{"id":2201,"date":"2020-04-28T14:48:08","date_gmt":"2020-04-28T21:48:08","guid":{"rendered":"https:\/\/phcprimarycare.org\/?p=2201"},"modified":"2020-04-28T14:48:08","modified_gmt":"2020-04-28T21:48:08","slug":"42320-safely-increasing-outpatient-health-care","status":"publish","type":"post","link":"https:\/\/phcprimarycare.org\/?p=2201","title":{"rendered":"4\/23\/20 Safely Increasing Outpatient Health Care"},"content":{"rendered":"

Safely Increasing Outpatient Health Care:<\/u>\u00a0 Yesterday, Governor Newsom recommended<\/a> a resumption of some types of outpatient medical visits, with appropriate precautions to prevent spread of infection.\u00a0 We know you are working on fine-tuning quality and efficiency of your virtual visits, while working to ensure your offices are safe for visits that need to occur in person.\u00a0 The CMA released a high level summary<\/a> on reopening physician practices.\u00a0 The PHC Medical Director team gathered together a number of best practices for re-opening clinician practices<\/u> of all types.\u00a0 Clinician Office COVID Guideline <\/b>is posted separately in this blog.\u00a0 It includes operational, staff, patient flow, and facilities recommendations.\u00a0 We hope it will be a useful check list clinical and operational leaders working to make their offices safe for employees and patients.\u00a0 Some useful additional advice for optimizing video visits can be found in this NEJM article<\/a>.<\/p>\n

Here is a weekly curation of COVID updates that we thought would be of interest to primary care clinicians, with a special focus on many less-recognized clinical manifestations.\u00a0 We appreciate leads on topics for future updates, as well as comments and feedback!<\/p>\n

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  1. PHC Policy Updates Related to COVID<\/u>\n
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    1. Home Blood Pressure Test Kits<\/u>:\u00a0 Virtual care of patients with hypertension includes the ability for the patient to check their blood pressure at home.\u00a0 Blood Pressure Test Kits are PHC benefit, provided with a prescription by community pharmacies<\/em> (not<\/u> DME vendors).\u00a0 The prescription can specify the size of the cuff that is in the kit (Medium and Large are the two most common), and should include the diagnosis of \u201chypertension\u201d on the prescription.\u00a0 You may work with your local pharmacy to see what brands are available and write the prescription for that brand.\u00a0 Currently, any BP cuff costing under $55 is covered (this limit is likely to increase soon).\u00a0 Pharmacies that have questions can consult the PHC website<\/a> for information; please let us know if they refuse to honor a prescription for a BP cuff, and we can reach out to educate them.\u00a0 More information about coverage of Ambulatory BP monitors and BP monitors that automatically send results to the PCP will be presented in a future update.<\/li>\n
    2. Virtual visits by Physical Therapy, Speech Therapy, Occupational Therapy<\/u>:\u00a0 PHC has activated special codes<\/a> normally used by MediCare for coverage of video visits by PT\/ST\/OT to provide education and observation of patients who do not need an in-person visit.\u00a0 We have educated our therapy network of these changes.\u00a0 Patients needing PT\/OT\/ST services need a prescription from a referring clinician (no need to use the PHC RAF system).<\/li>\n<\/ol>\n<\/li>\n<\/ol>\n
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      1. Role of Serology Testing in Managing COVID.<\/u> While PCR\/RNA\/molecular testing is steadily becoming more available, unapproved serology\/antibody tests are making their way into the market in a somewhat chaotic fashion.\u00a0 Jill Taylor of the N.Y. State Department of Health stated in an excellent National Academy of Science presentation<\/a> yesterday that over 125 new serology\/antibody tests (many of questionable accuracy) are now available in the United States, although only 5 had official FDA recognition for emergency use.\u00a0 She states that many rapid serology tests will detect milder coronaviruses that cause cold-like symptoms (low specificity), causing rapid surveillance studies to suggest higher rates of immunity than actually exists.\u00a0 Furthermore, we cannot equate presence of an antibody response to true immunity to re-infection.\u00a0 These factors make antibody testing currently unhelpful<\/u> for counseling individual patients about immunity or safety to return to work.\u00a0 This may change in the near future.<\/li>\n<\/ol>\n

        \u00a0 Seroprevalence studies done in early April in Los Angeles<\/a> and Santa Clara<\/a> are\u00a0 \u00a0 \u00a0 \u00a0 good examples.\u00a0 Both estimate that about 4% of adults have antibodies in their\u00a0 \u00a0 \u00a0 \u00a0 blood, about 50-fold greater than the number of confirmed positive COVID tests.\u00a0 \u00a0 \u00a0 While some cross-reactivity with milder coronaviruses may be inflating the\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 number, the bottom line is that the vast majority of the population is still\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 susceptible to SARS-CoV2, even in these two counties with California\u2019s heaviest\u00a0 \u00a0 \u00a0 COVID-19 toll.\u00a0 Current estimates<\/a> are that 60-70% herd immunity would be\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 needed for COVID infection rates to fall.<\/p>\n

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        1. How much PCR testing capacity do we need<\/u>?\u00a0 The current testing rate<\/a> in the United States is about 0.4-0.5 PCR tests per 1000 population per day. \u00a0Dr. Ashish Jha of the Harvard Global Health Institute estimated that about 1.5 to 2.5 PCR tests per 1000 population per day will be needed to provide the robust testing of all symptomatic individuals, their asymptomatic contacts, and certain asymptomatic essential workers<\/strong> to safely allow significant resumption of economic activity.\u00a0 For the PHC counties, this would be a total of about 4000-6000 tests per day.\u00a0 This is possible with the current spectrum of tests available, and far more achievable than the 60-100 PCR tests per 1000 population per day recommended by the Roadmap to Pandemic Resilience<\/a> report released on April 20.<\/li>\n<\/ol>\n
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          1. Additional study on N95 decontamination <\/u>suggests less repeat decontamination cycles than studies previously reviewed in this newsletter.\u00a0 This study<\/a> looked at the ability of N95 masks to filter SARS-CoV2 and evaluated integrity using post-sterilization fit testing.\u00a0 This suggested that dry heat sterilization can only be done twice before the N95 fails a fit test.\u00a0 Of note, this study was not yet peer reviewed and comments posted pointed out some important methodological concerns.<\/li>\n<\/ol>\n
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            1. Communication aid for having difficult conversations about COVID.\u00a0 <\/u>VitalTalks Tips<\/a> is a free smart phone app that help with difficult conversations with patients, with several sections devoted to COVID-related situations.\u00a0 I recommend loading it on your smart phone and taking a few minutes to scan through some of the questions\/topics that are included.<\/li>\n<\/ol>\n
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              1. Therapeutic updates:<\/u>\n
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                1. A well-publicized Randomized control trial of hydroxychloroquine<\/a> showed increased mortality.<\/li>\n
                2. Trial of remdesivir in macaque monkey model<\/u>:\u00a0 (summary from UCSF ID newsletter<\/a>)\u00a0 Researchers developed a macaque model of respiratory SARS-CoV-2 infection that recapitulates important aspects of human infections.\u00a0Investigators from the NIH\u00a0studied<\/a>the effect of remdesivir treatment starting near the peak of viral replication. Remdesivir was administered\u00a0with a loading dose\u00a012 hours after respiratory and ocular inoculation, followed by a daily IV dose for 6 days,\u00a0similar to protocols for humans.\u00a0 At 12 hours after the initial treatment, the remdesivir-treated monkeys had fewer symptoms and less radiologic evidence of pneumonia compared to the control-treated monkeys, a trend which continued during the 7-day study.\u00a0The remdesivir-treated monkeys had lower viral loads and titers of infectious virus in the lungs and less damage, but interestingly, drug treatment did not decrease viral shedding in the nose, throat, or rectal swabs.\u00a0While the Gilead remdesivir clinical trial results are not yet known, this primate model suggests that early treatment of COVID-19 with remdesivir may prevent progression to severe pneumonia\u00a0and sterilize viral cultures in the upper and lower airways.\u00a0Upper airway\u00a0viral shedding\u00a0was still detectable; however, the significance of PCR detectable virus in the absence of viral growth is not known.<\/li>\n
                3. ACEI\/ARB not just safe, but also protective<\/u>:\u00a0 Early data from China indicating that hypertension was a risk factor for COVID severity, combined with the fact that the ACE2 receptor in the lung led to speculation that use of ACEI or ARB increased risk of COVID complications.\u00a0 However, a new report from China<\/a> showed actually that ACE\u00a0 or ARB use among hospitalized patients with COVID was associated with increased <\/em>survival.<\/li>\n<\/ol>\n<\/li>\n<\/ol>\n

                  7.\u00a0Clinical Updates:<\/u> As time passes, more reports are showing the wide spectrum\u00a0 \u00a0 \u00a0 \u00a0 of signs and symptoms associated with COVID.\u00a0 Some of these are contrary to\u00a0 \u00a0 \u00a0 \u00a0 the early information we had about the disease, so they are important to\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 incorporate into our clinical decision making, so we don\u2019t reassure patients\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 infected with SARS-CoV2 that they have something else, leading to spread of\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 infection (something we are concerned is occurring, due to the shortage of\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 tests).<\/p>\n

                  A.\u00a0<\/span>Co-infection rate with other respiratory pathogens.<\/span>\u00a0A\u00a0<\/span>study in Northern\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 California published in JAMA<\/a>\u00a0found that 20% of those diagnosed with\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 COVID were co-infected with another respiratory pathogen.\u00a0 Based on this,\u00a0 \u00a0 \u00a0 individuals with symptoms potentially due to COVID should be tested for\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 COVID, even if another test, such as rapid influenza or RSV tests, are\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 positive.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 B<\/span>.\u00a0Smell and taste disturbance in COVID.<\/u>\u00a0A\u00a0physician in Italy<\/a>\u00a0noted (in\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 the setting of the epidemic) that sudden anosmia or dysgeusia with\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 nausea \u2013even without other respiratory symptoms\u2014was universally\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 found to be associated with a positive PCR test for COVID.\u00a0 \u00a0A\u00a0recent\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 JAMA study<\/a>\u00a0of patients with these abnormalities found that most\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 (97%) eventually develop other symptoms of COVID (including even\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 nasal congestion in 35%), but that 12% noted anosmia or dysgeusia as\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 their first symptom.\u00a0 A\u00a0case report<\/a>\u00a0of one such patient found mucous\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 obstruction just below the olfactory nerve, but no imaging abnormality of the\u00a0 \u00a0 \u00a0 olfactory nerve itself, suggesting the etiology may be\u00a0 obstructive, but not\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 ruling out direct infection of the olfactory nerve.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0C.\u00a0Why are COVID patients dying at home?<\/u>\u00a0The\u00a0report yesterday<\/a>\u00a0that\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0two individuals in Santa Clara who died in early February were found\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0to be infected with COVID is not only interesting for the historical\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 epidemiologic implications, but also as an indicator of an important\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0scary clinical scenario:\u00a0hypoxia without dyspnea.\u00a0\u00a0<\/strong>A\u00a0NY times\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0article<\/a>\u00a0(highly recommended reading) noted that these individuals\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0have pneumonia with decreased oxygen levels but with a normal CO2.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0They compensate with a more rapid respiratory rate but don\u2019t feel the\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0dyspnea until the pneumonia worsens with elevated CO2, at which\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0time they decompensate quickly, potentially dying at home or requiring\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0intubation by EMS.\u00a0 The article gives anecdotes of the use of oxygen\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0saturation monitors by patients sent home with pneumonia to monitor\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0for detecting hypoxia earlier.\u00a0 PHC is looking into options for making\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0oxygen saturation monitors available to our members.\u00a0 There is a\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0world-wide shortage of these devices currently.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0D.\u00a0CT scans identify asymptomatic COVID in New<\/span>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0York<\/span>.\u00a0\u00a0Another\u00a0report<\/a>\u00a0from an Emergency Room Physician in New\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0York found that a number of asymptomatic individuals or minimally\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0symptomatic individuals who came to the ED for other reasons were\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0found on CT to have COVID pneumonia.\u00a0 This included a patient with\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0abdominal pain, nausea and vomiting and another with symptoms of\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0acute coronary syndrome.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 E.\u00a0Are there cutaneous manifestations of COVID-19?<\/u>:\u00a0 (summary\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 from\u00a0UCSF ID newsletter<\/a>)\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Cutaneous findings were rarely reported (<1%) inlarge studies<\/a>\u00a0from\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 China.\u00a0 A\u00a0recent study<\/a>\u00a0from Italy found that 18 of 88 (20%)\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 hospitalized patients had skin findings: erythematous rash (78%),\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 diffuse urticaria (17%), and vesicles resembling varicella (5%)\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0\u00a0Another report<\/a>\u00a0from Italy described 22 patients with\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 papulovesicular eruption resembling varicella. In both reports, the\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 trunk was most commonly involved, and itching was uncommon.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Individual case reports of patients with COVID-19 and a\u00a0diffuse\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 erythematous rash<\/a>,\u00a0diffuse urticaria<\/a>,\u00a0petechial rash<\/a>,\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 and\u00a0violaceous lesions in the toes<\/a>\u00a0have been described as well\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 (sometimes called \u201cCOVID toes\u201d), as shown below.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Photo: Northwestern University<\/p>\n

                  \"Northwestern<\/a><\/p>\n

                  \u00a0 \u00a0 \u00a0 \u00a0The American Academy of Dermatology has launched a\u00a0COVID-19\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0dermatology registry<\/a>\u00a0to better understand the cutaneous manifestations\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0of COVID-19.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 F.\u00a0Neurologic manifestations of COVID:<\/u> (summary from UCSF ID\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0newsletter<\/a>)\u00a0 What neurological manifestations are seen in patients with\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 COVID-19? Several reports were published this week on neurological\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 findings in patients with COVID-19. A Chinese study described 214\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 patients and found that 36.4% had neurologic manifestations which\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 included dizziness (16.8%), headache (13.1%), myopathy (10.7%),\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 impaired consciousness (7.5%), taste impairment (5.6%), smell\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 impairment (5.1%), acute stroke (2.8%), and seizure (0.5%). A second\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 French study of 58 ICU patients found agitation (69%), corticospinal\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 tract signs such as clonus (67%), and confusion (65%). 13 patients\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 had MRIs which revealed leptomeningeal enhancement in 62% and\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 acute stroke in 15%. 7 patients had an LP \u2013 all were normal and\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 negative for COVID-19 by PCR. Conclusion: Neurologic finding are\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 common in patients with severe COVID-19. Possible mechanisms\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 include hypercoagulability, inflammation, exacerbation of underlying\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 vascular comorbidities, or direct CNS infection. However, only a single\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 case of meningoencephalitis with a positive CSF PCR has been\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 published to date.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 G.\u00a0Ocular manifestations of COVID-19:<\/u> (summary from UCSF ID\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 newsletter<\/a>)\u00a0 The main ocular manifestation of COVID-19 is\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 conjunctivitis. A recent report described the ocular findings in a cohort\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 of 38 patients from China: 12 patients (38%) had chemosis,\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 conjunctival hyperemia, and epiphora (watery eyes). All 12 patients\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 had moderate, severe, or critical illness, suggesting that ocular\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 findings may be found in more severe disease. Notably, one patient\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 had epiphora (\u201cwatery eyes\u201d) as the first symptom of COVID-19. Two\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 out of the 12 patients had a positive conjunctival swab for COVID-19,\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 suggesting the possibility of transmission directly from the eye. Prior to\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 this report, there were also a few case reports where conjunctivitis\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 was described as part of the clinical syndrome of COVID-19.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 H.\u00a0Is COVID death sometimes due to multiple blood clots to lungs?<\/u>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0(summary from UCSF ID newsletter<\/a>)\u00a0 Are patients with COVID-19\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0hypercoagulable and would they benefit from intensified\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0anticoagulation interventions? A report<\/a> indicates that some patients\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0who die of COVID have many blood clots found in the lungs.\u00a0 A\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0hypercoagulable state is well described in patients with pneumonia and\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0sepsis.\u00a0 Elevated D-dimer and elevated IL-6 (mediator of cytokine\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0induced coagulation) are correlated with poor outcomes in COVID-19.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Among 21\/183 non-survivors hospitalized with COVID-19 pneumonia,\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a071% met criteria for disseminated intravascular coagulation. In a\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0retrospective study of severe COVID-19 cases with coagulopathy,\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0heparin was not associated with a benefit in reduction of 28-day\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0mortality except in a subset<\/em> of patients with very high d-dimers levels.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Bottom line: More data are needed to inform these clinical decisions. In\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0the meantime, in light of patient isolation and limited mobility, we agree\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0with The American Society of Hematology (ASH) recommendation that\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0\u201call hospitalized patients with COVID19 should receive pharmacologic\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0thromboprophylaxis with low molecular weight heparin (LMWH ) or\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0fondaparinux (suggested over unfractionated heparin to reduce\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0contact) unless the patient is judged to be at increased bleeding risk.\u201d<\/p>\n

                  That\u2019s it for this week!\u00a0 We hope this is helpful; again we welcome feedback.\u00a0 We appreciate all that you and your team are doing to support your patients, your community and your families in this challenging time,<\/p>\n

                  Robert Moore, MD MPH MBA<\/strong><\/h5>\n
                  Chief Medical Officer<\/h5>\n","protected":false},"excerpt":{"rendered":"

                  Safely Increasing Outpatient Health Care:\u00a0 Yesterday, Governor Newsom recommended a resumption of some types of outpatient medical visits, with appropriate precautions to prevent spread of infection.\u00a0 We know you are working on fine-tuning quality and efficiency of your virtual visits, … Continue reading →<\/span><\/a><\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[1],"tags":[],"class_list":["post-2201","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"yoast_head":"\n4\/23\/20 Safely Increasing Outpatient Health Care - PHC Primary Care Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/phcprimarycare.org\/?p=2201\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"4\/23\/20 Safely Increasing Outpatient Health Care - 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