Practice News
July 10, 2020 Covid 19 update
Arizona continues to be the leader in number of Covid 19 cases per capita for the US. We continue to see on average over 3,000 new cases a day, and this week have had a few days with over 4,000 new cases a day. This is way worse than just back in May when we were seeing 300-400 new cases a day.
The largest growth in number of cases in Arizona continues to be in the 20-44-year-old age group. However, the largest number of deaths remains in the 65 and older age group.
While it is not completely clear why the number of cases has skyrocketed, it is strongly believed the increase is due to people not wearing masks and congregating in groups greater than 10 individuals. Once again, I want to emphasize the largest risk of spreading the virus is when people are close together in a room or other setting. When we talk, sing, cough or sneeze we are spreading bacteria, viruses and other organisms. Right now, the best approach is to try to stay at home as much as possible and to wear a mask if you need to go somewhere.
Hospital admissions have increased dramatically over the last 10 days. On June 30, there were 2,876 patients admitted throughout the state with confirmed or presumed Covid infections. As of yesterday (July 9, 2020), that number was up to 3,432. Likewise, the number of intensive care unit admissions for that same time period is up 30% going from 675 to 876. The hospitals continue to be inundated. Here in Arizona there is a system called the SURGE which allows hospitals to transfer patients to other hospitals in the city, or state, or even neighboring states when they cannot accommodate Covid patients. This system has been needed intermittently over the last several weeks.
Covid 19 is a fascinating and perplexing virus. Along with the typical respiratory symptoms, in some individuals, it is causing blood clotting issues. We are seeing blood clots form in the small blood vessels in the heart, lungs, kidneys and liver amongst other sites, which is leading to organ damage, strokes and deaths. One of the approaches being utilized in severely ill patients is the use of medications to prevent blood clots from forming.
In addition, we are seeing various neurological symptoms occurring with Covid infections, including hallucinations and altered cognitive function. All these complications are believed to be related to the virus binding to ACE2 receptors in various parts of the body. However, once again this observation needs more evidence.
Finally, I want to finish with a joke from Jerry Avenaim, a photographer. “An epidemiologist, an ICU doctor and a scientist all walk into a bar. I’m just kidding, they know better.”
Take care everyone.
Jeff Mayer, MD
June 29, 2020 COVID 19 Update
Covid 19 cases continue to increase daily here in Arizona. Not including today’s numbers, we have had over 3,000 new cases a day 7 out of the last 10 days. Today’s numbers are artificially low due to a reporting glitch per the state health department.
Hospital admissions, and especially ICU admissions, for Covid 19 continue to rise, and we are now in a crisis throughout the state. The issues remain not having enough nurses and other personnel along with fewer beds available. Please note the situation is not out of control, and for the moment the system is able to handle the demand.
Once again, most new cases continue to be in patients under 40. Anecdotally, patients admitted to the ICU now seem to spend fewer days on the ventilator compared to a few months ago. It is unclear if that is due to some of the therapies being utilized, or to relatively younger patients or to something else.
In the most severely ill patients there are several therapies being utilized with Dexamethasone being the most recently talked about. Dexamethasone is a steroid which when given to patients on ventilators has been shown to improve survival. However, it does NOT appear to help, and may even be harmful when given to less severely ill patients.
Some people who have recovered from a Covid 19 infection test positive again by nasal swab soon after recovery. We do not really know exactly what this means, yet one theory currently going around is that these individuals merely have reactivated expression of RNA, rather than recurrent infection. Remember it is the virus RNA that we are detecting when we do a nasal swab. If true, this could be good news, as the theory goes these patients are actually protected by antibodies which are not being detected on our current testing. In addition, it suggests that a vaccine could still be protective even if our usual markers are not identified. Realize though this is just a theory.
One of the challenges of Covid 19 is the vast amount of information that is flowing from various research centers and hospitals around the world. For better and for worse, scientific information now is widely publicized when released. This information is often not subject to the usual review for good methodology and errors in calculation. Part of this is due to the time urgency of discovering a treatment for Covid 19. However, it creates situations where people do not know what or who to trust. Two examples of this issue are the Dexamethasone mentioned above, which has relatively strong data and study to back its usefulness, and Hydroxychloroquine which did not. I know I have made this point in another message, yet please try to remain scientifically skeptical, asking yourself how do the sources know what they claim to.
It goes without saying everyone needs to continue to wear masks when out in public and to try to minimize going out when the number of cases is so high. In the office, we are seeing patients 4 days a week, yet I continue to do telephone follow ups with patients as well. Unfortunately, we can not fully do our annual Wellness Exams by phone or telehealth, and we are working hard to catch up since we lost 2 1/2 months when we suspended them in mid-March.
Finally, this message is coming to you on a Monday since this Friday July 3, the office will be closed for the holiday. I continue to remain available by cell phone, yet ask if you would please call the office during business hours as I am seeing patients. I wish everyone a very happy and healthy week and my next message will come out next week.
Take care.
Jeff Mayer, MD
Covid update 6-19-20
Today is Friday, June 19, 2020.
Last week when I sent this message out, Arizona had recorded approximately 1,600 new cases for the day. Today, we have set another new record with 3,246 new cases reported. With one big exception, we are now in the scenario that we hoped would be avoided back in March when the initial stay at home order was issued, namely the exponential or rapid increase in cases. Unfortunately, a notable increase in the death toll is soon to follow.
The big exception is the level of preparedness at the hospitals and also in the community. The hospitals are better equipped from both a supply situation and an experience level. Likewise, in the community we have a better understanding of how the disease is spread, and a better sense of what to worry about.
Overwhelmingly, the largest risk of spreading the virus is when people are close together in a room or other setting. When we talk, sing, cough or sneeze we are spreading bacteria, viruses and other organisms. In general, 6 feet is felt to be the distance at which the concentration of these particles is low enough so as not to cause infection. Wearing a mask, prevents or at least reduces the propulsion of these particles into the air, thus lowering the risk of transmitting an infection to someone else.
The largest number of cases in Arizona continue to be in the 20-44-year-old age group. However, the largest number of deaths is in the 65 and older age group.
Covid 19 is going to be around until we either have enough herd immunity or a vaccine to control it. Unfortunately, even with the number of cases being recorded we are most likely below 10% immunity in the population. We need 70% to be protective.
So, what needs to be done is for everyone to avoid large gatherings, especially those where people are not staying at least 6 feet apart and wearing masks. Even in smaller public settings, masks should be worn. No one wants to inadvertently be the cause of someone else’s illness or worse. I will do another update middle of next week when information and trends are clearer.
Take care.
June 12, 2020 COVID19 Update
Unfortunately, Covid 19 cases in Arizona have essentially gone off the scale. Today’s numbers show over 1,600 new cases, and we have been averaging over 1,000 new cases a day. In addition, the death rate is slowly increasing, now averaging about 30-35 new deaths a day, up from 20-30 deaths a day two weeks ago.
The hospitals are getting full and ICU beds are in short supply, especially in the Phoenix area. While no one predicts that the hospitals will get overwhelmed in the short term, the hospitals have been instructed to activate their emergency plans, indicating the seriousness of the current conditions.
These numbers were not predicted by the models being used, indicating how imprecise such tools can be at times. In addition, modelling is now not very helpful in predicting where the number of cases will go.
Currently, there is no indication Arizona will go back to the general stay at home order. However, it is recommended those at high risk for a complicated case of Covid 19 remain at home for the time being. That group includes people with underlying lung disease such as asthma and COPD, diabetics, immunocompromised individuals (such as from chemotherapy or other medications or HIV), and older individuals.
I am disheartened by the reluctance of some to wear a mask when in public. We do not have great ways to reduce the spread of Covid19, yet wearing a mask is one which works. A few weeks ago, two hair stylists in Missouri exposed 140 customers to Covid19. The stylists were wearing masks, and according to news reports, amazingly none of the customers has tested positive or come down with Covid19 two weeks after the exposure.
We now recognize that the combination of loss of smell, taste, fever, decreased appetite and diarrhea are 99% specific for COVID19. We already knew that a loss of smell was an early sign of infection.
Studies done with convalescent plasma so far remain disappointing. Convalescent plasma is when antibodies to Covid 19 are taken from people who have recovered from an infection and infused into someone with active illness. Some limitations of the studies are that most of them involved seriously ill patients, rather than those with less advanced infections. Once again time and additional study will determine if this treatment has any value.
There are several vaccines moving into phase 3 clinical trials. Phase 3 trials are the final step before a drug or vaccine can be approved for widespread use. They are the phase where the effectiveness of a treatment is determined along with evaluating additional safety issues and side effects. Many treatments never make it out of phase 3 trials. Hopefully, one of the studied vaccines will succeed.
Finally, the ongoing fires around the Tucson area have created unhealthy air quality and I do recommend avoiding outdoor exercise until the smoke has diminished. Take care.
Jeff Mayer, MD
June 5, 2020 Covid19 update
First off, some updates on clinic hours. Even though the number of reported cases continues to climb here in Arizona, we have restarted scheduling patients for routine follow-ups and physicals. We are restrained by the desire to not have more than one patient in the office at a time, so we are running at only 2/3 of our normal capacity. We are seeing patients every day except Wednesday. Once again, if you need anything please call the office, or if after hours, call me on my cell phone.
In my last message, I mentioned there was data indicating that ACE inhibitors (a blood pressure medication) may be protective against a more serious COVID infection. Unfortunately, that data may have been falsified, and the New England Journal of Medicine has now retracted the study.
This event highlights a major problem with COVID-19, which is that some of the studies being reported (even in well-respected sources) can be incomplete or even not trustworthy. In addition, there is a lot of pseudoscience going on, especially on the internet. Pseudoscience is the practice of presenting something as scientifically based when in fact it is not. What this all means is we need to remain scientifically skeptical about what we hear regarding COVID-19.
Realize though, there is good science going on, and the challenge is to piece all the disparate pieces of data together into a more complete picture. For instance, just this morning there was a study publicized which suggests that people with Blood Type A may be at a higher risk of a more serious infection. I consider this data to be preliminary, with much more study needed to see if this association is real, or just a phenomenon of what was initially analyzed. Such studies are not completed quickly, so the answer to this question will take months if not longer.
This past week has seen a dramatic increase in the number of cases in Arizona, and to a lesser extent in Pima County. We are now averaging almost 1,000 new cases a day in the state. While some of this increase is due to a larger number of tests being performed, we are seeing increased hospitalizations for COVID 19 as well. It remains unclear right now if any of these increases are due to the reopening of businesses and other facilities. Regardless, the virus remains very prevalent in our community, and wearing a mask and staying 6 plus feet away from others will help reduce spread. I still recommend that people do not get their hair cut or dine in restaurants.
Finally, please continue to remember that this virus is very contagious, and remaining vigilant about protecting yourself from it remains paramount. Take care.
COVID 19 5-29-20
The data in Arizona continues to show a high number of cases weekly. As I have mentioned in past messages, I average the number of new cases over 7 days to get a better idea of where the trend is. Today’s numbers show 702 new cases, which is the highest number thus far. However, that does not mean the number of cases is going up as the reporting of new cases to the state health department lags by a few days. We are still averaging over 300 new cases a day though, which to me is double the number I want to see. Unfortunately, the number of deaths reported daily has remains in the 20’s.
What this means is that the virus is still present in the community at approximately the same level as it has been for the past month. Even though recommendations to stay at home have relaxed, there is still significant spread of the virus.
It is estimated that up to one third of Covid 19 carriers are asymptomatic, which makes prevention so tricky. A lot of what we do in prevention is about probability, and our recommendations are designed to lower the probability of getting an infection. For instance, wearing a mask helps reduce the risk by decreasing droplets in the air, yet it is only effective if everyone wears a mask. Likewise, when the average daily number of new cases drops below 150, the chance of getting an infection will be lower since there will be fewer carriers.
Another key variable is air space and air circulation in a room. For instance, if you are in a standard size room, say 9 by 12 feet and there are 2 or more people in the room without masks, then there is a good chance any droplets or aerosolized particles will remain in the airspace of the room for an extended period of time, thereby increasing the risk of infection. Unfortunately, air conditioning or fans may just circulate or spread those particles more, which would not be desirable.
Proximity to others is also a risk. Staying at least 6 feet apart (and maybe even further) will help reduce exposure. Certain activities such as haircuts and nail salons and massages can not maintain this distance, and therefore represent a higher risk of exposure. Likewise, eating in a restaurant (or even walking into a restaurant where a lot of people are eating) also presents a higher risk, since the people dining in will obviously not be able to be masked. That is why I continue to recommend not doing those activities at this time.
Finally, when Covid19 was first being discussed 3 months ago, there was concern that certain blood pressure medications such as ACE inhibitors (Lisinopril and Monopril for example) and ARBS (Losartan, Valsartan and Olmesartan for example) increased the risk of having a severe case of COVID19. Subsequent research has shown this not to be the case, with ACE inhibitors possibly even being protective against a more serious infection. In addition, data is suggesting that cholesterol meds such as Lipitor and Crestor (the statins) are also potentially protective against a more serious infection. These drugs appear to reduce the inflammatory reaction that occurs with COVID 19. This data is not conclusive, yet it is very interesting. I will speak more about this in my next message. Take care.
Covid 19 update 5-15-20
The governor’s order to stay at home will expire at midnight tonight. However, he has advised those at highest risk to remain at home and I strongly agree with this recommendation. Modelling suggests Arizona will not see a decline in cases until June, and unfortunately the data is supporting that observation. While many of the new cases reported this week are the consequence of testing more people, we continue to see an increased daily death rate. According to the state health department website, some of this increase reflects an adjustment in the guidelines for registering Covid 19 deaths. Nevertheless, we are not seeing any decline in the parameters I believe are important.
When social distancing and stay at home orders were recommended back in March, the hope was to reduce and even eliminate the virus from the population. Now two months later, the strategy seems to have switched to one of containment only. We have recorded over eighty-five thousand deaths in the short span of just 3 months. By contrast, influenza (the flu) had an estimated death rate of thirty-four thousand in 2018-19, the last year for which statistics are fully available.
Certain countries have temporarily eliminated the virus from spreading. However, as we are seeing with South Korea, it does come back, and finding the balance between resuming normal life and controlling the spread of the virus is difficult. We will be dealing with this issue for months to come. At the moment, the only certainty we have regarding Covid 19 is uncertainty. There is some very interesting data though, and next week I will share that with you. For now, I wish everyone well and remind you to please call me either at the office or on my cell phone should you need anything. Take care.
COVID 19 Update May 8, 2020
Hello. This is Dr. Jeff Mayer with another update on Covid 19. Today is Friday May 8, 2020.
Almost two months ago, Governor Ducey issued the first stay at home order to prevent the spread of COVID 19 Coronavirus. Since that order, we have seen a dramatic increase in the number of illnesses and deaths due to COVID 19 nationwide. Arizona has its share of cases and deaths as well, yet thankfully not as bad as anticipated. Nonetheless, as of today, the state health department reports Arizona has 10,526 documented COVID 19 cases and 517 deaths.
A few days ago, Governor Ducey modified his stay at home order. Initially, it was to extend to May 15, yet he has now allowed certain businesses, such as hair stylists and even restaurants, to reopen today with social distancing and other infection control practices. From what I have read, he based this decision in part on the fact that we are seeing a lower percentage of COVID 19 tests be positive for the virus. He feels this indicates a significant reduction in risk of transmission of COVID 19. I respectfully disagree.
The number I most closely follow is the number of new cases reported each day. Specifically, I look at the weekly trend of new cases, rather than any individual day, because reporting of cases is often delayed. I see the number of new cases each day increasing. Part of this increase is a consequence of increased testing (and hence more detection). Yet I want to see the number of new cases trending well below 150 a day to feel confident that we are truly on the decline. We currently are still over 300 cases a day.
To refresh everyone’s memory, public health officials have used models to predict when different areas of the country would peak in terms of numbers of cases. Based on that, Arizona is believed to have peaked already. However, peak is followed by plateau, when we stay at that high level of new cases each day for a while. Decline is the final stage, when we see new cases go down each day until there are none. Just like plateau, the decline stage can last weeks or even months.
I therefore recommend that everyone continue to try to remain at home at least for the next week or two. I especially advise those at higher risk to be patient, and not see hair stylists, and not sit down in a restaurant just yet. If you can, I do encourage you to get outside and take a walk or do other outdoor activities. If you will not be around anyone else, you should probably be ok doing those activities without a mask. However, if you are in a more popular area such as on the Loop or Sabino Canyon, I do recommend a mask or similar nose and mouth covering while exercising.
With regards to the office, we now have enough protective equipment to begin seeing patients daily. However, we have postponed that date to May 18. When we start seeing patients, we will arrange appointments so we only have one patient in the office at a time.
Finally, this pandemic and the sudden changes it has caused to our country reminds me of an old African proverb I learned from Bishop Desmond Tutu (1984 Nobel Peace Prize recipient) at UCLA in the 1980’s. “There is a little bit of heaven in every disaster.” One can look at all the news reports and see this, yet on a more personal level, I hope each one of you can find your own little piece of heaven in this awful historical event.
Data from the Arizona state health department on number of new cases daily. Pay attention to the increase over the last week or so. Be aware the numbers/bars at the very far right of the graph are not up to date. The map reflects the breakdown by county of cases in Arizona.
Weekly update COVID 19 April 24, 2020
Not much is changed from last week. In Arizona we continue to see approximately 300 new cases a day, which is okay news. If the disease was rapidly progressing we would expect to see a much higher rate of new infections each day. One popular model predicts we are peaking this week here in Tucson. Currently the stay-at-home order is set to expire next Thursday, April 30, and Governor Ducey will announce next week what will be done. For those who may be interested, I have posted a link to an article on 5 different projection models being used nationally on the website.
Some data is starting to emerge on different therapies being tried for Covid19. Hydroxychloroquine either alone, or in combination with Azithromycin, has been disappointing and even potentially dangerous. The FDA today issued a report stating the combo may affect the electrical system of the heart, putting a person at risk for sudden death. In addition, a VA study publicized earlier this week showed no improvement in survival with the combo, and a higher death rate in those individuals who only got hydroxychloroquine alone.
Despite high hopes, Remdesivir, a drug developed to treat Ebola virus, has so far not shown to be beneficial either. Other medications are being looked at in multiple trials going on throughout the world. Hopefully one of these trials will discover a treatment.
The greatest challenge is treating those individuals who end up on ventilators. Often there is a combination of two processes going on: the viral infection itself, and their own immune
system’s over reaction to it. This “Cytokine storm” as it is called, leads to a massive inflammatory process in the body, which can potentially cause more damage in certain ways then the infection itself. This reaction can happen with other infections and conditions, and it has been heavily researched for the past 25 years. Unfortunately, we still have few improvements in therapy.
One distressing outcome of this Coronavirus pandemic is the number of scams and false information that have popped up over the last several weeks. Medicare patients specifically have been targets of scams through the years, and this week a patient told me she was called and offered a “free” Medicare Kit (there is no such thing). She did not give the caller any information. I want to emphasize that you should NEVER give your Medicare or Social Security number to someone who calls you unexpectedly on the phone. When we refer someone to a specialist, or order something for them such as a wheelchair, we will forward that information to the office we are utilizing.
Likewise, there are no therapies or preventative treatments available (apart from social distancing and wearing a mask) for Covid19, so please do not purchase anything. Also, if someone calls offering to sell you a mask or similar protective equipment, it is almost certainly fraudulent.
Finally, I am anticipating we will resume seeing patients in the office after May 10. Most likely, we will only have one patient come in each hour so we may preserve social distancing. Please everyone stay safe and call me if you have any questions.
Link to Covid Model article
https://www.nytimes.com/interactive/2020/04/22/upshot/coronavirus-models.html
