By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

The data on the effectiveness of mindfulness in reducing stress, anxiety, and cravings for controlled substances is strong. Mindfulness is also demonstrated to increase happiness.

In spite of this, many health care professionals and patients have difficulty fully embracing mindfulness as a therapy or practice, long term. Many authors have commented on this, with myriad different explanations and analyses. (For example, this essay contrasts mindfulness with psychotherapy.) Here are some underlying beliefs that may contribute:

1. Mental illness and experiencing stress are signs of personal weakness to be covered-up or suppressed, instead of understood and addressed.
2. The mind and body are separate. Those who strongly believe this cannot believe that trying to use their mind to make their body feel better or function better.
3. Mindfulness takes too much time. Individuals who believe that mindfulness is helpful may conclude that it takes too much time to practice mindfulness regularly. Does one really need to go on a two-week meditation retreat to get into a better state of mind?
4. Mindfulness equals deep breathing and meditation. Is breathing in through the nose and out through the mouth repeatedly always the best way to re-focus the mind?

The Greater Good Science Center at UC Berkeley embraces a broader conceptualization of mindfulness. Each person is encouraged to try different methods of becoming more mindful (using a broader understanding of mindfulness than its meditative Buddhist roots), finding a method that resonates especially with their personality and beliefs.

The Center performs original research to further the evidence base on different practices, which looks at the concept of micro-dosing mindfulness: spending very short periods of time several times per day to experience a sense of awe about something in your environment, and sharing this with your friends and family. This might be something beautiful, like a flower, a pet, a story or a piece of music. It might be something more intricate and complex, like a well-engineered race car, an innovative food dish, a piece of sculpture, a formal ceremony, or a novel gadget. Whatever it is, you should focus on it for a moment at the exclusion of all else, appreciating some of the intricacies and details, experience a sense of awe, and then perhaps share the details of the experience briefly with someone in your life. For example, take a picture of it with your phone and share it with a brief description of why it affected you!

This last step, the sharing, is critical for making this mindfulness practice not just a method to reduce stress but to increase happiness.  Sharing strengthens interpersonal connection, especially important in this time of physical distancing.  Interpersonal connections are necessary (but not sufficient) for a person to be happy, according to neuroscientist and author Laurie Santos.

Of course, when our friends, family, colleagues or patients share something that gave them a sense of awe, we should pause, give our attention to what is being shared, reflect back what we have heard, and allow ourselves to share some of that awe.

Robert Moore, MD MPH MBA

Chief Medical Officer

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

Last Thursday, California released the details of its previously announced “resilience roadmap,” giving requirements and recommendations for safely allowing resumption of activities based on public health risk.  This roadmap starts to give us some longer-term understanding of how the future will unfold in the months ahead. Stages 2 is fairly detailed now; stages 3 and 4 will have additional detail added later.  County health departments have been given important responsibilities in this process, ensuring sufficient community testing to allow opening up to occur, overseeing local implementation of the planning, workplace changes, and citizen communication.  We appreciate the difficult tradeoffs they are balancing in their decision-making; thank you!

The governor’s office is now shifting focus to developing strategies to address the massive budget shortfall being faced next year; their “May Revise” of the budget is due soon.  All programs that rely on state funding (education, health, public safety, transportation) are concerned about what cuts the state will use to prepare a balanced budget.

As of last week, six counties in the PHC service area (Marin, Sonoma, Napa, Yolo, Mendocino and Humboldt) now have mandates for facial coverings/masks when indoors or in crowded outdoor areas where physical distancing cannot be maintained.  Local community groups have stepped up to provide masks/facial coverings to vulnerable populations, including the homeless.  This demonstrates that a community need, combined with community spirit can ensure community-wide adherence to such requirements.

Here are a selection of updates gathered in the last 12 days, which we thought you would find helpful.  Thanks to everyone for sending suggestions and feedback!

1. Policy updates
   1. Verizon offers FCC grants to promote telehealth deployment.  Since it is a federal grant program, the paperwork and steps are rather complicated.  See the online application to get started.
   2. Congregate living environments have been particularly susceptible to COVID outbreaks across the U.S.  The CDC has posted guidance for owners/managers of these facilities to prevent spread of COVID-19.  Please pass this on to the managers of facilities where your patients live.

2. Public Health Update:  This pre-print article recalculates the estimated Ro (R-naught) of COVID-19 taking transmission of asymptomatically infected individuals into account.  Their revision increases the Ro to at least 5, with a mean likely Ro of 15.  This higher Ro helps explain the rapid spread in New York City, and the stubborn persistence of new cases and deaths in the California in spite of Public Health mitigation efforts.  The implication:  a higher level of herd immunity will ultimately be needed to eliminate outbreaks.

3. Efficient use and access to PPE.  In previous communication, we presented some PHC-generated guidelines on re-opening outpatient medical practices.  The AMA released similar guidelines.  In our discussions with local PCPs, insufficient access to sufficient masks and other PPE is a major barrier to re-opening.  Here are some new resources:
   1. CDC guidelines on optimizing efficient use of PPE.  The Centers for Disease Control and Prevention have released optimization strategies for PPE offer options for use when PPE supplies are stressed, running low, or absent.
   2. Free PPE Decontamination for Reuse.  The State of California, in cooperation with federal partners, is offering Battelle Critical Care Decontamination Systems as a solution to the N95 shortages impacting California, which will be available to all practices, free of charge.  There was some early miscommunication indicating that it was only available for hospitals, but we have confirmed that this is not true; outpatient health care offices may also use this service.

4. COVID Testing Updates
   1. Population Testing: Why is Open Testing a Goal?  The availability to test for SARS-CoV2 RNA is expanding steadily in our region, leading to rapid changes in local recommendations for testing.  While most PCPs are testing based on presence of symptoms or contacts with either cases or vulnerable populations, some external testing sites are encouraging anyone who wishes to be tested to get tested.  While on first blush this looks like an inefficient use of COVID tests, an interesting finding shows that there is some psychology to this policy.  When “asymptomatic” individuals who test positive are questioned, over half actually did have mild symptoms that they discounted at the time, suggesting that subconsciously these individuals were worried enough about these mild symptoms to seek out testing.
   2. Limits of “Rapid” RNA tests.  The first rapid COVID RNA test (Abbott) to come on the market has several important limitations.
      1. Once the specimen is collected, it must be run within 2 hours.
      2. Unlike the standard tests, no viral transport medium can be used; it can lead to false negative results.
      3. The company has not validated this test on asymptomatic individuals, and so recommends only using it for those with symptoms.  This recommendation may change in the future.
   3. Limitations of serology test interpretation.  The California COVID-19 Testing Task Force put together a succinct, easy to understand explanation of what serology tests help with and what they should NOT be used for.  The FDA has updated its policy on SARS-CoV2 antibody testing after a flood of serology tests came to market, some with poor performance and fraudulent labeling.
   4. New method of RNA testing.  Researchers are working to adapt the CRISPR gene editing methodology to identify SARS-CoV2.  Instead of amplifying, the viral sequence to the point of detection (done in PCR tests), the CRISPR method finds the viral sequence and then sends a signal, which is then detected.  The charming name for this testing methodology is SHERLOCK. If this technology is perfected, it will allow large scale rapid testing for RNA.

5. COVID disparities.  The COVID-19 outbreak initially involved cruise ship customers, international travelers and their direct contacts, and evolved to a pattern of community spread, disproportionately affecting individuals who live in crowded conditions and who continue to work as essential workers.  A steady stream of epidemiological data has showed that community spread in cities has disproportionately affected socioeconomically disadvantaged individuals.  This is reflected in analysis of hospitalizations and deaths in New York City, which showed Manhattan (with a higher median income) with less burden of disease than The Bronx and Queens, which have a much lower median income.  Evaluating race/ethnicity disparities in context is important, as there are many subconscious biases and tropes which humans are prone to attribute as causes of these disparities (thoughtfully summarized in this excellent NEJM article).

6. COVID Treatment Updates.
   1. Remdesivir:  Gilead asks Federal Government to Distribute for Compassionate Use:  Most Hospitals left out. Remdesivir is less available than previously as Gilead turned over responsibility for distribution of the drug to the Federal Government.  Remdesivir was approved under Emergency Use Authorization on 5/1/2020 for IV administration to hospitalized COVID-19 patients, based on preliminary data from the ACTT-1 study. Per the EUA factsheet, recommended adult dosing is 10 days for critically ill patients (intubated/ECMO) and 5 days for all others, with the ability to extend to 10 days if no clinical improvement. Per the distribution website, hospitals identified by the U.S. government as a recipient for donated remdesivir will be proactively contacted; to find out if your hospital has been designated to receive donated remdesivir, you can email remdesivir@amerisourcebergen.com Certain hospitals were given a supply, others were granted none.  The basis of this allocation has not been clear.
   2. Elevated PTT in serious COVID—Anticoagulate anyway!  This article found that the elevated Partial Thromboplastin Time (PTT) found in critically ill COVID patients is due to the presence of Lupus Anticoagulant, as part of an antiphospholipid syndrome.  As a result, it is an indication of a hypercoagulable state, needing anticoagulation.  Another study (added to several done before with similar findings) showed that critically ill patients with COVID had better outcomes if administered low molecular weight heparin.
   3. Pediatric Multisystem Inflammatory Syndrome (PMIS). A number have reports have been issued in the past two weeks on this topic, affecting 64 pediatric patients in New York and more in other countries with a serious condition that looks somewhat similar to Kawasaki disease:
      1. A child presenting with persistent fever, inflammation (e.g. neutrophilia, elevated C-reactive protein and lymphopenia) and evidence of single or multi-organ dysfunction (shock, cardiac, respiratory, renal, gastrointestinal or neurological disorder). This may include children meeting full or partial criteria for Kawasaki disease.
      2. Exclusion of any other microbial cause, including bacterial sepsis, staphylococcal or streptococcal shock syndromes, and infections associated with myocarditis such as enterovirus.
      3. This literature is evolving quickly; any potential cases would warrant consultation with a pediatric infectious disease specialist for therapeutic advice.
   4. List of all clinical trials for treatment of COVID.  The Medical Letter has shared a comprehensive list of all drug trials being used to test    treatments of COVID.  It is worth a quick look to get a sense of the many strategies being considered.

That’s it for this week!  We at PHC continue to be proud to support and serve you as you support your community in your daily work.

Robert Moore, MD MPH MBA

Chief Medical Officer

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

See below for this week’s extensive collection of news and information on COVID-19, curated for topics of interest to primary care providers.

These summaries are being posted as blogs on phcprimarycare.org.  We have also posted a draft of our recommendations for re-opening outpatient practices on the blog.

Your team at Partnership HealthPlan is here to help and support you as you adapt to this new medical world we are all now living in!

1. Optimizing physical exams conducted by video.  Several physicians with extensive experience in providing primary care by telemedicine have posted videos sharing their best practices.  Here are some links to some of the ones that are particularly helpful.
   1. General overviews of best practices:
      1. “Bedside” manner by video (10 minutes)
      2. General physical exam (5 minutes)
   2. Provider directed patient self-exam
      1. Overview (16 minutes)
      2. Free CME from Stanford (15 minutes)
      3. Patient assisted virtual palpation (3 minutes)
   3. Best Practice on Observation (4 minutes)
   4. Specific Types of Exam 
      1. Abdominal exam (6 minutes)
      2. Neurologic exam (20 minutes)
      3. Musculoskeletal exam (6 minutes)
   5. Orthopedic exams
      1. Knee
      2. Hip and Groin; Sample exam
      3. Shoulder Exam: flexion, adduction, abduction; preparation for patients before visits
      4. Neck: range of motion, nerve root compression

2. COVID Testing
   1. Antibody tests covered by PHC and MediCal.  MediCal codes (86318, 86328, 86769) are a benefit with an effective date of April 10, 2020.  The code for the single step method test is 86318, which has a Medi-Cal rate posted.   Rates have not yet been set by the state for the other two tests.  We recommend checking the CLIA status of these tests before ordering them to conduct in your office.

B. Caution:  Antibody tests using Lateral Flow Assay have variable sensitivity.       (From UCSF ID)  Researchers in the UK (pre-print) evaluated a panel of           antibody-based COVID-19 tests – a novel Enzyme-linked immunosorbent         assay (ELISA) in the lab and 9 commercially-developed Lateral-Flow                 Assays (LFAs) to be used at the point of care. Serum of patients diagnosed       with COVID-19 served as the positive controls and serum of patients in UK       before December 2019 served as negative controls. ELISA identified                 COVID-19 IgM or IgG antibodies in 34/40 cases and 0/50 controls, yielding       a sensitivity and specificity of 85% and 100%. The sensitivity of ELISA IgG       improved to 100% when restricted to patients exhibiting symptoms for ≥10       days. No patients were IgM positive but IgG negative by ELISA. LFA had a       sensitivity of 55-70% with a specificity of 95-100%. IgG titers rose for 3             weeks post symptom onset and began to fall by 8 weeks, but remained             above the detection threshold. This small study was limited by small                 sample sizes and has not yet been peer reviewed. Bottom line: This study       suggests ELISA is best used to identify COVID-19 exposure 10 or more           days following symptoms. Despite being available at point of care,                     currently available LFAs have variable sensitivity. Whether a positive                 antibody test to COVID-19 by one of these tests correlates with immunity is       not known.

C. Persistent virus shedding associated with lower levels of SARS-CoV2 IgG:       persistent infection? A recent report showed that some patients shed viral         RNA in stool for a prolonged period after symptoms resolved and viral RNA       is no longer detectable in nasopharyngeal swabs.  Another analysis from           China of a subset with renewed detection of RNA after several negative             tests found an association with lower levels of viral-specific IgG.  This               suggests that a suboptimal immune response is associated with                         persistent or recurrent infection.  More study is needed, but this                         reinforces caution needed when interpreting positive COVID antibody             tests, especially the LFA tests, as noted above.

D. PCR/RNA tests using sputum contain more viral material than                           Nasopharyngeal swab. This pre-publication summary showcases another         option for appropriate settings, and may be collectable via self-collection.         This may generate more droplets in collection process, but saves swabs           which are often in short supply.

3. COVID Epidemiology Updates
   1. Using COVID RNA tests of sewage for population monitoring. As noted previously, SARS-CoV2 RNA has been detected in stool of many individuals with symptomatic COVID.  A recent report found that SARS-CoV2 can infect the enterocytes of the human GI tract, suggesting that virus shedding is directly from the GI tract.  Several countries have used RNA detection in sewage to detect COVID-19 infection in a community several days before the first symptomatic cases are confirmed.

    According to an article in Nature, several groups are conducting these              sewage tests in the United States.  One area of development is to look at          the RNA load in sewage to estimate community prevalence of infection.            KQED reported that ten Bay Area Counties and Shasta County are testing        sewage; a separate report indicated that Lake county has conducted tests.        In Lake county the sewage tests converted from negative to positive a few        days before the first cases were identified and confirmed.

    Once a community believes it is COVID-free for a period of time, sewage          testing may be able to confirm this, and act as an early warning of the                return of COVID to a community.  Decades ago, this methodology was used      extensively in tracking polio incidence in communities.

B. Heat and humidity of the environment may decrease transmission COVID        is spreading quickly around the world in countries with a wide variety of            climates.  Urban crowding seems to be one of the larger risk factors.  Other      respiratory viruses have less transmission in the warmer months of the              year.  This may be partly due to the thicker protective mucous in warmer            and moister climates, and partly due to more prolonged indoor exposure          to people in cooler weather.  An elegant analysis of data from multiple                countries suggests that there is some slowing of the COVID doubling                rate in more tropical climates compared to more temperate climates.                  This is a mathematical/epidemiological modelling exercise; it will be                  interesting follow further data analysis from within the United States.                  Somewhat suggestive: COVID spread was more rapid and harder to                  control in the Midwest and Northeastern states which are emerging from          winter, compared to states in the West and Southwest.

C. Pre-symptomatic infections most infectious.  Another complex                            mathematical analysis of available data published in the journal Science            compares the degree and timing of infectiousness in the course of                    different infection scenarios:  pre-symptomatic by droplet/aerosol;                      symptomatic by droplet/aerosol; by environmental contact (fomites); from          asymptomatic individuals.  The graphic below summarizes their                          conclusions:  tau represents the time since infection.  Again, this is a                  model; more data will undoubtedly refine it; it reinforces the rationale for            population wide facial covering to reduce transmission.  I speculate that            the decreased infectiousness of symptomatic individuals may be related            to greater caution taken in this phase.

D. Why are mortality spikes greater than can be accounted by reported                 COVID  deaths, in countries around the world? Last week, an analysis of           reported mortality data from around the world found that, in many                       countries,  the overall mortality rate increased sharply, but much more than       would be accounted for by COVID-reported deaths.  A few days ago, a             similar phenomenon was reported in the United States, for the last two             weeks of March, when COVID deaths accounted for only 53% of excess           deaths.  Here is the graphic:

     Interestingly, most of these excess deaths were in the Eastern US, the               percentage is notably less in Michigan and absent in Washington state.             There are multiple possible contributory explanations/factors; more                   analysis will shed more light on this.

E. COVID deaths outside the hospital (often at home), not counted in official          estimates; possibly related to the hypoxia without dyspnea described in a          prior update.

F. Strokes in young patients, related to hypercoaguable state induced by              COVID infection, which may be due to the recently documented direct              infection of endothelial cells by SARS-CoV2, with subsequent damage,            promoting thrombogenesis.  New York City found a doubling in the rate of          strokes in the past month, with half the cases in younger patients infected        with COVID.

G. Patients not going to hospital due to fear, dying of heart attacks, strokes,           other emergency medical conditions.

H. Increase in suicides.  Of note for the first possibility:  PHC now covers O2       sat monitors (HCPCS E0445) provided by DME companies.  However,           due to an international shortage, your local DME vendors may encounter           difficulty fulfilling a prescription for an oxygen saturation monitor.  PHC is           working on an alternative consignment and distribution process for O2 Sat       monitors; more to come.

4. Updates on therapeutics
   1. Tocilizumab for reducing cytokine storm. (From UCSF ID)  Two recent papers seek to uncover the mechanisms behind the development of acute respiratory distress syndrome (ARDS) in a subset of COVID-19 patients often >7 days after onset of symptoms. Blanco-Mello et al compared the transcriptional response of SARS-CoV-2 to other respiratory viruses including Influenza A in a variety of immortalized tissue culture cells, infection of primary airways cells, in vivo samples derived from SARS-CoV-2 infected ferrets, and finally from post-mortem samples collected from the lungs of humans who died with SARS-CoV-2 or normal lung biopsies. These studies, together with serum profiling in the ferret model, revealed a unique and inappropriate inflammatory response characterized by low levels of type I and type III interferons, elevated chemokines, and elevated Interleukin-6 (IL-6) expression.

    Giamarellos-Bourboulis et al compared 28 patients with COVID-19 and            ARDS to 26 patients COVID-19 without ARDS. Control groups included            patients with 2009 H1N1 Influenza A and patients with community acquired      pneumonia-associated sepsis. Some patients with COVID-19 associated-        ARDS had macrophage activation syndrome, and most had immune                  dysregulation characterized by low expression of HLA-DR on a subset of          monocytes (CD14 positive) that is triggered by monocyte hyperactivation,          excessive IL-6 release, and profound lymphopenia. This pattern is distinct        from ARDS-associated bacterial sepsis or 2009 H1N1 influenza. Together,        these studies suggest that COVID-19 associated ARDS may be                        characterized by both a reduced innate immune response coupled with an        exaggerated inflammatory cytokine response.

    A preprint report of a study of 30 patients with severe, deteriorating COVID        pneumonia treated with tocilizumab to block IL-6 eliminated the                          development of cytokine storm, compared to a matched control group.              Larger studies are in process.

B. Alpha-lipoic acid reduces systemic inflammatory response in COVID.  α-          Lipoic acid (ALA), as an antioxidant, has been confirmed to reduce                    systemic inflammatory response in patients with acute coronary syndromes,      liver transplantation patients, and kidney-pancreas combined                            transplantation  patients.  A preprint of a study suggests a benefit in                  reducing cytokine storm in critically ill patients with COVID.  Again, more            study is needed.

C. Remdesivir:  Gilead announced that their trial of Remdesivir has reached           its primary endpoint, which likely means a survival benefit has been found.       More information and detail will be coming soon.

5. Focus on inpatient care issues with COVID patients.  Given the seroprevalence data from Santa Clara (the COVID hot-spot in Northern California), it is likely that over 97% of residents of PHC counties have not yet been infected with COVID-19.  There is a strong possibility that we will see an increase in COVID hospitalizations in the future, with recruitment of community physicians to assist with their care.  All physicians therefore need to learn the essentials of caring for COVID inpatients.  Here are some highlights to help prepare.

A. Free clinical simulation of caring for patient with COVID on general hospital       floor.  This simulation takes about 15-20 minutes and hits on many                    highlights of caring for COVID inpatients that are not in the ICU.  I highly            recommend it.  The next three items are elaborations of some themes of          this simulation.  The subsequent five items relate more to critically ill                  patients in the ICU.

B. Risk factors for deterioration.  There are many models for estimating the          risk of deterioration.  Here is one called the Early WArning Score (EWAS),        using just 5 factors: age, underlying chronic disease, neutrophil to                      lymphocyte ratio, C-reactive protein, and D-dimer levels.

    Low risk is a score of 0-2, medium risk is a score of 2.5-3, high risk is a            score of 3.5 to 4.5.  The 14-day cumulative incidence of clinical                          deterioration in the low-risk group was 1.8%, which was significantly lower        than the incidence rates in the medium- (14.4%) and high-risk (40.9%)              groups.  Note the heavy weight given to elevated D-dimer level.

C. Aerosolization of COVID with different types of oxygen therapy.  The                simulation above indicates that less hazardous aerosol is released into the        room with a non-re-breather mask than with other high-flow oxygen delivery      methods.  This study casts some doubt on this popular wisdom, indicating        that the aerosolization of all oxygen delivery methods are about the same.        Bottom line:  wear a tightly-fitting, fit-tested N95 when entering the room of        a COVID patient on oxygen.

D. Heparin reduces hypoxia in hospitalized COVID patients. Since we are             seeing a variety of blood clots in patients with COVID (strokes, pulmonary         emboli, peripheral blood clots), and anti-coagulation is usually beneficial for       most hospitalized patients, it is not surprising that this study found                     improved hypoxia from use of prophylactic heparin in COVID inpatients             without active bleeding.

E. The range of survival for ventilated patients varies greatly by                              hospital/geography:  From a survival rate of 12% in New York City to a              survival rate of 94% in at San Francisco General Hospital.  This is partly            related to the effect of an overwhelmed hospital system, in New York, but          another factor is the organization of health care delivery at different                    hospitals.  SFGH’s CEO Susan Ehrlich has rigourously overseen the                implementation of lean management methods throughout their leadership        structure, which led to strong independent, self-improving teams.  I would          speculate that this is contributing to their amazing outcomes.

F. Outcomes poor for CPR in hospitalized COVID patients with cardiac arrest.      This report notes that if patients with COVID get to the stage of cardiac              arrest, CPR is unlikely to lead to positive outcomes.  Less than 1% of                COVID patients receiving CPR survived without permanent neurologic              sequelae.  This is helpful information for advance care planning                         conversation.

G. ST-segment elevation in COVID: clot vs. myocarditis?  Although the                   COVID virus infects blood vessel endothelial cells, potentially contributing         to blood clots (as noted earlier), this summary found that most patients with       ST-segment elevation on EKG are found to have no obstruction of                     coronary  arteries, suggesting that myocarditis from direct COVID infection       may be the more dominant underlying etiology, as first noted in                         Washington state’s experience.

H. Many critically ill COVID patients found to have aspergillus superinfection.        This pre-print found Aspergillus in 33% of lung specimens of intubated              COVID patients.  This might be colonization or superinfection, the latter            due to impaired immune response.  Evaluating Bronchial secretions of              COVID patients for superinfection with both bacteria and fungus seems            prudent, to not miss a treatable superinfection.

 I. Gut microbiome associated with risk of cytokine storm? Why do some              COVID patients become seriously ill, while others do not?  This analysis            speculates that the proteins produced by the gut microbiome (called                  the fecal metabolome) may affect the probability of developing cytokine            storm.  More analysis is needed to understand how this might be leveraged      for prevention or treatment.

6. What is “Crazy Paving” and what does it have to do with COVID? Crazy paving refers to the appearance of ground-glass opacity with superimposed interlobular septal thickening and intralobular septal thickening, seen on chest High Resolution CT. It is a non-specific finding that can be seen in a number of conditions. Here are two CT scan views showing this pattern, along with a picture of a mosaic paved pathway that inspired this whimsical radiological description.

Crazy paving:  not exactly a yellow brick road, but I’ll say goodbye for now.

Robert Moore, MD MPH MBA

Chief Medical Officer