COVID-360º: Vaccines, Testing, and Management

COVID-360º: Vaccines, Testing, and Management

COVID-360º: Vaccines, Testing, and Management 1200 1200 nodMD

Full Event Transcript

 

Dustin Hoyman:

Hello everybody my name is Dustin Hoyman. Thank you so much for joining us on this Tuesday afternoon. We’re really excited to share some really great content with you. But before we get started I want to make sure that everyone can hear me okay, so go ahead and click in the chat button and go ahead and type in your favorite cookie in the button just to let me know that you can actually hear us okay, you can see us okay. 

We’ve got a lot of content and it’s gonna be coming at you pretty quick, so hopefully everyone can hear. So go ahead and just type, type something down to that chat if you can hear and if you can see and everything is good to go. So I haven’t seen anybody just put in the chat so far. Let’s see if we can get some messages in here. 

Perfect, great! Now we are good to go so everything is live, everything is good, so we’re going to go ahead and get started. Perfect, thanks. Now we got some people coming through. Alright so I’m going to run through today’s format for you. We’ve got three different speakers that are talking over one hour, so it’s going to be super fast paced, but don’t worry we’re going to have the recordings and the slides available immediately after this, so as soon as the event is done you’ll get an email with all of those for you. If you have any questions go ahead and keep them to the very end, like I said this can be very past, i’m sorry very fast, so we want to make sure that all the speakers have time to talk and really have a good chance to give you the good information they’ve had. They’ve been preparing for a really long time so it’s really important, so keep those questions towards the end, go ahead and drop them in that chat button or the questions and there’s, we’ve got that section as well. So our speakers today are: Dr. Patterson, Dr. Murthy and Emily Schmitz, and without further ado I’m going to go ahead and start with Dr. Patterson. Dr. Patterson take it away.

Dr. Patterson:

Thanks Dustin. So I wanted to spend a few minutes, actually 15 talking, about making sense of the COVID-19 test, because there’s a fair amount of confusion about them, especially the new player on the block, the antigen test. So, let’s do the PCR test first, it’s the commonest one, the one of those everybody, everybody knows about.

PCR is short for polymerase chain reaction. It’s basically looking at the virus genetic signature and that the RNA it’s an RNA virus, and the PCR looks for the couple of genes on the RNA and it detects very small amounts of that and then amplifies it with the gene called polymerase, so a hundred thousands and thousands of times, so you get a signal that can be read on a colorimeter or something else. So, the PCR detects the presence of the virus, it’s a test for current COVID-19 and infection and it uses a clinical specimen, these are a nasopharyngeal swab, or a saliva sample, or a nasal swab which is about halfway back people who have had the nasopharyngeal swab tell me it feels like a brain biopsy. So, what does a positive test result mean? It’s understood to mean that you have active COVID-19 infection. So how fast and how accurate is the PCR? Well the test itself takes about two hours and the turnaround time in the lab run at ASU is about 24 to 36 hours. But it’s one of the issues about the PCR test has been done by other facilities is the turnaround time can be prolonged. A lab in Arizona had 50,000 of them backed up just a few weeks ago, so it’s considered the most reliable test and it detects very small amounts of virus in a 0.1 ml and you just need to know that an infected person usually has millions more virus particles than that next.

So let’s talk about the antibody test, the COVID antibody or antibodies arise in a response to an acute infection, so the antibody test identifies people who have had Coronavirus infection and it indicates some degree of immunity. It’s main value is in population surveys. There was a big survey done here in Arizona recently, a zero survey, we haven’t got the results yet, but I would expect that the prevalence of zero positivity is going to be way down around 1% or 2% no higher than that. So how the antibody test works it’s different than a PCR test or an antigen test, it actually uses a blood sample, so you have to have a finger prick or a venipuncture and it looks for the immunoglobulins classical serology test, so a positive result means that you had a past infection or you could have recent infections some weeks after the infection has occurred. So how fast is it? Well an immunoassay takes a few hours, but the turnaround time generally is a few days and it’s not an urgent situation because you’re doing prevalent surveys for population rather than for diagnosis of disease. 

So let’s move on to the newcomer on the block the COVID-19 antigen test. So what that antigen test does is identifies people who are currently infected and who are communicable, they have high enough virus titers that they’re going to be giving it away to somebody else if they’re close to them. So it’s used to rapidly screen at risk patients or front line workers in hospital. So how it works is, you take a clinical sample like a nasal swab or saliva, and it looks for the service protein, the outside coat of the virus, there’s a spike protein there and it measures the antigen, one of the antigen components of that it’s kind of like a doctor’s office strep test in a way. So what does a positive antigen test mean? A positive antigen test means that you’re communicable, and you have an act of Coronavirus infection. The big advantage of the antigen test of course is it’s fast, you get an answer in 15 minutes and it’s only slightly less sensitive than a PCR test.

So this is just a table which summarizes the three tests that I’ve talked about: the PCR test is a test for the virus gene. The antigen test tests for the virus code protein, so both of those tests are used to diagnose current infection. And the serology measures the antibodies to the virus and it is used for population surveys.

So here are some little known secrets of coronavirus testing. The first is that the PCR test is very, very sensitive, it detects really tiny amounts of the virus, a hundred or so virus particles in a tenth of an ml and the thing that’s not appreciated all the time is that it can stay positive for weeks. I just finished a rotation at our ASU lab where we signed out about 20,000 samples last week and I’ve noticed a lot of patients stay positive for four or five week., I saw one of a month ago that was positive for six weeks but that’s well beyond the infectious period, which will be over in about 10 to 14 days. So the antigen test then is only slightly less sensitive than the PCR, and a very well known infectious disease consultant in Florida says that the tests are really be caught called the communicable COVID-19 test because you need a high enough virus titer to be communicative and then, but you’re going to give it away. So it seems to me it would be a great test to if you need an objective test after the quarantine per period is over and you want to know whether somebody can return to work, it seems to me that the antigen test would be ideal here because if you’re antigen negative you’re non-communicable and you can go back to work that’s the idea of that anyway.

So there have been discordances between the antigen and the PCR and that’s been troublesome to people who have used both. We’ll talk about the kind of discordances, the first is where the antigen is positive but the PCR is negative and this has been troublesome in institutions who’ve tried the Sofia, the quidel Sophia test. Some of those turn out to be that way and the first person historically that was called an intention of that was governor Dewine, in Ohio, who before he saw president Trump at the White House had an antigen test, which was positive and they said okay governor you can’t go in to see the president. Then he went home and had a PCR test and it was negative. And there has to be a biological reason why that is the case and really it’s unclear right now what the precise meaning of a positive antigen in the PCR negative situation is. Now the reverse discordance is where the antigen is positive and you do a confirmatory and the PCR is positive, so what does that mean? It indicates, in my view, that you had a recent COVID-19 infection, but you are no longer, you are not communicable, so you could discontinue quarantine. My colleague, Dr. David Harris, in the lab at UFA in Tucson does the antigen test for the university there, and he’s done that figure is a typo, it should say he’s done more than a hundred thousand of them to date and it’s the main carrier, a main test that they use at the university of Arizona in Tucson, they do antigen tests on their athletes, their students, and anybody they suspect of having a COVID-19, and he did a series of 300 EER and ICU cases and did both, the antigen and the PCR test and his view, this is unpublished material, but he, as a result said that the positive predictive value for the antigen test was 96%. The interesting thing that he found, because his laboratory can do virus cultures as well, be in a research laboratory and in those cases that were antigen negative but PCR positive, they could not grow the virus. So that’s a very interesting piece of information and it suggests that a positive PCR test may not only be due to live virus, but could be due to dead virus or portions of the genetic material and when you think about it that does make sense because we hope it does. It does make sense, because we heat inactivate the virus when we’re doing the PCR test, in other words we take the live virus and we kill it and then we do the test and it works just fine, so it doesn’t only depend on the virus.

So the newcomer, the new kid on the block is the card test, an antigen card test, called Binax now and Abbott is the company that makes it and the federal government bought up 150 million of them, which is entire, the entire Abbott manufacturing capability for about three months and the federal government’s been distributing it to skilled nursing facilities and assisted living. But to be honest I haven’t talked to anyone yet who’s actually gotten and used some experience. I was on a webinar about a month ago and there were people in the midwest who have used it and spoke very highly of it, So it’s just like a pregnancy test, a card test and you read it visually at 15 minutes and it has a, you can see the picture there’s two bars, two blue bars there, next to a QR code, and there’s a control bar there that needs to be moved from blue to pink, while when the test is done so it’s very easy to read.

So, that’s pretty much the three tests for COVID-19, the antigen test I think is under appreciated and will come into its own in the next little while in this pandemic. So I wanted to transition to Dr. Murthy with a slide here about testing in response to a case, this is not news to anybody on this call, if you have a resident or a patient patient-facing staff member, who is symptomatic or is involved in surveillance testing, there’s a protocol that we all are prescribed to follow by the state and by the federal government and your repeat test on everybody that’s negative and still exposed and you either test them every three days or twice a week depending on the prevalence in the community around you, I’m sure you’ve all had that experience one way or the other. So I’m going to throw the ball to Dr. Murthy, take it away.

Dr. Murthy:

Thank you Dr. Patterson. Alright so I’m going to continue on the excellent  information provided by Dr. Patterson. So how do we build on those, that information? Particularly we now have those testing tools available, an antigen test. I totally agree with what Dr. Patterson outlined. I think it’s a valuable tool that could be used at the point of care, particularly screening, particularly our healthcare workers and also patients whom we suspect to be having high clinical suspicion with symptoms. With the PCR, which may take sometimes more than 12 hours after 24 hours, that antigen test definitely has a big role now, in able to kind of identify those high-risk patients and put them in proper isolation precautions. So with that, my focus has been to work with the facilities and also give the guidance, how do you define an outbreak? And then how do we leverage the testing information to minimize the outbreak? Make sure we establish the parameters, control that outbreak, and make sure we keep the patients or the residents safe. So I just want to introduce some of the definitions, when I say PAC setting, Post Acute Care setting, I’m including: skilled nursing, long term care, assisted living, and also of course long-term acquitted care centers. So the definition for an outbreak is basically: any positive lab test, again, it could be either a PCR or antigen test, in a resident of the facility or a healthcare worker. Or if the test is not available, two or more patients or residents, or healthcare workers with nuanced symptoms, the symptoms as you know have been much more broader now. Initially we had those respiratory symptoms listed as: cough, shortness of breath, fever, sore throat. Now we have expanded symptoms, now it includes: gi symptoms, now we have headache, in fact fatigue and myalgias are also part of the expanded symptoms, so in in this situation, the identification of symptoms and, this is the key word, there 72 hours of each, other that qualifies for the definition of outbreak in the facility.

How about in a hospital setting, in Acute Care settings? Because this is a different demographics, different set of patient care, so here it is defined as two or more patients, again a positive test, PCR or antigen, and here’s the biggest thing, patients who have been admitted for a non-COVID condition, and seven or more days later. So that’s one of the first definitions, or patients who are from different household, that means not having any close contact, and I just want to outline the definition of close contact, it means: less than six feet or two meters with a patient who is positive for COVID, and the contact is more than 15 minutes. So that is the definition for a closed contact. So sometimes you may not have a mixture of this criteria. You may have a positive test, or a person who has a high risk symptoms, but be in contact with the suspected COVID,  so you see that the definition a little bit kind of in available gray area but at least it established just a guideline, how do you define the outbreak in this acute care setting.

Now once we identify the outbreak? And now I’m going to generalize whether it’s in an Acute Care setting or in a Post-Acute Care setting, the key thing is, what? Action. What are the interventions? How do we make sure these interventions are effective? How do we make sure we protect our residents, our patients? So one of the things that’s been outlined, is all about communication, many of you are in the healthcare setting, or have hands-on approach with this management, there is on top of all the testing that’s available not establishing those protocols, not communicating with the stakeholders definitely would not help us succeed so the key thing is the communication. How does communication happen? I think one of the first things is having a robust policy set up right, you know? We have so many resources right now, but obviously we rely on the CDC guidelines, we rely on our local health department and county guidance, so those are the very important tools, to have those updated policies set up, then communication. Those policies should be available to all our healthcare personal, staffing and of course, be able to implement to the patients who are exposed or suspected to have COVID.

The second piece is protection. Particularly the staffing, and I’m sure you come across the scenarios where in the facilities one of the staff has higher symptoms or suspected trees, and there’s a crossover between patients in, let’s say a skills setting and also in the long term setting, what happens is with an inability to control that staffing part, there is definitely a potential for an outbreak. How do we make sure our staff are well protected? Screening, as Dr. Patterson mentioned, we now have more tools, we have more testing tools now, which will help define the test results in a much faster way, so anytime you suspect staffing or the patient with symptoms, screening should be instituted right away. The number two: personal protective equipment. This is again a very important part of it, we all gone through the process of shortage of PPES and everything now with we’re in a situation where we are seeing those searches and I still think one of the most important thing is appropriate, utilization, education and making sure these are followed by everybody, every stakeholder in the facility. And the third thing is: education. Education, education, particularly recognizing the symptoms and the number two, when do we initiate those testing for the high-risk patients.

One of the biggest things is how do we protect the patient? When do we initiate the transmission based precautions? This is something I really am passionate about as an infectious disease physician, you know? We get so many calls actually and there’s so much grade and some confusion. When do we institute transmission based precautions? And, when do we discontinue the isolation? This confusion sometimes can lead to those outbreaks and that’s where we talk about, what is an appropriate intervention? I think consistent implementation of those isolation precautions is a key thing, and then being prepared. As I mentioned CDC local health department, we have those resources kind of falling back on those resources tapping into the guidelines, talking to the infectious disease experts can definitely help the facilities and the stakeholders being prepared to control any outbreak of COVID-19.

So when do we define an end of an outbreak? Again, this is definitely a little bit of a gray area, and this is some of the definition I have found, but again, it has to go facility by facility based on the risk population. So I, at a minimum 28 days off from the last documented symptoms or a last positive test in an asymptomatic person. So this is one of the kinds of criteria to define the end of an outbreak. Again, you want to be on the side of caution, that means the longer the better. The reason is the fluctuation or the chance of another outbreak.

So this is something I’m going to spend a couple of minutes on, the transmission based precautions, and I definitely love to get some questions and feedback. The definition is clear cut, but it’s the application that’s been challenging. So what I’ve done is I kind of put this together in a different categories, very easy to follow, we used to have a test-based strategy for discontinuation of the isolation, CDC now recommends not to be the first line, so right now the focus has been on the symptom-based strategy. So what does it mean? So, we’re going to define a patient based on the illness, a mild to moderate illness and clearly not an immunocompromised patient. So this is the criteria for this patient, the guidelines recommend: 10 days from the symptom onset and at least 24 hours of antipyretics and without using any antibiotics, that’s very important, and again the other, the third component is of course: symptom improvement. Particularly like, as I mentioned earlier, those broad-based respiratory symptoms, are GI symptoms. 

This is one of the challenging situations. This is the patient population who are severe to critically ill. So, what is severe to critically ill? I’m going to outline some of the criteria. So this is the patient population who are requiring oxygen support, so there are three different things I can define. One of them is: patients who have oxygen saturation less than 94%, one. Number two: respiratory rate more than 30 per minute. Number three: you do a chest x-ray, you see infiltrates more than 50% on the imaging bilateral or united interstitial infiltrates. These things qualify for the severity of the illness, patient illness. What is critical illness? Critical illness includes patients who go into septic shock, who develop multi-organ failure so those are considered critically ill patients, and severe immuno compromise. So this has been evolving now, who is which? Which patients are considered immunocompromised? And particularly the right word is severely immunocompromised. What it means is that we used to classify diabetes or also like a chronic kidney disease as immunocompromised, but now the revised guidelines recommend patients who are transplant, immunosuppressive medications, chronic steroids more than 15 to 20 milligrams per day for over 30 days. So those are the criteria that meets the immunocompromised status. So what the guidelines say? 10 days and up to 20 days. You see the difference from the mild to moderate illness, to the severe and immunocompromised patients? The duration is definitely much longer, up to 20 days. In some cases we come across where we keep the patient beyond 20 days, the reason is they fall into a much higher category, so we have to sometimes go case by case as well. And the number two is of course, making sure the patient is afebrile for 24 hours, without using any of those fewer subconscious medications, and of course the last thing is symptom improvement. So if you see the common theme is: clinical judgment. To me, that’s as an infectious disease specialist, we always approach case by case, categorize the patient based on the risk factors and then make a determination when can we stop the transmission based precautions.

This is another gray area, right? These are the patients who are not confirmed actually, so although the two scenarios I described earlier are clearly the patients with positive testing, these are the cases where you suspect, and how do we approach it? Always rule it out. You know as Dr.  Patterson mentioned, molecular essay. We do not use antibodies in this setting, we tend to use either a PCR study or of course the antigen test. The number two in case of high clinical suspicion, we always recommend implementing the isolation precautions. The reason is one again, protect the patient, protect the staff, minimize any outbreak. And one of the things is, if testing is not available or testing has not been done, so what do you use? You can use the symptom-based strategy, as I outlined earlier, the 10 days and no fever for 24 hours and symptom improvement. and the last thing, I want to repeat this clinical judgment and level of suspicion guides your transmission based precautions in the suspected cases. Thank you.

Emily Schmitz:

Thanks Dr. Murthy. So I’m going to talk briefly about medication management during a COVID pandemic,, the couple of them, the biggest questions that we get is, what I wanted to cover de-prescribing and medication adjustments. We primarily focus on these, because we want to decrease risk of transmission to our communities and our facilities, and that’s one of the ways that we do it. We also get a lot of questions related to anticoagulation therapy in patients with COVID and then I’m going to give just a really brief update on vaccines as well. So deep prescribing has become a real buzzword in the pharmacy world, especially in our long-term care facility, facilities, and as consultant pharmacists we’re always trying to decrease medications anyway. But at this point in time with COVID, it’s even more important for us, because we want to decrease risk of transmission to health care workers and also it decreases nursing time, and we’ve had so much shortage in staffing, that decreasing our med passes is also helpful for nursing. So as we look at the potential to discontinue medications, the first thing that we do is try and look at medications that may be considered of minimal benefit or unnecessary. It’s easy to look at things like iron, vitamins, herbal supplements, docusate, we also look at proton pump inhibitors, antihistamines. For iron there’s studies that suggest we can go down to every other day dosing if we’re unable to discontinue iron all together. With vitamins we primarily are looking at discontinuing things like multivitamins, some of the B vitamins, sometimes probiotics are appropriate for us to discontinue as well, and as we look at life expectancy of patients, sometimes it’s appropriate for us to look at long-term preventative medications as well, like statins, sometimes even aspirin, depending on our goals for the patient and their life expectancy. It’s sometimes appropriate for us to discontinue those medications, and then we’re also looking at temporarily discontinuing some medications like calcium, magnesium, sometimes B12, there are cases where we will hold those, especially in active cases of COVID, where we’re trying to decrease medications overall. 

So, we are trying to optimize medications, but also reduce the frequency of monitoring, so when we’re looking at frequency of monitoring in stable patients we’re trying to decrease Accutex and sliding scale insulin, decreasing blood pressure monitoring when they’re stable and also decreasing lab draws, and reducing frequency of labs. Our overall goal has been to try to get our medications to med passes to twice a day if possible, so we’re trying to change short acting drugs to long-acting formulations, especially when it comes to diabetes medication or blood pressure medications, many times that’s possible, we can also sometimes do that with Namenda, changing from the regular release to the long acting Rx formulation. We’re not typically doing this with pain medications as we are continuing to try and continue short term, short acting medications for pain, but in other medications we definitely are trying to go to long acting or decreasing from three times a day to two times a day dosing. This is often possible with medications like Gabapentin, or twice daily dosing, maybe with PPIS and other medications as well. So we’re trying to consolidate our administration times and timing of doses of medications so our real goal, again like I said is if we can get to twice a day overall, that’s best case scenario and for that we are sometimes temporarily changing dosing times for statins Levothyroxine things that are typically giving given at certain times, or changing from Q12 to BID, which gives us a little bit more flexibility in dosing times. And then reducing the risk of transmission, one of the big questions we get is about nebulizers. We do recommend when possible to switch to handheld inhalers with a spacer, that’s not always a good option in our patient population and the medications aren’t always available, but when they are, there does seem to be some support that MDI multi-dose inhalers are less likely to cause transmission than nebulizers because of the aerosol aerosolization. And then with acetaminophen, we are trying to change scheduled acetaminophens when appropriate to PRN, and this is because we don’t want to mask a fever when we’re doing fever surveillance in our COVID populations or in patients that are potentially exposed to COVID, and again as we already discussed, decreasing unnecessary monitoring and the frequency of monitoring with blood pressures, science scale insulins or accu checks, and labs as well.

So another question that we frequently get is about anticoagulation in patients with COVID. There is no consensus on treatment for clotting disorders with COVID, we are aware that it is a major risk factor for patients with COVID and we are currently trying to follow AMDA, The American Medical Directors Association. They’ve put out this interim guidance, they have a risk tool, for who’s at low risk and high risk for clotting and we’re using that tool then to determine therapy and when to provide therapy. So with patients, especially this is for long-term care specific residents or post-acute residents with mild to moderate disease, that’s with mild to moderate COVID symptoms that are being treated in place, if they’re already on antithrombotic therapy they’ll be continued and then we’ll consider starting anticoagulation if they’re high risk, and if they are high risk, then we’re treating for up to 45 days. If they have severe disease and their palliative treatment and we’re treating in place, then anticoagulation is not recommended. However, if they’re opting not to have palliative treatment, then if they have severe disease, likely they’d be transferred to the hospital. If they come to you, and this is what we see most frequently is patients discharged to our post-acute or long-term care setting, after hospitalization with moderate to severe COVID, then typically if they’re getting prophylactic anticoagulation, if they’re high risk that’ll be up to 45 days at low risk, we’re seeing shorter durations 10 to 14 days sometimes, it just depends on the risk of clotting. If they’re getting a therapeutic dose of anticoagulant, so they’re getting usually Lovenox or Eliquis or Xarelto at treatment doses because they actually had a clot or because they have D dimer levels that are more than six times normal, then they should be treated for at least three months of anticoagulation. And then the other question that we frequently get is that patients come to us on Lovenox and whether or not we can switch them to oral anticoagulation, and there is support to do that, so typically a prophylactic dose for Lovinox is going to be 40 milligrams, daily if we’re switching over oral anticoagulation, usually we are using eliquis elliquist 2.5 milligrams bid twice a day, or Xarelto 10 milligrams daily.

And last, I just wanted to briefly touch on vaccines. I know as most of you are aware that our long-term care facilities and post-acute facilities will be prioritized to receive the vaccinations when they come in, the CDC has partnered with CVS and Walgreens to offer these vaccinations on site. It is possible to get these vaccinations from your pharmacy, but I’m not aware, at least in the state of Arizona, of any pharmacies that will actually be providing the vaccinations. This is because the vaccines are going to be coming in doses of a thousand and they require ultra low temp fridges for storage, there’s other logistical and documentation issues, So at this point we’re recommending for our facilities anyway, that they do sign up for the vaccines to be provided to them through CVS or Walgreens. There is the site right there to register for that. The registration needs to be done by november 6th, in order for that to happen the vaccinations will be provided at no cost to facilities and available to employees and residents as well. They will be provided on site and we are not sure at this time, but there is a possibility that there’s going to require two doses. It depends on which vaccine actually comes to market. At this point, optimistically, I think that the beginning of the year would be when we’re expecting to start seeing our first vaccinations available, we’ll see what happens, it may be optimistic but. That’s all I have, so with that I will turn it over to Dustin for questions.

Dustin Hoyman:

Thank you so much, I really appreciate it. So, there’s a lot of information that was covered there. Thank you so much we did get a question that came in during Dr. P, during your presentation there, I’ll go ahead and start with, so that way it gives time to people to start entering their questions. And this is from Matt just from ABX tracker, he asked: you know there’s so many different types of Coronavirus, how can we be sure the positive cases are indicative of the virulent viruses that cause COVID-19 illness? And then you know, what are some of the positives of catching past or almost not effective forms of Coronavirus?

Dr. Patterson:

Well it’s a great question Matt. So let me answer the second question first: of course I’ve made the point that the PCR test can detect, not actually infectious forms of virus positivity, so this is one of the limitations of just becoming more and more appreciated that it is one of the limitations of PCR by itself. Now with regard to the different types of Coronaviruses true, now we know a lot more about Coronaviruses than we did five years ago and there are there some common cold is due to various Coronaviruses, if you actually but the PCR test is very specific and it’s been tested before certification that it does not cross-react with any of the other Coronaviruses. So you can be comfortable that if the PCR is positive you’re measuring the SARS-COV-2 virus, the virus associated with COVID-19, as to what it actually means in the usual case, it means that you have active disease, but this is where I think the antigen is about to come into its own in the next little while.

Dustin Hoyman:

Perfect, thank you for that. I appreciate it. Does anybody else have any other questions? Or Dr. Murthy, Dr. Schmitz, any of you have any additional things to ask each other? Since you’re here.

Dr. Murthy:

I just want to make a quick comment on Emily’s anticoagulation. That’s one of the biggest kind of risk factors, particularly with the fatalities, right? There are so many cardiac complications that start happening as is outlined, in particular in those of the severe, higher severity or critically ill patients, so the question to Emily is: Is there any indication for a full dose treatment, anticoagulation wise of course? And the duration, should we go beyond those sometimes 45 days up to 3 months? Is there any other kind of new research that’s coming along that will help us minimize those like micro thrombus, right? Or those cardiac complications?

Emily Schmitz:

Right, I think the jury is still out on that, I think it’s probably wise to err on the side of caution right and it also depends on conversations with families and what the goals are, or what our prognosis is for the patient. But definitely, we are seeing people left on them longer term than 45 days just for prophylaxis, as if they’re at high risk, it’s just hard we’re so new in this still we don’t have a lot of long-term study on it. So, what do you, what are you seeing?

Dr. Murthy:

We actually, the way we operate is mostly as I said, by clinical scenarios and case by case, so you have to do a stratification, and make sure we kind of count those underlying risk factors, particularly with patients who have established cardiac disease. And also who particularly now, there are some patients who are on anticoagulation, let’s say with chronic atrial fibrillation, is that anticoagulation adequate? You do we need to do something, so the way our approach has been always hybrid patients case-by-case approach.

Emily Schmitz:

Right. And I would just caution you know, as well as we see more and more people on anticoagulants, we deal with so many issues with drug interactions, issues with side effects, potential for bleeding. So I would just encourage everyone to make sure that you’re utilizing your pharmacist to evaluate those risks with your team, because we’re definitely increasing. We definitely are seeing a lot more people on anticoagulants at this point, and we already know that our patients are at high risk, not only for clotting but for bleeding.

Dr. Patterson:

Yeah, exactly. I just saw a paper, this morning actually, where the people that have heart problems, as a result of COVID-19, and we think it’s quote myocarditis, which if you look at a hearted autopsy you’ll see lymphocytes infiltrating the the muscle cells, but actually what’s been shown by a carefully done series of autopsies on those patients is that it’s the virus actually involves the endothelial cells of all blood vessels, so if you like it’s widespread endotheliitis that causes symptoms to show up in all the places that we notice that it is. And i guess I’m kind of a fan of  stepping on the gas early in that regard. It’s kind of like oxygen, when they’re starting to get short of breath, it goes fast, they get into trouble with their lungs and getting them on oxygen is really important. I’m kind of making an argument that maybe the same thing might be true of a decision to anticoagulate. Anyway that’s my sense.

Emily Schmitz:

I think interestingly too, I’ve seen in a few of our patients now new onset of afib post COVID, I’ve had at least three patients now with that, so I think there’s a lot more to the cardiovascular side of this that needs to be looked at, once they’re over the acute infection.

Dr. Patterson:

Endothelias of the conduction system.

Dustin Hoyman:

Perfect. So we got another question from Roland Salinas, he asked: what is causing the false positives in PCR? Can you talk about false positives really quickly.

Dr. Patterson:

Well it’s a relative term I mean, if if you get a positive PCR it means you’ve got fragments of the virus or live virus, and so I think the the usual cause for that is you see it’s on the backside of an infection where you see a rise in tighter of the virus and on the back side it goes away kind of slowly often,, it doesn’t go away in a week or ten days it goes away in two weeks or three weeks and during that period if you happen to see the patient you can think of it as a false positive, it causes some confusion. I hope that’s an answer to Roland’s question. ask another maybe.

Dustin Hoyman: 

Sure. We still have a lot of people on the webinar, so feel free to ask questions and of course I see a lot of people from both the skilled nursing as well as assisted living facilities, so quick shout out to Angels of Colorado, we’ve got Aspen in here. Any of you have questions for you to hop in we’ve got a lot of brain power, so feel free to use it.

We did get a comment again from Matt just. He wanted to say, as people from skilled nursing and assisted living facilities urged to lean on your consulting pharmacist, so Emily I know that that’s probably your realm of things, so I just wanted to say that there’s people out there that support you and the consulting pharmacist there you’ve offered a lot of benefit.

Emily Schmitz:

Thanks. Thank you. Yeah it has been really important during this time to try and we are always trying to reduce meds, but during this time especially, it’s been a challenge and an important piece to reducing nursing time and transmission.

Dustin Hoyman:

Yes definitely. We just got another question, how does an assisted living facility obtain the rapid tests? Dr. P, that’s probably a good question for you.

Dr. Patterson:

Yeah. well, of course, I’m part of a mail-less email lists and the if you wanted to order the Binax test or the antigen test from Abbott you couldn’t do it now because the federal government has bought up every, 150 million tests, the production capacity into the new year, so the only way you’re going to get it is to find someone at the state level or the federal level that can answer the question, who’s distributing it here in the state of Arizona? I’ve been trying to find that out for a week, so if you find out you let me know too.

Dustin Hoyman:

Great thank you so much. So because we do have so many people here from skilled nursing assisted living facilities, I know one question that comes up a whole lot is, staff testing strategies and how the staff should be tested in general, you know? In lieu of any sort of rapid test or anything like that, can one of the three of you comment about uh staff testing and just making sure that everyone is covered free as they’re working with patients?

Dr. Murthy:

Yeah sure, I can go fast Dustin. So you know one of the recommendations are the same thing like the goal is to minimize any outbreak and make sure we stick out our patient and of course more importantly, staffing. So the recommendations are in doubt, in fact the guidelines do say testing all the healthcare workers are staffing whenever you have the criteria that meets the the deficient of outbreak. So my short answer is, high risk, when you suspect hey this is not a normal pattern, where there is a new case that’s happening, all the staffing should be offered the testing, the question is what type? And as Dr. Patterson mentioned, we are leaning more towards the antigen test actually and I’ve seen in facilities too, the reason is one of course, the faster reporting of the results has definitely helped streamline those cases and of course number two, availability. So to me antigen test has definitely taken a bigger role in screening all the staffing in the skilled or assisted living or a long-term care facility

Dr. Patterson:

Yeah, the the frequency of testing is also defined by state guidelines, so there’s that and then if you have a COVID unit, like a separate area where you can send positive test patients or symptomatic patients, then the frequency of testing can be done there so you don’t necessarily have to test all of your staff, twice a week for example, you could test the ones that are known contacts and it’s it’s a very interesting problem to try to solve is to get the exposed staff members treating the exposed patients in a separate unit, that would be more or less ideal, but it’s hard to actually make that happen.

Dustin Hoyman:

So just got a question from Becky, she says: did I understand right that you said, if someone has a negative antigen test but a positive PCR test they would not be communicable? And if so, does this symptomatic slash asymptomatic matter, heard that the antigen tests were not as reliable for asymptomatic people?

Dr. Patterson:

Well, of course the test is actually, the antigen test is accredited, or released for symptomatic patients, so it’s kind of the evidence is still growing and my feeling is if you have a negative antigen and a positive PCR they’re non-communicable. Now the state accreditation people have a different view of that, so we’re kind of constrained by the old if you like the old-fashioned, to be funny about it, the old-fashioned view in view of the fast-changing evidence, but to me a negative advantage and a positive PCR is a non-communicable patient or staff member. Stay tuned on that one.

Dr. Murthy:

Right. That’s what I’d like to add quickly, then you can utilize the symptom-based strategy, that’s when you can apply, and then say okay if this patient is asymptomatic or symptomatic, if the patient is symptomatic then you utilize those criteria but watch the symptoms, make sure fever is improved and then 10 days, so that way you’re making sure, even the test maybe there’s some discordance there, you’re kind of taking care of that situation particularly keeping those residents safe. So I would say definitely apply the symptom-based strategy in that situation.

Dr. Patterson:

Yeah it’s the asymptomatic patients that get our, that are our problem, yeah there’s no clean answer yet.

Dustin Hoyman:

Great! It looks like the questions are kind of drying up here, so I would like to go through with each of you and if somebody wants to reach out with you for further information where’s the best place for them to contact you? So, Dr. P I’ll start with you.

Dr. Patterson:

ppatterson5@cox.net is my email address and my cell number is three 928-580-3552 and I take calls 24 hours a day. Isn’t that right Emily?

Emily Schmitz:

Wait, that doesn’t come out right.

Dr. Patterson:

Yeah but it’s if it’s really late a text works just as well.

Dustin Hoyman:

Sure thing. Is it okay if I share with everybody your contact information, your email? When I send out the slides.

Dr. Patterson:

Absolutely, please do.

Dustin Hoyman:

Okay, definitely. And Emily, if somebody has questions for you, how should they reach out to you?

Emily Schmitz:

I’m sure they can email me at erschmitz@srxconsultantgroup.com I will send that to Justin, you can share that and then I can also put it in the chat.

Dustin Hoyman:

Perfect, that’d be great thank you.

Emily Schmitz:

Medication questions please.

Dustin Hoyman:

And then, Dr. Murthy if somebody has a question, how can they reach you?

Dr. Murhty:

So we are part of The Nod, the best thing is our website www.NodSpecialists.com has extensive information, we have blogs, we have nice articles, and the best way to reach me would be our our 24/7 coverage 602-551-8052 and, Justin feel free to share my email it’s mkmurthy@nodmd.com, so preferably phone, text works good, but our site, I just want to direct folks to our www.NodMd.com site again, we will really update the latest trend in terms of topics wise good blogs and lots of educational materials thank you.

Dustin Hoyman:

Great, thank you. So we only have a few minutes left before we are at our time, are there any other points or anything that we should add before we wrap it up?

Dr. Patterson:

Well you know since we got a few minutes, why don’t we do the poll question that I set up there? So yes, you can tell them how to do it.

Dustin Hoyman:

Sure. In the right hand corner of the screen, you should be able to see a poll that Dr. P. was talking about earlier, about the test, you can go ahead and click into that and let them know if they’re using the test there. I actually lost it, I hope everyone can still see it here on that one.

Dr. Patterson:

Yeah, yeah. I’m trying to find out how many people have made the Sofia antigen test work in their surveillance in the way they take care of people. I know it’s not without problems, so I just want to know how many have you know jumped in and got their feet wet with it

Dr. Murthy:

Is it widely used, Dr. Patterson?

Dr. Patterson:

Yeah, I would say it’s pretty widely used, the difference it’s people have been slowed down by this situation where they get a positive antigen and then they do a PCR test, which is kind of the recommendation from some of the authorities, and then the PCR test is negative, so they’re saying well this is how do we interpret that and it is a problem.

Dustin Hoyman:

Perfect, great. Anything else, Emily do you have any other points to make?

Dr. Murthy:

So isolation precautions as I mentioned, that’s one of the biggest challenges we face at the facilities in doubt, I think kind of stratifying those patients right, based on the severity of the illness and making sure that the days symptom-based strategy. I just want to make sure test-based strategy is mostly used for asymptomatic patients where you can count from the day of the testing and there is some serious guidelines where you can, if you want to take the patient off the isolation, you do the two tests, negative tests, but now it’s more of utilizing symptom-based strategy, as a first-line approach to kind of establish a transmission based precaution plan.

Dustin Hoyman:

Great thank you. Mary, yes, this is recorded as soon as this will end, everyone will get an email of the recording and then I’ll send out the slides as well as the contact information for everybody, as well as the risk assessment tool that Emily had mentioned previously. So I’ll make sure that all of that’s wrapped up in a nice little tiny email for everyone who attended or registered the webinar.All right great it looks like that is about it. So like Dr. Murthy said, if there’s any other information that you want to access or anything, you can go to www.nodmd.com there’s a lot of information that’s up there. We’re gonna have future webinars, we’ve got some other resources that we’ll post. So Emily I’ll post your tool up there as well, as the slides and everything here so that way you can find that. So that’ll all be up hopefully by tomorrow and then, thank everyone so much for joining. I really appreciate it. We had a great crowd today and thank you to all our speakers. Thank you all, thank you and thanks all. Bye, bye.