with exceptions for essential activities of course). All non-essential businesses will be closed. Restaurants may only provide take-out or delivery services. Worship services are to be provided by video or teleconference. All elective medical, surgical and dental procedures are prohibited. Essential activities (which are exempt from the stay home order) include physician visits, work in essential businesses (healthcare for example), outdoor activities (provided social distancing can be maintained), to care for a pet or family member, and shopping for food or medical supplies.

We anticipate a similar order for Collin and other nearby counties soon. Update 03/24/20: Denton County has issued a mandate similar to that for Dallas County. Unfortunately, Collin County has not (see above).

Second, it appears that the rate of increase in case numbers in Italy may finally be slowing from it’s prior 15%/day (or more) to 10% yesterday and 8% today. Lets hope the trend continues and is a reflection of slower disease spread and not less testing.

03/22/20:We have had many questions about the safety of delivered, takeout or drive-through food. For home delivery, “no touch” delivery is ideal (pay in advance to include tip) and you should assume that all packaging is contaminated (so dispose of delivery bags on the outside, wash hands, transfer food from containers to other serving dishes, discard containers). Don’t touch your face. Wash hands, heat food as needed, pour a glass of wine and enjoy the meal with family. Similarly, drive though meals are possible but more challenging. Taken food home, open the bag, pour the lettuce-wrapped burger onto a plate, discard the bag. Then, wash your hands and enjoy.

03/21/20: The case growth rate in Italy has been essentially unchanged for the past several days at about 13-15%. While there are reports that they are no longer testing people who are not seriously ill, we hope that is not the case as that would mean that the rate of disease spread has actually increased overall.








03/20/20: Additional thoughts as we (rather poorly) attempt social distancing. Just returned from a trip to get groceries. Many shoppers completely ignoring the 2 meter radius, a few attempting a 20 meter separation and appearing almost frantic. 

Our daughter called my wife and of course she answered, touching her face with her phone. I’d probably have done the same because when we’re all a bit on edge and your teenage child calls, you answer. Fortunately it was not urgent, but was a good reminder - if you need to contact someone who may not be at home, send a text message rather than calling.

When you must leave home, do so in pairs so that you can watch each others’ hands and hand hygiene. When bringing in Amazon packages or groceries, put them in “time out” in an unused room or separate refrigerator. At least 24 hours for cardboard containers and 72 hours for canned goods. Overkill? Maybe…but I’d rather look silly at home than on a ventilator.

After shopping or touching anything not attached to you, clean your phone with a hand wipe and then wash your hands.

We saw several people with N95 masks, none fitted properly, one person used only the top elastic band, leaving the mask hanging in front of his face. This is such a waste and comes as hospitals and physicians cannot get them.

The efforts people are making at social distancing are definintely the best plan, but we’re not very good at it yet and we have to get better.

03/20/20: The number of cases in Germany and Spain continues to grow rapidly with disease spread. We anticipate large increases in the numner of cases in the United States as testing becomes more widely available. We won’t know for several more days how rapidly the disease is actually spreading here however.

There is a fascinating (and sobering) podcast from WSJ today about how hospitals are coping with COVID-19 spread.

03/20/20: California Gov. Gavin Newsome ordered residents to stay at home unless absolutely necessary. This should be the standard nationwide. Stay home, stay safe, stay healthy.

Our Advice for Patients

Frequent and careful hand washing is the most important way to stop the spread of this virus, with a close second being avoidance of persons infected.

Wash your hands after touching anything not attached to you, and before touching your face.

  • For all patientsIf you can remain in your home, do so. Work from home. Leave home only when necessary. If you must leave home, practice social distancing (in general, stay at least 6 feet from other people when possible). Avoid handshaking, hugging and other social contact greetings. We recommend that all patients avoid crowds (movies, grocery stores on Saturday afternoon, basketball games, church services). While exercise is great in the long-term, gym surfaces may be contaminated and we would recommend not going to the gym until further notice. Similarly, exercise, yoga, stretching or other group activities should be avoided. Be attentive to anyone near you with a cough, and avoid them. Use hand sanitizer after getting gas, using ATMs or shopping (and before touching the inside of your car). Self park rather than valet parking. Postpone manicures and other close personal encounters (including most routine preventive medical care like annual physicals). Tanning booths should always be off limits, but they are particularly now. We recommend not traveling by air within the United States unless absolutely necessary. Careful attention to hand-washing and avoidance of anyone who appears sick is important. If you must travel by air, choose the bulkhead window seat as this eliminates three fourths of possible disease sources. 

Wash your hands after touching anything not attached to you, and before touching your face.

  • For patients who have diabetes, high blood pressure, heart disease, COPD, asthma or any other significant medical condition, as well as patients older than 60 years (CDC definition, not ours): Avoiding this disease is critically important for high risk individuals. Stay home as much as possible. If you must leave home, wash your hands or use alcohol hand gel after touching door handles, shopping carts, elevator buttons, etc. 

Wash your hands after touching anything not attached to you, and before touching your face.

03/19/20: Department of State advises US citizens to avoid all international travel and sets global level 4 health advisory. We would add that avoidance of non-critical domestic travel is prudent.

We have had many questions about whether patients should obtain chloroquine (related drug hydroxychloroquine) or other drugs which may have activity against SARS-CoV-2 and the short answer is “no.” While early data is encouraging, there have not yet been randomized trials (though many are ongoing or planned), so the reports are based on observations only. Among the first suggestions that chloroquine might be effective in treating SARS-CoV-2 came from an Infectious Disease journal in mid-February 2020 and another publication followed later in the month. While encouraging, there is not yet sufficient evidence to recommend this as treatment, and certainly not as prevention. And the drug is entirely unavailable as a result of panic caused by news briefs. Pharmacies do not have chloroqine, we cannot even get this now from medical supply companies. This link is a comprehensive review of the use of chloroquine in COVID-19 disease.

We have seen yet another controversy in the management of SARS-CoV-2. The French Minister of Solidarity and Health tweeted that ibuprofen should be avoided in patients with COVID-19. An article in BMJ reports a similar recommendation, as does the World Health Organization (WHO). There is some disagreement, but the experts we trust advise avoidance of ibuprofen and similar drugs in patients with COVID-19. We recommend using Tylenol first in any patient with fever, regardless of the suspected cause. If that is not effective, call us and we will discuss next steps.

We have had many questions about whether patients should stop or change blood pressure medications based on the possibility of infection with SARS-CoV-2. At present, we recommend against making any changes on this basis and that is also the recommendation of the American College of Cardiology, American Heart Association, and the Heart Failure Society of America.

As of 03/19/20, COVID-19 continues to spread rapidly (about 15% increase in cases per day) in Germany, Spain and Italy. France reported a 17% increase. Data for the United States likely reflects both spread of disease and wider availability of testing. The graph below shows total cases as of noon 03/19/20.


There are news reports that many hospitalized patients in the United States are younger and some have concluded that the disease has somehow changed or is now more severe in younger patients. We believe that this is incorrect and represents wider spread of disease in younger adults, not more severe disease. The risk of hospitalization, ICU admission and death by age group in the United States is approximately as shown at right (and this is similar to earlier data from China and elsewhere). There definitely is increased risk for older adults and the CFR remains above 2.6% overall.


Delivered food may be a safer alternative than grocery shopping and may be a way to help restaurants stay in business. If possible, pay in advance with a credit card and include the tip to avoid exchanging money or a physical credit card. Remove the food from delivery packaging, discard the packaging and then wash your hands carefully to avoid contamination of your home. Some delivery services offer “no-contact” deliveries in some areas and if available, this is best.

An analysis of available hospital beds from the Harvard Global Health Institute suggests that any extensive infection in the United States would overwhelm our acute care hospitals. In the graphic below, green areas have hospital beds available, yellow are full and red areas represent areas where demand is more than twice the available bed number. 

From the same data set, an analysis of hospital capacity in the Dallas area demonstrates excess demand beyond capacity for various disease rates of spread and total infections. Containment of SARS-CoV-2 to prevent widespread disease is absolutely critical.

Hospitals Dallas
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On 03/18/20, Italy’s new case rate was 11.8%, Spain 15%, and as of noon, France had not reported today’s data. The Netherlands,  Austria, and Germany continue to report higher rates (17%, 19%, and 30% respectively).

A new publication from CDC and others suggests that the SARS-CoV-2 virus is most stable (in an experimental model) on hard surfaces such as plastic and stainless steel, where it was detected for up to 72 hours post exposure. Virus was not deteced on cardboard after 24 hours.



On 03/17/20, Italy reported 3,526 new cases, an 11% increase, for the second day in a row. This remains a devastating growth rate for infections, but is at least hopeful as the prior rate was 15% per day or higher. Hopefully the rate of new infections will continue to slow. The rate of spread remains higher in most of Western Europe and the United Kingdom, where an increase of almost 40% was hopefully related to increased testing and not actual disease spread. The number of cases in the United States increased by 18.5% (to 5,723) but this also is likely the result of increased testing. 

On 03/16/20, The US National Institutes of Health (NIH) said that the first participant has been dosed in a Phase I study of the experimental COVID-19 vaccine mRNA-1273. The National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health, is funding the trial. The vaccine is called mRNA-1273 and was developed by NIAID scientists and their collaborators at the biotechnology company Moderna, Inc. Scientists at NIAID and Moderna were able to quickly develop mRNA-1273 because of prior studies of related coronaviruses that cause severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). This is the most rapid development of a vaccine ready for testing in history.

As of noon 03/16/20, France has not reported updated disease numbers. The growth rate seems to be slowing a bit in Italy (to just over 11% per day), but Austria, Belgium, Germany, Spain, and the Netherlands continue to report between 15 and 20% increase in total cases per day. There now also appears to be person-to-person spread in tropical climates, so it may be less likely that warm temperatures will slow this disease. This remains unclear at present however. 

There have been social media posts recommending that patients stop certain types of blood pressure medications because of increased risk with COVID-19. There is NO evidence to support changing blood pressure medication at this time. Of course, if that changes, we will contact affected patients immediately.

(updated 03/15/20): There is now grave concern regarding the Italian national health system’s capacity to effectively respond care for patients with COVID-19 pneumonia. Italy now has 350 cases per million residents (and growing at about 15% every day). If this trend continues for three more days (updated math from linked article and latest number of cases), total cases will exceed 30,000 and intensive care units will be at maximum capacity. On 03/15/20, Italy reported an additional 3,590 cases (continuing the 15% per day trend).

Spain has followed Italy’s lead in national lockdown. Travel restrictions have been extended to include the UK and Northern Ireland.

(posted 03/14/20): Looking at European countries with more than 500 total cases (Italy, Spain, Germany, Switzerland, the UK, Norway, Sweden, the Netherlands, Denmark, Belgium, Austria, and excluding France where reports have not been updated) there are a total of about 39,000 cases with 6,050 new cases overnight (a growth rate of just over 15% per day). If this continues, the number of cases will double every 4.5 days and Italy will not be the only country where healthcare systems are overwhelmed.

(posted 03/14/20): The corresponding data for the United States suggests a 7 day doubling time (with 2,500 cases and 250 new cases overnight), but widespread testing has not yet started and it is too early to project the growth rate in this country. 

On 03/13/20, Louisiana has postponed its presidential primary. President Trump has declared a national emergency to allow an increase in feveral aid for all states under the Stafford Act. The Dallas Zoo has closed for at least one week and Dallas County has banned gatherings of more than 500 people and discouraged even smaller gatherings. There are now five confirmed cases of COVID-19 in Collin County, 13 in North Texas and 49 in the State. These numbers will certainly grow rapidly.

On 03/13/20, the FDA granted emergency clearance for Roche Holdings’ 2019-CoV test. This should allow testing in laboratories equipped with Roche machines (about 100 across the country).

CDC has published a very detailed Community Mitigation Strategy Guide, definitely recommended reading for all.

Additional details are now available about the relationship between age, underlying conditions and mortality. While only 4.7% of patients developed “severe” disease, the mortality in this group was 49%. Though based on much less robust data, mortality rates by age appear to be similar in the United States and South Korea.

Age           Case fatality rate (%)             Underlying disease            Case fatality rate (%)

00 - 09                  0.0                            Hypertension                               6.0
10 - 19                  0.2                            Diabetes                                     7.3
20 - 29                  0.2                            Cardiovascular disease                10.5
30 - 39                  0.2                            Chronic respiratory disease           6.3
40 - 49                  0.4                            Cancer (any)                               5.6
50 - 59                  1.3                  
60 - 69                  3.6
70 - 79                  8.0
80+                     14.8

Influenza mortality by age is much lower (for ages 0 - 17, 18 - 49, 50 - 64 and 65 and older the case fatality rates are 0.01, 0.02, 0.06 and 0.83% respectively).

We know the primary symptoms of COVID-19 are fever, fatigue and cough. Unfortunately, these are also common with influenza and other respiratory viruses.

Fever: 98.6%.                      Fatigue: 69.6%.    Cough: 59.4%.    Aches: 34.8%
Difficulty breathing: 31.2%    Nausea: 10.1%.    Diarrhea: 10.1%
Headache: 6.5%                   Vomiting: 3.6%

On 03/12/20, Princess Cruises announced a two month “pause” in operations. We anticipate additional similar steps by other cruise lines. Kuwait has suspended all commercial flights from 03/13/20.

As of 03/12/20, the CDC reports widespread sustained transmission of COVID-19 in Europe, classifies risk of travel as “Level 3” and recommends against travel. For any Americans who are in these countries, or have recently visited, self-quarantine for 14 days is recommended. 

The US State Department has issued a similar global advisory. "The Department of State advises U.S. citizens to reconsider travel abroad due to the global impact of COVID-19. Many areas throughout the world are now experiencing COVID-19 outbreaks and taking action that may limit traveler mobility, including quarantines and border restrictions. Even countries, jurisdictions, or areas where cases have not been reported may restrict travel without notice."

On the evening of 03/11/20, the National Basketball Association (NBA) season was suspended indefinitely after a dramatic incident in which two teams were pulled off the court seconds before a game began and a player for the Utah Jazz tested positive for the coronavirus. The Trump Administration announced that the April 15th tax filing deadline will likely be delayed, and that restrictions on passengers entering the United States from Europe will begin later this week.

On 03/11/20, the World Health Organization (WHO) designated COVID-19 as pandemic, the first ever caused by a coronavirus. In a rather ominous note, they add, “we have never before seen a pandemic that can be controlled…” Let’s hope this is the first.

On 03/11/20, USA Today reported that individuals who break quarantine in the United States could be detained. This opinion appears to be correct, as "The federal government derives its authority for isolation and quarantine from the Commerce Clause of the U.S. Constitution. Under section 361 of the Public Health Service Act (42 U.S. Code § 264), the U.S. Secretary of Health and Human Services is authorized to take measures to prevent the entry and spread of communicable diseases from foreign countries into the United States and between states.The authority for carrying out these functions on a daily basis has been delegated to the Centers for Disease Control and Prevention (CDC).”

On 03/10/20, CDC published a Mitigation Strategy policy document describing various community responses to local COVID-19 transmission. This is worth reading for leaders of businesses and households as it provides a comprehension list of strategies for each phase of spreading disease.

On 03/10/20, an article in the Annals of Internal Medicine supported 14 days as the appropriate quarantine duration.

On 03/10/20, the American Medical Association (AMA) added its contribution to the managment of COVID-19 by fast-tracking the approval of a unique billing code for testing. Yep, really, that’s the what we got from the best and brightest today. Not science, a rush to get a billing code ready.

On 03/10/20, the Centers for Medicare & Medicaid Services (CMS) did something useful for a change. In the memorandum issued, CMS outlines the flexibilities MA and Part D plans have to waive certain requirements to help prevent the spread of COVID-19. These flexibilities include:

  • Waiving patient copayment for COVID-19 treatments in doctors' offices or emergency rooms and services delivered via telehealth as well as for COVID-19 testing
  • Waiving prescription refill limits (to allow patients and physicians to prepare for possible drug shortages, quarantine or restricted travel)
  • Relaxing restrictions on home or mail delivery of prescription drugs

Additional Resources:

An excellent article by Tomas Pueyo which reviews the epidemiology of COVID-19 and lists measures to take to prevent spread.

CDC has published a very detailed Community Mitigation Strategy Guide, definitely recommended reading for all.

Select this link for CDC information about hand washing. We are particularly fond of the Show Me the Science section of course.

Select this link for information regarding environmental cleaning and disinfection.

Select this link for additional precautions for patients at increased risk.

Select this link for information about caring for suspected or confirmed cases where hospitalization is not required.

Select this link for a map (updated nightly) with case distribution data.

The latest  from the Centers for Disease Control and Prevention (CDC) follows. This page is updated every few days and provides excellent summary and detailed information for both prevention and management of COVID-19.

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