We Are Members of Privia Medical Group

As of January 25, 2021, we are proud members of Privia Medical Group!

Antibody Testing Update

There has been a lot of recent talk about antibody testing for COVID-19 (remember, this is different than the swab test to detect if you currently have COVID-19; antibody testing is a blood test that is intended to show if someone has had the infection), and we have understandably started getting a lot of questions from patients wondering if their child should get tested for antibodies to SARS-CoV-2 (the coronavirus that causes COVID-19). Right now, the answer is essentially “no”, and we thought it would be helpful to explain why.

Questions with the tests themselves
There are currently lots of tests available on the market; very few have been validated by any federal body (FDA, CDC, NIH – for more information on this, see the following article). Some are even falsely claiming FDA approval. There is a lot of concern about accuracy with many of these tests. In addition to the regular issues surrounding testing (accuracy, quality of the methods and materials), another concern with these tests is whether they will be detecting antibodies to other coronaviruses (which cause some of the common colds seen every year). In the coming weeks, there should be some clarity about the best tests to use for detecting antibodies to SARS-CoV-2.

Questions about what the information means
Even if we assume the test being used is high quality and accurate, there still remain many questions re: what the information means. For instance:

  • What level of antibodies is protective?
  • Does the presence of antibodies indicate that someone is no longer to contagious to others?
  • What antibodies is the test testing for (IgM or IgG or both/mixed)?
  • What part of the virus are these antibodies being detected directed against and are these the important antibodies, i.e. are these ones that confer protection?

Additionally, because of strange truths of statistics, in areas with a relatively low prevalence of the disease (which may still be true of Central Florida), a positive test is more likely to be a false positive than it is to be a true indicator of having had the illness.

So if someone gets an antibody test that is positive and concludes that they might have had COVID-19, that is probably a reasonable assumption. However, it does NOT mean 1) that you definitely had it, 2) that you are no longer contagious, 3) that you cannot get infected with SARS-CoV-2, 4) that you can safely go around without a mask, unable to pass or catch the infection.

What situations is antibody testing currently recommended
Currently recommended uses include:

  • Testing someone in whom COVID-19 is strongly suspected but had a negative viral swab
  • Testing someone in preparation to donate plasma for the treatment of someone else currently sick

(To read more guidance on antibody testing, see the following from the Infectious Diseases Society of America)

Another use of these tests is for testing populations to try to get a more accurate idea of “seroprevalence”, i.e. how many people in a community might have already been exposed. These are widespread public health efforts and will hopefully be happening much more in the coming weeks-months. More useful for a population than for an individual. But currently there are too many questions about the tests available and what the information will mean to recommend testing. At this point the market and the enthusiasm have outpaced the science.

As with everything with our current situation, the recommendations will be changing over time. Antibody testing is almost certainly going to play a significant role in how we navigating this virus, but it does require a little patience right now. So stay tuned; we will provide updates as this evolves.

(If interested in reading more, see the following articles from the New York Times and Washington Post and Nature)

COVID-19 Update

Some numbers

As of 3/27/20…
  • In Florida – ~2500 positives, ~25,000 negatives, ~8% of tests performed have been positive; almost 30,000 total tests done, 29 deaths
  • In Orange County, we have had ~1500 tests with 120 positive cases
  • In the U.S., we will likely reach 100,000 cases today; currently there are ~15,000 hospitalized, ~600,000 tests performed, ~1300 deaths

Some updates

Further efforts to keep everyone safe and healthy…
  • Wait in your car until your room is ready. We have implemented the process of allowing patients, if they prefer, to wait in their car until their room is ready by communicating with text messaging. Patients with appointments will receive a text message from us, asking them to let us know when they arrive. They will then be checked in for their appointment and will receive another message letting them know that we are ready to room them and which door to enter.
  • We are seeing only well visits in the morning and seeing sick visits in the afternoon. It is extremely important that your child continue to be seen for their regular well visits, especially the younger children, and continue to stay up to date on their vaccinations. In order to provide an environment that families can feel more confident will not be unnecessarily putting them at risk for exposure to COVID-19, we are temporarily arranging our day this way. This does mean that the walk in time for sick visits from 8:15-9:00 am is temporarily suspended. Though we are thoroughly practicing many different measures that we believe also address and reduce this risk, we hope this will allow us to continue to meet the needs of our patients, both when they are well and when they are not.
  • We have increased our utilization of telemedicine visits in a variety of ways, and we believe this has been and will continue to be a useful alternative during this time.

And finally, some inspiration and encouragement

Here for you and your family.

COVID-19 Update

Number of cases / Positive tests
As of 3/22/20…
  • In Florida – 1007 positives, ~9500 negatives, ~1000 pending; ~11,500 total tests done, 13 deaths (average age ~79)
  • In the U.S., approaching 33,000 cases, ~200,000 tests performed, ~414 deaths

Update on Testing

Unfortunately we are still in a situation of very limited testing capabilities; therefore
  • it is still difficult to get tested unless meeting the strictest of criteria (illness in someone with close contact with a confirmed case of COVID-19; illness in someone with international travel to an area of outbreak; illness in someone immunocompromised; illness in an elderly patient). Tests are trying to be used in these patients as well as in healthcare workers with illness.
  • The turnaround time for test results is taking up to 7 days in some cases.
Because of this, many patients with possible COVID-19 illness will need to be treated “presumptively” with isolation/quarantine and monitoring, even in the absence of a positive test. This is, as stated before, a rapidly evolving situation, so stay tuned.

Pediatric Cases

On an encouraging note, the pediatric cases in Florida so far have been relatively few, not severe, and no fatalities. Obviously, this could change as more illness is seen, but this is consistent with reports from other countries and for now we are encouraged by this.

“Homeschooling”

Finally, many local students will be beginning their “homeschooling” this week. We realize this is potentially stressful for many/all (kids and parents alike), and though it is not a “pediatric medical” issue, it certainly is a big part of our children’s overall health. Therefore, we wanted to offer what we hope will be some helpful resources. So see the following links and tips, including some from my wife Adair whom I asked to share some of her best thoughts, which she kindly did.
Tips:
  • Routines! Establish a consistent schedule.
  • Don’t be discouraged by days that don’t go well. This is inevitable. Don’t evaluate “how it’s going” on a daily basis. Look at larger chunks of time (at a minimum, weekly; perhaps every two weeks) and then tweak as necessary.
  • Consider having your child take up a hobby during this time.
  • Ask your friends who have homeschooled their children for their best tips.
Articles:
Here for you and your family.

COVID-19 Update

Number of cases / Positive tests

As of 3/20/20…
  • In Florida – ~563 positives, ~5700 negatives, ~1100 pending; ~7200 total tests done
  • In the U.S., approaching 20,000 cases, ~120,000 negative tests, ~256 deaths

Telemedicine Visits

As many of you are aware, we have the capability of doing virtual visits for appropriate conditions, and we are planning and prepared to significantly increase the utilization of these visits in the coming weeks. Most commercial insurance plans in Florida have historically not paid for these visits (though we hope the Florida legislature will change this soon). However, due to the current outbreak, many more of the payers are agreeing to pay for telemedicine visits and there have been some Federal legislative directives towards making sure these visits are covered during the current outbreak.

“Is all this an over-reaction?”

I had mentioned in the previous update that I wanted to address some of the comments I have heard questioning or not understanding why such extreme measures were being taken for a disease whose absolute numbers are much less than a typical flu season and whose symptoms can be quite mild in a large percentage of the patients. Many of these sentiments have been expressed by comparing COVID-19 to influenza, and this is understandable and potentially helpful as influenza is something we are much more familiar with. However, often when this comparison is being made, it is being done in a spirit of “why are we so worried about COVID-19? The numbers are so small compared to what we see with flu!” (As an aside, we think the American public should be more concerned about influenza than is typically the case, and so if these statements were being made in the spirit of a healthy respect for influenza and the regular impact it has, that would be welcomed). These “downplaying comparisons” to flu are in many ways not helpful and not accurate. It must be stated that this is definitely not the same as the flu and definitely appears to have the potential to be much worse than the flu. The extreme measures currently being enacted are not being done so because of the current number of COVID-19 cases and deaths. In fact, none of the recommendations are even because of fear that the disease will continue at the current incidence for the coming weeks and months. The concern, based on data learned from other countries, is based on what might be, not what currently is. Comparing it to influenza (in terms of absolute numbers of cases and fatalities) is sort of like looking at influenza numbers in October of a season and concluding that it has been a mild flu season because we have so fewer cases than last year. In this way, the comparisons are not helpful and not accurate.
There are ways that comparing it to flu actually are helpful and instructive. COVID-19 does seem to be transmitted in a very similar method to influenza. Though there are some symptoms that are similar, the illnesses seem to present somewhat differently in that influenza typically has an abrupt onset (i.e. you tend to feel sick and miserable from the very beginning), whereas COVID-19 seems to begin mildly and then in some cases progress to more serious cough and difficulty breathing.
It certainly could end up being not nearly as bad as many factors would suggest (and we all hope that is true), but the decisions being made are based on what is currently known about the virus, not what we are hoping is true. And what is currently known is definitely concerning for all of us as a community (even if as an individual, there is a high likelihood it would be fairly mild).

An article with some practical advice

See the following article from the Washington Post about grocery shopping in a time of COVID-19 

And, finally, some relevant wisdom from 500 years ago

Many of us are wrestling with how one’s faith should guide our actions and emotions in a time like this, and there have been many encouraging words written offering perspective and even personal encouragements shared with our team from families of the practice. We are so grateful for those. In that spirit, I find the words of church leader Martin Luther from 500 years ago when asked how the church should respond in such a time inspiring and instructive and wanted to pass them along.

“I shall ask God mercifully to protect us. Then I shall fumigate, help purify the air, administer medicine and take it. I shall avoid places and persons where my presence is not needed in order not to become contaminated and thus perchance inflict and pollute others and so cause their death as a result of my negligence. If God should wish to take me, he will surely find me and I have done what he has expected of me and so I am not responsible for either my own death or the death of others. If my neighbor needs me however I shall not avoid place or person but will go freely as stated above. See this is such a God-fearing faith because it is neither brash nor foolhardy and does not tempt God.”

So… unless your presence is essential and needed, please stay home and follow the recommendations of our leaders.

Here for you and your family.

COVID-19 Update

As expected, things are changing quickly in terms of increased number of cases. This is due to both the actual spread of COVID-19 as well as increased testing. Florida has the fifth highest number of confirmed cases currently in the United States.
Number of cases / Positive tests
As of 3/19/20…
  • In Florida – ~328 positives, ~1300 negatives, ~1100 pending; ~2800 total tests done
  • In the U.S., approaching 10,000 cases, ~70,000 negative tests, ~132 deaths

One of the common questions I keep hearing is “Why are we as a country taking such extreme measures when it seems like 1) relatively speaking there is not much illness and 2) in most cases it isn’t that serious?” I will address each of these separately – the first today and the next on a subsequent update – by providing some resources that might be helpful.

As you are all aware, the state of Florida has issued a number of measures re: public places and public gatherings, and we continue to encourage eveyrone to take these seriously and abide accordingly.

Here for you and your family.

COVID-19 Update

Number of cases / Positive tests
As of 3/17/20…
  • In Florida – ~200 positives, ~1000 negatives, ~1100 pending; ~2300 total tests done
  • In the U.S., ~6000 cases, ~50,000 negative tests, ~100 deaths
What we as an office are doing differently
  • We are attempting to screen all patients – phone calls and office visits – in order to direct patients in the most appropriate way (whether being seen in office, home management, or referring for possible COVID-19 testing). Re: testing, this continues to be difficult, both in terms of patients being able to be tested (due to continued limited availability) and knowing exactly where to go. We are continuing to learn about this and trying to guide families appropriately. As many of you are aware, one of the most difficult aspects of this situation has been around the limited availability of tests. Due to this, testing is being prioritized for 1) those with severe illness, 2) those in high-risk categories (e.g. elderly with underlying medical conditions), and 3) healthcare workers. Patients outside of these categories can still receive testing, but priority is being given to these individuals.
  • We have put some of the “high-touch” items in our office away for the time being.
  • Like many other medical facilities (as well as other businesses), we are also screening our employees for any signs of illness at the start of each day.
A few good resources, articles, and misc. thoughts
  • The Florida Department of Health has just updated their dashboard, and they’ve done a really good job. I think you will find it interesting and informative.
  • Good video from WHO explaining the story of what we are dealing with.
  • Webpage for kids to better understand the novel coronavirus.
  • The CDC has recommended that all gatherings of 50 or more people be canceled or the next 8 weeks. Additionally, the President has recommended that everyone avoid gatherings of more than 10 people for the next 2 weeks. Obviously, the specific cutoffs of these recommendations are somewhat arbitrary, but the spirit of the recommendations is clear – limit our interactions with others starting now. The lower the number of people, the better, and when interacting, it is best to keep some distance between people. This responsible social behavior is our “vaccine” for the time being, and our community is dependent on everyone following the guidelines.

We will continue to provide helpful information in the days ahead.

COVID-19 Message from Dr. Middleton

In an effort to come alongside you and your family, I want to share some thoughts re: COVID-19 and where we currently are. As you have undoubtedly already appreciated, the situation is changing almost daily (perhaps even faster). I have been a little hesitant to send out anything because it is so dynamic as well as in an effort to not “add to the noise” (we have all received so many emails from everyone from various airlines to our favorite fast-food restaurants).  But for now, I wanted to offer some updates and some thoughts that I hope will be helpful.

What we know

The number of COVID-19 cases in the U.S. has increased significantly and quickly, is continuing to do so, and that pattern is likely to continue in the coming weeks and months. Currently, the risk of your child having COVID-19 – without a known exposure to someone with laboratory-confirmed COVID-19 and without international travel – still seems very low, certainly as compared to influenza and other seasonal respiratory illnesses. However, this is likely to change in the coming weeks and months as more community spread of COVID-19 is anticipated. Much of what is known about the illness itself is based on the experience of other countries as well as other parts of the U.S. that are further along in this new illness. At this point, it does appear that children are far less affected by the illness, remarkably less likely to have severe illness. However, as we focus on reducing community spread, it must be remembered that children are often the primary ones to spread respiratory illnesses, even when and perhaps especially when they do not have a severe illness.

What we don’t know

Part of what makes the current situation difficult is that there is still a lot of unknown, and everyone trying to predict the future (a difficult proposition at best) and then make decisions that will alter it in a better direction. Many of these decisions are difficult for us as individuals (inconvenient, expensive, frustrating) but are being made in the spirit of what is best for the community. The experience of other communities supports the position that extreme measures at the beginning are far more effective than extreme measures later. We will likely know far more in the next 2-4 weeks re: what our community is likely to experience, both in terms of number of illnesses and severity, even though the outbreak will undoubtedly continue far longer.

What we are doing

What are we as an office doing? There are a few ways we are acting differently, and in many ways, we are not doing anything differently. As an office, we are always trying to make sure our office is clean and the risk of exposure to infections is low; we always want to answer your questions re: your child’s health; we always are trying to communicate with you in a variety of ways. We meet as a team every day, and these days those meetings are as you would expect often a discussion of the current situation to make sure that we are all well-informed, on the same page, and doing whatever we can to serve the families of Middleton Pediatrics with excellence. None of that has changed, though we are trying to do even better in all these measures. In terms of things we are doing slightly differently, consistent with CDC and DOH guidelines, we are trying to ask about exposure risks before bringing patients into the office. If you suspect your child could have coronavirus infection, it is recommended that you call our office prior to coming in. Additionally, you can call your local health department (see our webpage for contact information) if you suspect that your child has COVID-19 or has had a definite exposure.

On our webpage, we have put together some helpful links, local hotlines, and trusted sources of information (see https://www.middletonpediatrics.com/patient-resources/covid-19-updates/). Keep checking as this will continue to be updated.

What we need

Issues like this demonstrate in many ways how connected we all are. Similarly, our responses must be done also with an eye towards the greater community, and our “living as a connected community” skills become even more important. These range from not hoarding toilet paper to not ignoring the recommendations of our health authorities. Some oft-stated reminders that are worth restating: wash your hands and encourage/teach your children to do the same; if soap and water are available, use soap and water and don’t worry about scrambling to find hand sanitizer; if you or your child is sick, please avoid going to public places. Two other communal “skills” are worth mentioning, specifically as they relate to pediatrics and children – staying well-informed and staying calm.

Re: staying well-informed – At this point, the amount of information circulating far exceeds the spread of the virus itself, and much of the information is likely inaccurate and/or incomplete. We encourage you to be wise about your sources and to follow their guidance, especially as it relates to limiting our gatherings with large crowds of people. It is imperative that we look to trusted sources (see webpage for a list of trusted sources). The CDC, WHO, local and state health departments, epidemiologists and infectious disease specialists are all working tirelessly on behalf of all of us, and we are grateful for these individuals and organizations. Additionally, our local hospital systems and their clinical staff have been amazing in their efforts of preparedness as they seek to serve our community. We are blessed by their work; many parts of the country and world are not as fortunate.

Re: staying calm – As is already being experienced, this situation has the potential to produce a lot of anxiety and we need to be sensitive to our children in this way. Though it is indeed good news that children seem less susceptible to this illness, they are acutely susceptible to catching our anxiety. They tend to “adopt” our disposition – if we are calm, they will be too; if we are anxious, they likely will be too. Usually talking about it with your children will help alleviate anxiety, not increase it, provided that we allow them to ask questions, share what they are worried about, and provide them with accurate information (and are careful to not let our own anxiety be inadvertently communicated to them). It can also be helpful to tell them that some really smart people, some of the smartest in the world, are working on this to help keep it under control and keep us protected. There are some other resources listed on our webpage, and we will continue to pass along good resources as we find them. Additionally, everyone (governments, schools, healthcare workers, sports leagues, etc.) is doing the best they can to determine how best to handle the unknowns of this situation, and it is in all of our best interest to be understanding as we work together to keep our community healthy.

As the coronavirus clears our calendars and turns down some of our activities, we encourage you to redeem the time as a family. Play some games with your kids; take walks; watch movies; play outside. Those may be the best things we can do for our family’s health during this time!

Thank you for the opportunity and privilege of serving your family.

Michael Middleton