Medical Bits – Vol. 2.6: Your Health and Medical News

Much has happened since the outbreak of the COVID-19 Pandemic. For most Homo Sapiens toiling about alongside millions of other species on planet Earth, the last few months have offered a surreal journey and have reminded us that despite the transformation of our surroundings and the “control” we appear to exert over our environment, we remain at the mercy of Nature and the simple rules of biology.

We have discussed in the past that without viruses and their ability to transfer genomic segments between species, evolution and our own existence would be impossible to imagine. Since our last update on April 1st, we have learned a few things, while many questions remain unanswered.

• “The interconnectedness of the modern world has been a boon for COVID-19, but it may be its downfall, as scientists around the world focus their attention to its RNA genome and the 27 proteins it commands”, as outlined by The Economist a few weeks ago.
• A beta coronavirus harbored by bats, may have mutated when infecting an intermediary host, possibly the pangolin. Thus, recombining its genetic material and gaining the ability to be transmitted between humans.
• The genetic material from the virus infecting those early Wuhan patients was very similar, suggesting that the virus likely jumped from this intermediary host only once, and then spread through our fellow apes.
• Genetic sequencing and analysis of genomic divergences indicates this likely happened in early October 2019. It seems that those “Wet Markets” in Wuhan may have provided the perfect theater for bats to come into contact with pangolins and humans. The rest is history.
• Once this novel virus acquired the ability to be transmitted between immunologically naïve humans, transmission and circulation began, in and around Wuhan, spreading disease and wrecking economies and lives throughout all continents except Antarctica.
• Herd immunity is achievable… and Sweden is carrying out the experiment for all of us.

It is estimated that Stockholm will reach that goal by mid-June when 50-60% of its citizens become immunized after exposure. Epidemiologists estimate that 60-80% of the population must become immune in order to stop the transmission of disease. The Swedish model has been criticized by our Executive branch and many others, but while its mortality has been a bit higher compared to other Scandinavian nations, it is a lot lower than Western Europe and the US. More than 50% of their deceased have been nursing home residents and immigrants, raising alarms that vulnerable populations have not been adequately protected. We should keep in mind that Swedes in general are highly educated, physically fit, have a high level of trust in their government institutions and follow sensible and rational recommendations as few other nations do: I invite you to read more about it here: https://www.foreignaffairs.com/articles/sweden/2020-05-12/swedens-coronavirus-strategy-will-soon-be-worlds

Origins

As discussed in the past, zoonosis (infections originating in animals and passing to humans: think HIV, Ebola, SARS, MERS, and now COVID-19) have become more common as humanity covers the planet and invades the habitat of our cosmic journey’s co-habitants. Our encroachment of the habitat of numerous species, places humans in the path of other mammals and insects, increasing the risk of disease. In this case, it may well be that it was our fellow humans’ greed and disregard that may have created the perfect storm.

Two prior potentially deadly coronaviruses epidemics originated in viruses found in bats. The SARS-CoV epidemic may have spread from horseshoe bats from a cave in the Yunnan province of China into civets (small cat-like nocturnal mammal from the tropical forests of Asia) sold at the markets of Guangdong province and then into humans. The MERS-CoV jumped from bats into camels and then into their handlers and while deadlier, it is far less infectious.

Different coronaviruses infecting the same host are “happy” to combine parts of their genetic material. SARS-CoV-2 has a spike protein (S-protein of the receptor-binding domain – RBD) on the viral surface with a special configuration that allows it to interact with ACE-2 (Angiotensin-Converting-Enzyme type-2) receptors on the surface of cells of the respiratory tract (nasal cavities, paranasal sinuses, oropharynx, wind pipes (trachea-bronchi) and the alveolar surface in the lungs. This “receptor-binding domain” and the ability to attach to those cells provides the novel virus with its infectivity, allowing it to get incorporated into our cells to initiate a process of exponential and rapid replication which may lead to disease.

It seems almost certain that our new coronavirus SARS-CoV-2 originated by intermingling of coronaviruses from bats and pangolins.

As reported in Nature https://www.nature.com/articles/s41586-020-2313-x coronaviruses isolated from pangolins showed a congruence of over 97.8% in the amino-acid identity and in particular, the receptor biding domain within the Spike protein was identical, with only one non-critical
amino acid difference. These results of comparative genomic analysis indicate that our 2020 nemesis possibly originated from the recombination (or “love-making”, to use an expression that may be better understood by some elected officials and cabinet members) of a Pangolin-CoV-like virus with a Bat-CoV-RaTG13-like virus (There is no confirmation yet, as the rest of the RNA genome is 95% similar and other hypothesis need exploration).

Interestingly, for the past few years, wildlife conservationist in the US have been asking the government to provide Endangered Species Act protections to pangolins as more than 900,000 of them have been trafficked and killed over the past two decades. You would not be surprised to learn that the Trump “administration” has refused to act.

Pangolins are small spiny mammals with the appearance of ant-eaters and are perilous close to extinction, which does not seem to deter humans. It is one of the most trafficked mammals in China and South-East Asia. All 8 species are endangered, two critically, and protected under international laws.

They are illegally sold in “wet markets” and curiously, they are able to harbor the virus but do not become ill, thus, making the species a “carrier” of the disease.

You may wonder why are these shy, cute and inoffensive mammals now critically endangered? After all, they survived for more than 80 million-years in the wild. But you are fully aware that since our Homo Sapiens ancestors left East Africa to roam the planet some odd 300,000 years ago, we have been responsible for countless extinctions. Some of our cousins in South East Asia attribute special power to their scales and other body part which may have doomed the survival of these small companions in the cosmic journey we call life. Possibly more so after these rumors. Yet, they are as blameless for their existence as we are for ours!

We may come to call the Great Pandemic of 2020, the Pangolin’s Revenge!

My sophisticated patients and friends know that most conspiracy theorists have poor scientific knowledge and easily jump to conclusions that may fit their preconceived notions and help their political “destiny”. It is appalling to witness the President, his Secretary of State and countless other enablers repeat shameless lies and non-sensical theories.

In my opinion, before brandishing accusations or raising dangerous doubts that may cause real harm to humans here or abroad, politicians have the duty to have incontrovertible information to support their claims and our citizenry has the duty to demand it. Think of Cheney’s “weapons of mass destruction” obvious lies two decades ago and the loss of lives and treasure, let alone the suffering those reckless falsehoods precipitated that continue unabated to this day.

As you are aware, they are now all busy spreading disinformation and promoting hypotheses of potential “enemy action” and Wuhan Virology Institute origins. Since the advent of genetic engineering in the late 1970’s such claims of deadly “design biowarfare” have been propagated with gusto, but there is no shred of scientific evidence to support them in any of the infections suffered by humanity thus far and less so for the COVID-19 pandemic.

To be sure, this does not only reflect our unwavering optimism and trust in human ingenuity and good intentions. We are aware of the existence of over 70 biosecurity-level 4 laboratories in 30 nations, where dangerous pathogens are analyzed and in some, “gain-of-function” studies are carried out, and potential pathogens are manipulated to possibly make them capable of infecting other species or evading their immune systems. Yet, no credible evidence suggests that COVID-19 originated in a laboratory or under “bad intentions”. The recorded genomic sequencing testimony lends full support to Nature at work despite Trump and his supporters’ claims.

Definitions

• COVID-19 refers to the disease, (positive 2019 coronavirus laboratory test regardless of disease signs or symptoms).
• 2019-nCOV was the initial name of the virus, where nCOV stands for novel coronavirus. However, this name is not consistent with virus naming conventions.
• SARS-CoV-2 is the Gen-bank name for the virus, (96% identical in nucleotide sequence to SARS-CoV, the cause of SARS in 2002-3).

Transmission

• Person-to-person spread occurs via respiratory droplets, similar to influenza. According to a WHO – China report, the rate of symptomatic infection after confirmed exposure ranges from 1-5%.
• The mean incubation period is 5 days but may take up to 14 days after exposure for symptoms to appear.
• Most infections are not severe. In an earlier report from the Chinese Center for Disease Control and Prevention that included 44,500 infections, 81% were mild, 14% were severe with multi-lobar pneumonitis and 5% had critical disease developing respiratory failure.
• Initial case-fatality rate was 2.3% but likely much lower, as many cases are asymptomatic which lowers the case-fatality rate but allows for the creation of a larger reservoir, as asymptomatic individuals may transmit the disease and help propel the epidemic.
• Case fatality rate has ranged from almost 10% in Italy to 0.1%in Germany. There are multiple factors to consider. Age of population, access to technology, public health organization, etc.
• More than 80% of cases are mild and only 3% of all clinical cases occur in people under 20.
• Cruise ship outbreak off the coast of Japan, all the passengers and staff were tested, 17% of the population tested positive, but 50%were asymptomatic at the time of diagnosis.
• On Feb 28th, 2020, Li et al. reported the initial cohort of patients, describing that the median age was 59 years, with higher severity of illness in the elderly and among those with chronic conditions. There were no cases reported in children below 15 years of age, likely due to mild disease which escaped detection and implies that the case-fatality rate is a lot lower than initially perceived as discussed above.
• Another article by Guan et al. reported on Feb 28th, 2020, a mortality of 1.4% among 1100 patients with laboratory-confirmed disease but the case definition required pneumonia.

Mortality

• Out of almost 50,000 cases reported and analyzed:
• 15% mortality in patients over 80.
• 8% mortality in patients over 70.
• 4% mortality in patients over 60.
• 1% mortality in patients over 50.
• 0.4% mortality in patients over 40.
• Less than 0.2% mortality in patients younger than 40.
• 5% overall mortality in patients with underlying respiratory disease or malignancy.

Testing and Diagnosis

Poor initial national response and dismal leadership from the White House.

For a comprehensive discussion and review of our National poorly coordinated Pandemic response: https://www.nytimes.com/2020/03/28/us/testing-coronavirus-pandemic.html?campaign_id=34&emc=edit_sc_20200331&instance_id=17208&nl=science-times&regi_id=73874292&segment_id=23391&te=1&user_id=7c61cdd369e5e89648c819ddce494fef

• CDC initially inflexible on testing guidelines (needed travel or exposure history):
• Test required slow, overnight RT-PCR reaction with a specific model, designed poor primers and became aware a month later.
• FDA had stringent rules on testing:
  • Approved only CDC test; refused working tests from WHO and other countries
  • Required CDC to retest results of other labs
  • Allowed academic labs to develop own tests on 2/29/20
  • Approved rapid Roche test on 3/13/20
• Individuals who develop high fever and associated progressive breathlessness warrant testing.
• Individuals without high fever or breathing difficulty do not require immediate testing except if important for epidemiologic reasons or to limit infection to vulnerable groups.
• If you or a loved one develops respiratory symptoms, obviously COVID-19, influenza, another respiratory virus, or pneumonia are possibilities and sometimes impossible to tell them apart unless testing is completed.

Clinical Presentation

• Many patients with clinical disease, presented with fever, frequently above 102 F / 39 C.
• 60% dry cough
• 60% loss of sense of smell – characteristic feature.
• 35% body aches.
• 30% difficulty breathing, usually after 5 days of acute illness.
• 25% mild diarrhea.
• Pneumonitis (inflammation of the alveolar-capillary membrane where gas exchange is carried out) is the most common feared complication in patients with moderate to severe disease.
• Myocarditis and heart inflammation in less than 5% of patients with clinical disease.
• Activation of the coagulation system leading to small clots in the lungs and other organs is problematic in severe disease.
• White cells may be elevated or low and lymphocytes < 1500.
• The reported pediatric multi-systemic inflammatory syndrome is very rare and occurs in different types of bacterial/viral infections.
• Some patients have elevated liver function test.
• Minimal symptoms or even no symptoms are common.
• Tracking application reported in Nature:

Isolation

What if you traveled or a family member has an acute respiratory illness? Do they have COVID-19. Do we have to keep distance in order to avoid becoming vectors and spreading the disease?

• Test-based – may discontinue isolation;
  • Spontaneous resolution of fever and improvement in cough and shortness of breath and
  • Negative COVID-19 testing twice > 24 hours apart.
• Non-Test based – may discontinue isolation: o > 7 days have passed since symptoms first appeared and o > 3 days have passed since recovery of symptoms.

Goals of Mitigation in Pandemics

• Approximately 3-5% of total infected (not diagnosed cases) may require hospitalization.
• 2.5% may require support in Intensive Care Units.
• Average hospital stay is 2 weeks (1 week after diagnosis).
• Most patients who develop Respiratory Insufficiency requiring mechanical ventilation perish – Northwell Health System from NY reported that out of 5700 admissions, over 80% of patients who received mechanical ventilation died. Likely much lower as experience and new medical approach / medications utilized. In our experience, the mortality after ventilator support approximates 40%.
• Goal: slow down doubling time from 1 week to >8 weeks, such that at peak < 500,000 hospitalizations per week.
• Most important is to handle the current Pandemic and prevent the next one.
  • Prohibit wet markets.
  • Enforce the laws banning the trade of endangered species and limit the trade of wild animals.
  • Strengthen the World Health Organization and its surveillance teams worldwide.
  • Be prepared for the next Pandemic – Influenza, Ebola or Coronavirus or yet unrecognized new viruses. It will happen, but no reason to panic!
• Rapid diagnostic tests: may help determine who already had the disease and give us a better sense of the disease “denominator” and the time to reach “heard immunity” (usually when 70-80% of the population becomes immune).

New York State reported on April 27th that out of 7500 antibody studies, 15% were positive state-wide. In New York City, 24,7% of those studied were positive!

Clinical Trials & Treatments

There are over 300 clinical trials underway in China and as of today, May 11th, 2020 there are 1324 clinical trials listed on www.clinicaltrials.gov to evaluate several new, re-purposed medications and vaccination trials. The list keeps growing daily.

Sadly, as world leaders met in Brussels on May 4th to discuss global cooperation and pledge billions of dollars to face this challenge and organize a united shield, the United States was absent, once again abdicating its global responsibility and leadership role.

• There are 8 vaccine clinical trials underway and more than 95 vaccine candidates. An excellent review of the challenges was published in Science on May 4th: https://science.sciencemag.org/content/early/2020/05/12/science.abc5312 another good summary can be found here: https://www.nejm.org/doi/full/10.1056/NEJMp2005630?query=featured_coronavirus
• A webinar shared by one of my patients with a nice summary can be found here with collaboration from Duke University and NAIAD – Dr. Anthony Fauci: https://www.youtube.com/watch?v=-Gn8oJY1VHY&feature=youtu.be
• Another summary here: https://www.cfr.org/backgrounder/what-world-doing-create-covid-19-vaccine
• Novel RNA Vaccine – Phase I clinical trial launched March 10th at Kaiser Permanente Washington Health Research Institute in Seattle.
• Remdesivir, promising nucleotide analogue with activity against COVID-19. Previously used against SARS, but epidemic controlled and medication “shelved”. Now used for moderate to severe infection. In preliminary reports it reduced the time to resolution of respiratory failure and expedited clinical improvement. Likely best to use earlier in the course of moderate to severe disease. Several clinical trials ongoing and proven to shorten the course of disease and time to liberation from ventilators.
• Immune plasma – containing antibodies from recovered patients or immune individuals. Currently being utilized in most centers. Trials ongoing but it may be beneficial early on in patients with moderate to severe disease.
• Favipiravir is an RNA protease inhibitor that may accelerate viral clearance (median time decreased from 11 to 4 days) and accelerated radiographic improvement on chest radiography in an open-label, non-randomized study.
• Lopinavir-ritonavir has in-vitro activity, but a study out of China in 200 patients with severe pulmonary disease, failed to demonstrate clinical benefit or mortality. NO role at this point.
• Hydroxychloroquine: Recent study evaluated the outcomes of 1376 patients admitted with COVID-19 in NYC. 60% received HCQ. No benefit at all. NO role despite White House promotion.
• Other agents:
  • Camostat mesylate blocks viral proteases
  • Tocilizumab – Actemra – Interleukin-6 pathway inhibitor.
  • Toremifene
  • Irbesartan – Losartan
  • Melatonin
  • Paroxetine
  • Mesalamine
  • Eplerenone
  • Carvedilol
  • Sirolimus
  • Umifenovir.
  • UV LIGHT and BLEACH – Don’t try it.
• Home management and observation may be appropriate for the majority of patients who are likely to develop relatively mild disease.
• Supportive care measures – Intravenous hydration.
• Symptomatic relief
• Care of complications – Oxygen supplementation.
• High flow O2 administration.
• Mechanical ventilator support if progressive pneumonitis.

Mortality

• Initial case-fatality rate was 2.3% but likely much lower, as many cases are asymptomatic. This lowers the case-fatality rate but allows for the creation of a larger reservoir, as asymptomatic individuals may transmit the disease and help propel the epidemic.
• Case fatality rate has ranged from 5.5% in Italy to < 0.1% in Germany. There are multiple factors to consider. Age of population, access to technology, public health organization, etc.
• One problem is the inaccurate overall denominator.
• This is a lot lower than the mortality documented from the other coronaviruses emerging in the 21st century SARS – 9-10% or MERS -35%.
• An excellent tracker which includes the number of tests completed in different nations can be found here: https://www.worldometers.info/coronavirus/
• 2.5-5% of patients will develop severe disease some requiring Intensive Care Unit Support.
• Out of almost 50,000 cases reported and analyzed:
  • 15% mortality in patients over 80.
  • 8% mortality in patients over 70.
  • 4% mortality in patients over 60.
  • 1% mortality in patients over 50.
  • 0.4% mortality in patients over 40.
  • Less than 0.2% mortality in patients younger than 40.
  • 5% overall mortality in patients with underlying respiratory disease or malignancy.
• Another article by Guan et al. reported on Feb 28th, 2020, a mortality of 1.4% among 1100 patients with laboratory-confirmed disease but the case definition required pneumonia. Only patients with moderate to severe disease develop pneumonitis.

What should our patients do?

WHO and CDC recommend:

• Use contact and droplet precautions with mouth and face protection.
• What should our patients with existing respiratory conditions and vulnerabilities be alert to? The usual symptoms of influenza – fever –runny nose – dry cough and in particular, increasing trouble breathing, which may indicate progression of disease and development of inflammatory viral pneumonitis (damage of the pulmonary alveolar-capillary membrane where gas exchange takes place).
• If you have these symptoms, stay home. Treat your symptoms with over the counter remedies and remain well hydrated. Apply Grandma’s treatment!
• If you develop increasing breathlessness, intractable cough and associated high fevers over 102-103, grab a mask to cover your face and proceed to your Emergency Department for evaluation.
• If you become ill, testing your oxygenation daily with a pulse oximetry device may help give you early signs of trouble. You could purchase one for $20 online or YOU CAN DOWNLOAD the application FOR 99 cents – Pulse Heart Rate Oximeter

Additional Resources

The International Coalition for Epidemic Preparedness and Innovations (CEPI) is already working on up to eight vaccine candidates. One has launched as indicated above. If you would like to keep abreast of this rapidly moving field, see the references at the bottom of this summary.

Electron microphotograph of viral particles – SARS-CoV-2 – Covid-19 – NEJM

Debunking Myths: Q&A

Myth: Wearing a respiratory mask at all times will keep me safe!!! 

Partially. They may decrease aerosolization of viral particles and should be worn by those with acute respiratory infections to decrease the spread of viral particles. Regular surgical masks do not fully decrease the penetration of viruses. The N-95 masks are effective in catching viral particles and most suspended droplets, but serious business to wear for a long time, must be fitted, placed properly and importantly, removed accurately to prevent contamination.

It certainly makes sense to wear them in enclosed, public spaces, but not when in your car or walking / running outdoors.
In one study completed in a Japanese hospital, the use of surgical-type masks by health care workers did not reduced the frequency of colds or respiratory illnesses and subjects using masks were more likely to complain of headaches.

Myth: N-95 masks cannot be re-utilized!

Not true. Keep it clean / don’t bend it and clean the front with antiseptic wipes.

Myth: If I get COVID-19, I will develop permanent lung damage!

NOT true. As indicated above, most patients have low grade disease. Patients who develop severe pneumonitis may have modest lung damage that improves over time.

Myth: I can get COVID-19 not only once but several times and severity increases!

NOT true! Once you have the disease, your body mounts an effective immunogenic response and you are not likely to suffer it again! Gleaning information from the prior SARS epidemic (96% common genome) patients who recovered maintained adequate antibody titers for at least 2-3 years. The spike protein of SARS-CoV-2 is very stable and likely antibodies against this Receptor Binding Domain are neutralizing antibodies.

Commercially antibody tests are now available. If you think you may have contracted the infection weeks ago and are curious to know, a COVID-19 IgM / IgG test may provide the answer.

Myth: There are no diagnostic tests to help me determine if I had the disease!  A

s indicated above, we now have a way to identified immunoglobulins triggered by infection with COVID-19 and able to determine who has become immunized against the disease through a rapid IgG / IgM serologic test performed in a few drops of blood.

Myth: Taking an antihypertensive such as Lisinopril, enalapril, losartan, irbesartan or olmesartan, may increase my risk of COVID-19

Since the virus uses ACE2 receptors to attach itself to the respiratory mucosae! But on the other hand, increasing ACE2 receptor expression, common in patients with hypertension may reduce the risk of severe pulmonary infection. This is an active area of investigation and at present the recommendation is to continue with your usual treatment. In fact, there are two clinical trials looking at the use of Losartan and Irbesartan to decrease the severity of illness.

Furthermore, as reported May 9th, on the New England Journal of Medicine, patients taking this class of drugs for management of hypertension have a 40% lower risk of developing Influenza (rest assured that if you have hypertension, I have prescribed it to you as what is good for your doctor is good for his patients).

Other Questions

How careful should I be with groceries and other packages arriving to my house? I would encourage the use of common sense. Completely eliminating risks is impossible. But gently wiping down metal and plastic surfaces makes sense. More porous objects such as paper and cardboard decrease the survival of the virus generally to less than 12 hours and the viral load is very low.

May I pet a someone else’s dog? Yes. Dogs are not carriers of the virus and do not become infected. It is not likely that small aerosolized particles will live on the dog’s fur for long and the viral load may be too low to be infectious. A comprehensive review of the virus viability can be found here: https://www.nejm.org/doi/full/10.1056/NEJMc2004973

Do I need to wear a mask if I go outdoors for a walk, hike or running /biking? In my opinion, NO. To get infected we must inhale or expose our vulnerable epithelial surfaces from the respiratory tract to a sufficient viral load and casual exposure to low viral concentrations in an open environment and more than 6 feet apart is highly unlikely to pose a risk. And an excellent review of exposure and infection risks can be found here: https://www.erinbromage.com/post/the-risks-know-them-avoid-them courtesy of one my patients.

Is it safe to swim or be in the water with other people? Chlorinated water inactivates the virus and if the concentration of people in your vicinity is low, likely safe.

What do you think about the Swedish model, keeping the economy open with some social distancing but overall no major changes and sensible precautions? As indicated above, the experiment appears to be working in Sweden. I personally think it is the most rational way forward:

Open most businesses and factories with common-sense precautions. Open restaurants and airports decreasing the density of patrons and fliers, keeping some distance and alternating tables and seats. Washing hands frequently. Wearing masks, particularly when in confined spaces. Infection rates will continue at low levels and slowly will foster herd immunity and over the next 3-6 months normalize activities as dictated by local conditions. Keep in mind that morbidity, mortality and serious medical complications in those younger than 50 is very low and therefore, students and young, healthy workers should resume their activities and get the Nation moving forward. And in the meantime, the world effort towards vaccine development continues at full throttle. https://www.youtube.com/watch?v=-Gn8oJY1VHY&feature=youtu.be

The information from New York City indicates that of early May, 25% of the population already had evidence of immunity and in Stockholm up to 40% already have antibodies suggests that with this approach we may promote “HERD IMMUNITY” within the next few months. But we should take every precaution to protect vulnerable populations and in particular Assisted Living / Nursing Home residents.

The Swedish experiment: https://www.foreignaffairs.com/articles/sweden/2020-05-12/swedens-coronavirus-strategy-will-soon-be-worlds

Finally, I do not claim to have access to Delphi’s Oracle and I am certainly not on the slopes of Mt Parnassus to predict the future or have any more wisdom than you do, but I want my patients to remain informed and to be critical of any and all information.

You may have come across reports that patients were dying hospitals’ hallways, that there was no access to Personal Protective Equipment (PPE) and that the situation in NYC was desperate. After working in NYC – Queens (where the per capita incidence and prevalence still remains the highest in the US) for 4 weeks and discussing with my colleagues, I can attest those reports are mostly fiction and hype.

Sensationalist stories seem to be popular and somehow, command the attention of some fellow humans who seek out tragic stories, probably to confirm that there are some people out there a bit more miserable than they are…Best to tune off all negative or questionable news.

In the meantime, keep cool, do not panic, eat a nutritious and diverse diet, stay active and be happy!  And try to make the best lemonade with the “lemons” nature has thrown our way! COVID-19 is already here and is infecting members of our community. But panic is not a rational response and is not likely to help. This too shall pass! Remember that the only certainty in life is… death… and the only fountain of youth proven by science, experience and millennia are exercise, laughter, humor and a good positive attitude!

Enjoy every minute of this most interesting JOURNEY and cherish this family time!!!

Also, please join me in congratulating and thanking Patty Zhao for her invaluable work, wisdom and marvelous disposition! She is moving on to become a wonderful physician at University of Virginia!!!

PATTY: CONGRATULATIONS AND BEST OF LUCKS!

Emily Ferguson will take over her duties: Emilyf@chevychasepulmonary.com

As I mentioned, the one good thing that COVID-19 brought to the Picone Tribe is thriving! And has almost doubled his size over the past 6 weeks…

Ozzy Covy Picone – Becoming a monster! ?

Cheers!

Carlos Picone, M.D.
5215 Loughboro Rd, Suite 400
Washington, DC 20016

email: cpicone@chevychasepulmonary.com

References:

• https://www.nejm.org/coronavirus
• https://www.cdc.gov/coronavirus/2019-nCoV/index.html
• https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/
• https://clinicaltrials.gov/
• https://www.nature.com/articles/d41586-020-00154-w]
• PPT – Covid19-Science and Treatment. Drs. Steven Gordon and Serpil Erzurum – Cleveland Clinic.
• https://www.foreignaffairs.com/articles/sweden/2020-05-12/swedens-coronavirus-strategy-will-soon-be-worlds
• https://science.sciencemag.org/content/early/2020/05/12/science.abc5312
• https://www.nejm.org/doi/full/10.1056/NEJMp2005630?query=featured_coronavirus
• https://www.youtube.com/watch?v=-Gn8oJY1VHY&feature=youtu.be
• https://www.cfr.org/backgrounder/what-world-doing-create-covid-19-vaccine

We continue to offer Telemedicine appointments and office visits (the flesh and bone type) as of June 4th.

ANNEX: COVID-19 Timeline

From Nature: https://www.nature.com/articles/d41586-020-00154-w

• 21 December, 2019, a few patients became ill with severe pneumonia in Wuhan, Hubei province of China.
• 31 December, 2019, a new virus is identified in samples from 4 patients with pneumonia of unknown cause. All patients had been present at the Huanan Seafood Market in Wuhan. Viral genome isolated and sequenced. Initially named 2019-NCoV (Novel Coronavirus 2019).
• 8 January, 2020 – Nature reports on the new virus, cause of mysterious “deadly pneumonia” in Wuhan, China.
• 21 January, 2020 – First US case confirmed in Washington State. 30 yo man returning from Wuhan, China.
• 23 January, 2020 – China closes Wuhan.
• 24 January, 2020 – Second US case. 60 yo woman returning to Chicago after visiting China.
• 28 January, 2020 – Human-to-human transmission confirmed in Germany.
• 3 February, 2020 – Study of live virus published.
• 6 February, 2020 – Retrospective autopsies completed in mid-April in Santa Clara, CA confirms that first deaths occurred in early Feb.
• 14 February, 2020 – Chinese authorities reveal number of infections in medical staff: 1,716 health workers had contracted the virus, 6 of whom died
• 17 February, 2020 – First case in Africa
• 25 February, 2020 – U.S. emergency funding for coronavirus response
• 26 February, 2020 – Brazil reports first case in South America
• 28 February, 2020 – Coronavirus spreads to sub-Saharan Africa
• 4 March, 2020 – Multiple drugs under investigation for coronavirus
• 5 March, 2020 – China study suggests children are as likely to be infected as adults, but most do not become ill.
• 11 March, 2020 – Transgenic animals for CV research in high demand
• 11 March, 2020 – Coronavirus becomes a pandemic, says WHO.
• 13 March, 2020 – US President declares “national emergency”. It is no longer a “Chinese virus that will blow over by the spring”.
• 17 March, 2020 – First vaccine clinical trials begin in U.S. (National Institute of Allergy and Infectious Diseases (NIAID) and Moderna (biotechnology company in Cambridge, MA) – “launched in record speed,” 66 days from genetic sequencing of virus to the first human injection of the vaccine candidate.
• 18 March, 2020 – Deaths in Italy surpass those in China.
• 19 March, 2020 – No new cases confirmed in Hubei, China.
• 25 March, 2020 – Retrospective studies in Lombardy confirm that the virus was present in Northern Italy in early January 2020.
• 1 April, 2020 – Over 80% of ICU patients with COVID-19 have underlying medical conditions.
• 2 April, 2020 – Worldwide cases surpass 1,000,000.
• 7 April, 2020 – No new reported COVID-19 deaths in China
• 8 April, 2020 – Tracking App reveals lack of smell is key symptom.
• 15 April, 2020 – Trump – in his infinite wisdom and trust-worthy scientific knowledge – suspends WHO funding. Leonardo Da Vinci’s birthday celebrated by “scapegoating” the WHO.
• 15 April, 2020 – Worldwide infections surpass 2,000,000.
• 21 April, 2020 – Mars probe HOPE ships from UAE to Japan for launch after July 15th when Mars and Earth are aligned. It should reach the Red Planet by 2021.
• 21 April, 2020 – https://1daysooner.org/volunteer launched. 15,000 people volunteer to be exposed to virus and accelerate vaccine development.
• 27 April, 2020 – The five ways Trump is undermining environmental protection under the cover of the Pandemic: https://www.nature.com/articles/d41586-020-01261-4
• 29 April, 2020 – Remdesivir speeds up recovery!
• 7 May, 2020 – First CRISPR testing kit approved in US. It works by programming the CRISPR machinery to detect snippets of the virus genetic material and expedites results to 1 hour.
• May 11, 2020 – Over 4,300,000 cases and 290,000 deaths worldwide. Pandemic tracker: https://coronavirus.jhu.edu/map.html

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