News

CV🦠News – Week of May 18, 2020

Warm greetings, Friends of TVD!

Here is the seventh issue of CV🦠News to hit your email inbox. Time, even “pandemic time”, continues to pass quickly (at least here at The Village Doctor). Again, thank you to all five of our physicians, and also the various contributors to our Hope and Grace page, a collection of works and perspectives gathered from around the world. 

NOTE: CV🦠News is a labor love, both of science and taking care of our community. If you enjoy reading this, please share widely! Was this forwarded to you by a friend? Please subscribe here.

COVID-19 TESTING UPDATE
As of May 21st, patient testing for COVID-19 at Stanford University continues to be available through their Express Care program by appointment or at the Emergency department without an appointment, Appointments for Express Care can be made online through MyHealth or the MyHealth app, or by calling 650-736-5211. Our experience is that you will first get a call back from a nurse who will screen you for your telemedicine video visit with the doctor, who will then schedule you for your drive-by test, which takes only a few minutes. The testing sites are at The Hoover Pavilion and at the Galvez Street location in Palo Alto from 9 a.m. to 6 p.m., seven days a week. Patients with positive results will be called back and care plans established. Negative results can be found online on MyHealth after 24 – 36 hours.

Testing at the Stanford Emergency Department works as a “drive through” with a telemedicine visit. No appointment is needed, however, this is an Emergency Department visit and while there will not be charges related specifically to the testing for COVID-19, hospital charges will be accordingly higher than the other options here. The location is in the parking garage just adjacent to the Emergency Department on Pasteur Drive (the new main hospital at 500 Pasteur Drive). Patients are registered, seen by an RN wearing PPE and then by an MD via telemedicine, for consultation and testing, as appropriate. If testing is done, the results are back within 24 hours (which is faster than most other options).

The County of San Mateo is working with Verily Life Sciences, to test at 3 different sites around the county on different days. Verily is calling this undertaking “Project Baseline” and interested patients can sign up on their website and to schedule an appointment.

Lastly, testing is available through PAMF (Palo Alto Medical Foundation) Urgent Care “drive through”, but only in selected locations (Palo Alto and San Carlos), and only to PAMF patients with an order from their PAMF primary care doctor. Kaiser also has a similar program for their patients. 

**If you get tested through any of the above pathways, please be sure to keep your phone handy and answer unknown numbers to avoid delays in processing and getting your results**

 

DOES VITAMIN D FIGHT COVID19?
Unfortunately vitamin D is probably not going to save you from Coronavirus, although we all wish it was something as simple as that. Vitamin D, which in general is thought of as the vitamin related to bone health, certainly does have effects on the immune system and the body’s response to infection. Vitamin D helps keep mucosal defenses strong and prevent excessive inflammation. Past research has shown that vitamin D supplementation  lowers the likelihood of getting respiratory tract infections, so naturally, scientists have started to investigate if there’s a connection between vitamin D and coronavirus infection and disease severity. While this area is certainly worth researching, most of the existing studies have looked just at associations and correlations, which cannot prove cause and effect. A few studies out of Europe have indicated that low vitamin D levels are associated with more severe disease. The studies used the latitudes of the countries as proxies for vitamin d levels. For example, Spain and Italy have higher rates of vitamin D deficiency and have experienced the highest infection and death rates in Europe, so one study posited that “optimising vitamin D status…will have potential benefits for Covid-19.” A study out of the UK that used previously collected vitamin D data compared to Covid test results, however, said “Our findings do not support a potential link between vitamin D concentrations and risk of COVID-19 infection.” Finally, a study looking at high dose vitamin D supplementation as a potential treatment for critically-ill patients with low vitamin D showed no benefit. 

So for now, rather than ordering a bunch of vitamin D, it’s safest to assume that a number of factors (with complex interactions,) including age, general health, race, access to healthcare and genetic factors, determine the clinical course after exposure to SARS-CoV-2. All that said, taking a daily multivitamin is generally safe for most people (the Recommended Dietary Allowance (RDA) of Vitamin D is 600 IU daily and 800 IU if you are older that 70 years of age), but please keep social distancing, wearing masks and washing your hands as those continue to be proven methods to decrease your risk of getting coronavirus in the first place. You can read more here or here.

WILL THE HEAT OF SUMMER HELP THIS CORONAVIRUS?
As of now, there is little evidence to say that this coronavirus will have lower rates of transmission in warmer months. Scientists at Harvard  have been reviewing the literature on weather patterns and virus transmission. There is hope that perhaps there will be a decrease in summer months as did the Spanish Flu in 1918 however note that the Spanish Flu was an influenza virus and there is research to support the effects of humidity on influenza. There is no such effect on coronavirus known to date.  The good news is that chlorine pools are a safe option while maintaining physical distance, as you can read here. Note also there is a small immune boosting effect of Vitamin D which we know people will get more of by being in the sun, but as the piece above shows, it is unclear if Vitamin D actually helps with COVID19. The relaxing of physical distancing orders might mean more, rather than less, transmission this summer: it is still important to follow all safety measures such physical distancing, and the wearing of masks. Overall, here are some guidelines on how to enjoy your summer safely.

IS A KN95 THE SAME AS AN N95 MASK? CAN I TRUST THEM FROM CHINA?
KN95 respirator masks come in a few more varieties, some of which are not recommended.  For example, some use ear loops to hold them to your face, which just can’t reliably maintain the seal necessary to ensure there is no leakage around the mask.  Is this better than nothing? . . . hmm, maybe for personal use (although there are many domestic alternatives), but certainly not for healthcare workers in a clinical setting.  However, KN95 respirators approved by the National Institute for Occupational Health and Safety (NIOSH) are those with two firm elastic headbands and should deliver a comparable level of safety to N95 masks.   The trick is that many foreign manufacturers of KN95 respirator masks are turning out substandard masks with counterfeit certification marks, manufacturer’s names, logos, and model numbers.  The effort needed to research all of this would require a great need and lack of more trusted alternatives. If you are curious, you can read more about counterfeit respirators at the CDC website here.   

SUMMER VISITORS AND COVID RISK?
Summer is traditionally a time where our college kids come home for a summer job, some home cooked meals, and perhaps clean sheets. Visitors this summer require a whole new conversation about “quarantine”, and whether or not someone can simply come home, or needs to “self quarantine” in their room, or in a tent in the backyard. With the increasing availability of “coronavirus” testing (either for virus directly via PCR nasal swab or for history of exposure by a blood draw for COVID immune response), perhaps these tools can help us make decisions about loved ones and risk.

Note there are risks on both sides of this equation. Is the family at home taking their shelter-in-place very seriously, limiting their trips out of the house and always wearing masks when they do go out? Are there older parents or grandparents in the home who are at higher risk? And then what about the potential visitor? Have they taken shelter-in-place these last weeks seriously? Where are they traveling from? HOW are they getting here, driving by car by themselves (lower risk) versus flying across the country with a couple of stops at different airports (higher risk)?

To help us think about this we recommend dividing the scenarios into three different risk groups:

LOW RISK:
A low risk visitor driving a short distance to stay in a low risk home.

CONSIDER letting the visitor simply move in, no added precautions need to be taken. Their low risk situation simply mixes with the family’s existing low risk situation.

MEDIUM RISK:
A low risk visitor coming to visit a higher risk family (chronically ill or elderly family members at home), or a medium risk visitor (healthy student, but having to fly home) coming to a healthy household (low risk). Or perhaps a visitor who has been a bit casual about their attention to “quarantine” and coming home to a low risk, healthy home.

CONSIDER some amount of self-quarantine before along the visitor to mingle with the family, perhaps 7 days? Note there are challenges here, the biggest being that a sizable percentage of COVID patients never develop symptoms. This is especially true of our younger patients such as our college traveler here. This percentage might be 20% or higher. In patients who develop symptoms, only 50% develop symptoms by day 5 after exposure, 75% by day 7, and finally 97% by day 11. Additionally, even if they are going to develop symptoms, viral shedding happens ~2 days before any of these symptoms show up. You can see how a 7 day self-quarantine is still a bit of a compromise.

HIGH RISK
Examples here are easy: any visitor who has been casual about their quarantine for the previous 14 days coming to visit a high risk family, especially if they are flying home. In this scenario, the traveler should self quarantine for 11 – 14 days.

TESTING?
So what is the role for PCR Nasal Swab testing for coronavirus? We know that COVID patients can shed virus for ~2 days before symptoms, so getting a PCR test for the virus would let you shorten the above suggested self-quarantines by 2 days. Additionally, it would allow you to capture those patients who are never going to develop symptoms, but could develop COVID and be a risk to their family’s household. You can see how easy access to, and rapid turnaround of, testing, is so important.

What about “immunity testing”? Well, here we simply don’t know enough. If your incoming college kid takes the antibodies test and the results are positive for COVID IgG, this would strongly suggest that they have already had COVID-19, and as IgG immunoglobulin levels take at least 14 days to develop they are probably safe to be around. We simply don’t know enough yet to say definitively.

So you can see there are many variables, not the least of which is simply the risk tolerance of the traveler, and more importantly, the traveler’s family household. 14 days of quarantine is safe, but not only hardly perfect (see asymptomatic shedders), but quite impractical. A negative nasal PCR swab would be somewhat reassuring and is a reasonable measure to pursue in either of the Medium Risk or High Risk scenarios described above.


DISPATCH #8: THE GREAT PAUSE
“I am not panicking. I am preparing — preparing for the slog ahead. We now have a much better understanding of where we are, what we are dealing with and what we are up against. Now, it’s just a matter of which will prevail: pragmatism and science or politics. So, what have we learned?

  1. We were not prepared.
  2. We have a neutered public health system.
  3. We have a long way to go.”

Although published last month, this essay by my friend and colleague, Dr. Jordan Shlain, is compelling and information rich. I strongly recommend that you read it here.

HOPE AND GRACE
If you have made it this far, time for a reward, something to lighten your day, and acknowledge the human spirit. Find some escape, or perhaps even inspiration, in this collection of works and perspectives gathered from around the world. Please contact me directly if you have come across something that has lifted your heart today.  Dr. Eric Weiss

“If my words did glow with the gold of sunshine
And my tunes were played on the harp unstrung
Would you hear my voice come through the music
Would you hold it near as it were your own?”

Playing For Change (PFC) is a movement created to inspire and connect the world through music, born from the shared belief that music has the power to break down boundaries and overcome distances between people. PFC is  proud to share with you “Ripple”, this Song Around The World in honor of the Grateful Dead’s 50th anniversary. As Jerry Garcia said, “Let there be songs to fill the air…”

From basketball to breakdancing
Don’t expect typical ballet in Hong Kong Ballet’s 40th season film. The artists of the classical ballet company dance through a basketball court to the tune of Ravel’s “Boléro”, before the shot cuts to city views filmed in Hong Kong. Dressed in neon and pastel colours, the dancers’ movements are sharp and bold. Enjoy!

Travel to Places You Will Never Go
From my good friend, Jamis McNiven, “After shutting down Buck’s Restaurant my wife Margaret and I got down to the serious business of home defense from our redoubt in the Santa Cruz Mountains by making a half dozen stuffed dummies out of our old clothes from the 70s (‘look out, you vicious hoards, we have hippies on guard!’) and lashed them to the parapets of the hastily erected stockade, armed them with wooden muskets, posted the “Danger—rabid dogs with stainless steel teeth” signs (much to the pups amusement as they lolled about drooling and snoring on the couches) and battened down for the eventual zombie apocalypse

We then inventoried our 21 bags of flour and wondered whose job it was to pick up the yeast. In reality we are off the grid as we have been for 43 years. I realized I have been predicting the apocalypse for decades and thank god I’m finally right. Please send me likes. And so, I launch Pacific Voyages which is a series of vignettes about mostly obscure islands of the Pacific which populate this ocean most abundantly. So just sit back and take a break from the end of the world and travel with me to the ends of the world…

*****

Yours, in health and resilience,

Eric and the TVD MD team…