written by Jordan Hughes, PharmD Candidate Ohio Northern University

Coronaviruses are one of the largest groups of viruses that we know about in medicine, and it has an extensive range of natural hosts. Recently, newly evolved Coronaviruses have posed a massive threat to public health causing a worldwide pandemic.  The novel coronavirus that causes COVID-19 sparks an inflammatory immune response that is essential to control and eliminate the infection, however, certain immune responses can cause a decrease of gas exchange in the lungs. This causes a huge problem because oxygenation of the blood is essential for human life and is the basis for maintaining function of all major organs. So, will low dose naltrexone target certain immunological markers to ensure that the body does not injure itself during the fight against coronavirus?

Naltrexone is a pure opioid antagonist with activity and many opioid and non-opioid receptors. It is currently used for alcohol use disorders, opioid addictions and obesity. Naltrexone can be used for several different disorders depending on the dosage that is used, and the effects might differ when the doses are changed. Higher doses of naltrexone can be used for impulse control disorders and several other addictions. However, Low Dose Naltrexone (LDN), has been studied and shown promise in the treatment of many diseases such as Crohn’s disease, multiple sclerosis, and chronic fatigue syndrome. Dr. Bernard Bihari, known to some as the father of Low Dose Naltrexone, completed research that showed LDN was used to boost endorphin levels in patients by 3X. These endorphins levels can improve immune function and might be used to help at-risk patients to fight off the Novel Coronavirus infection.

To understand how medications attack and destroy the virus, we need to understand how the virus gets inside the body, how it infects the host, and how it is transmitted to others. Like many other infectious diseases, Coronavirus enters the body through direct contact with direct mucous membranes such as eyes, mouth, or nose. When the virus gets into the body, it will use the body’s own cells to replicate and spread. When the body recognizes the foreign virus, it will send in many natural defenses. These natural defenses will cause a fever, cough, inflammation, possible mucous production, and other symptoms. The virus can then spread from an infected person to others through droplets from a cough, sneeze, or contact with another person. That is why it is essential to follow social distancing guidelines, wash your hands regularly, disinfect areas high touch areas, stay home if you are sick, and wear a mask when you need to go out in public.

The next issue that we need to tackle is clarifying the process of the virus replication and the triggering of the important immune responses. To understand this process, we need look at the shape of the coronavirus.

The coronavirus uses its membrane to protect itself from attack. The spike coming from the outside of the membrane is used to connect to the body’s cells and insert replicating data into the cells to continue to make more of the virus.

The body will recognize the infection and send a variety of immune responses to attack the invader. The body has several natural defenses that are activated by Coronavirus. Some of the defenses are toll-like receptors, IL-6, transforming growth factor beta, and many other pro-inflammatory defenses in the body. These defenses will attack the virus by using complicated pathways and mechanisms. These mechanisms will trigger fever, irritation and inflammation in the lungs, and cough which are the main symptoms of the COVID-19 disease.

Toll Like Receptors (TLR) have several downstream effects when they become activated by an agonist like coronavirus. The downstream products include tumor necrosis factor alpha, IL-6, and inflammatory factor nitric oxide (NO). When low dose naltrexone blocks these TLRs, it inhibits the production of these inflammatory cytokines and acts as an immunomodulator through the suppression of innate immune cells.

Low Dose Naltrexone (LDN) has been proven to reduce several pro-inflammatory cytokines in the treatment of other diseases, but due to the recent discovery of this novel virus, we are unsure of the effectiveness of LDN on this virus. In one study where LDN was used to decrease fibromyalgia pain, the treatment group found reduced plasma levels of many inflammatory cytokines that are also released during immune response to COVID-19. These people found 18% reduction in overall symptoms, and the study suggests that that LDN plays a key role in the reduction of several key pro-inflammatory cytokines and symptoms.

The proposed mechanism by which LDN would work to effectively inhibit the coronavirus from causing severe illness is complicated and theorized. This means that the lungs would become less inflamed and have a larger amount of useful surface area in which oxygen could be passed from the lungs into the blood. When considering the mechanism of the Coronavirus, and the inhibitory effects of LDN, we are proposing the use of LDN to promote treatment and prophylaxis of this new infectious virus. Dr. Phil Boyle, an Irish physician has also proposed the immune enhancing effects of LDN for COVID-19 prophylaxis at doses of 3 mg to 4.5 mg nightly. He claims that daily LDN acts to normalize one’s immune system and could perhaps downregulate an overactive immune system in a time of infection.

When considering the possible benefits in contrast with the risks of using LDN, we should consider prior research to evaluate the likelihood of LDN causing severe adverse reactions. A meta-analysis was conducted analyzing the adverse effects of LDN compared to placebo. This study analyzed 11,194 patients and concluded that LDN does not increase the risk of serious adverse effects over placebo. These studies confirm the overall safety profile of oral LDN in the treatment of patients with varying doses and disease groups. This shows that the use of LDN in patients who are at-risk of contracting COVID-19 safe and highly advantageous.

A vaccine for the novel coronavirus is underway but could take months to years to finally hit the market. However, LDN is available now. With limited treatment options for the Novel Coronavirus and the severity of the disease, it is imperative to search for therapeutic options to improve immune health and reduce the spread of COVID-19. Low Dose Naltrexone could be used as an immune boosting agent for those who are at high risk of contracting the COVID-19 disease. Those who should be considered for this Low Dose Naltrexone therapy include the elderly, those who are immunocompromised, and those who have structural lung disease.

Health Matters is a weekly radio show sponsored by the Medicine Center Pharmacy on WHBC 1480 AM in Canton, Ohio. This episode pharmacists Brad White and Paul White discuss Tips for Staying Safe and Well this Winter.

Coronavirus Resources:

This program aired on March 6th, 2020 and the information detailed in the audio of the podcast was current at that time. We have updated this post with local resources to keep you informed about the developing situation at hand.

Ohio Department of Health

CDC COVID-19 Site

Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU)

Coronavirus Symptoms vs Influenza Symptoms

Steps to Prevent Illness

Managing Coronavirus-related Stress

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This episode is sponsored by Mercy Medical Center and Studio Arts and Glass.

Health Matters is a weekly radio show sponsored by the Medicine Center Pharmacy on WHBC 1480 AM in Canton, Ohio. This episode pharmacists Brad White and Paul White discuss coronavirus with Mark Adams, Health Commissioner for Henry County and former Director of Environmental Health at Canton City Health Department.

You can find all our Health Matters Podcasts here:  iTunes   Google Play  Stitcher

It is impossible to escape the news and concerns spreading in both our community and globally about coronavirus. Locally as health care professionals who are concerned are directed toward influenza currently. Statistically, we can expect an 8% of the population to develop the flu, 1% of those with influenza to become ill enough to require hospitalization, and 0.05% of people with influence to die from the virus. If you're wondering how the coronavirus compares to influenza and what our state and local health departments are doing about coronavirus.

We'd like to remind our listeners today that our program is available on our podcast. You can search the App Store for “Health Matters with the Medicine Center Pharmacy” and listen to any of our programs anytime. You can also post up the questions you have today to our live Facebook feed. [01:33]

Mark Adams: Tell us about yourself

I was at the Canton Health Department for 25 years; leaving there as the Director of Environmental Health. And two years ago came out here to Henry County to serve as the Health Commissioner. And things are wonderful. It is a completely different change in public health going from a lot of environmental health issues that exist around sanitation and issues like that to coming out to one that deals now with sewage. The health department in a much smaller county provides a lot of the other types of health care. For example, in Henry County, we have only had a pediatrician part-time for a very small period of time: one pediatrician. So, the health departments out here in Northwest Ohio have to provide a lot of that care or be able to contract with somebody or work with other people to provide that care for the citizens to make sure that they're just as healthy here as they are in other places that have more resources. [02:38]

What is coronavirus? How did it get its name?

Well, it's named as such because of the way it looks. If you look at it, it’s this round virus that has these spiky projections and it resembles a crown. So, it was named coronavirus after the word Corona, which is in Latin.

There are seven coronaviruses that can be transmitted from human to human. To give an example, people might remember if I mention SARS, back in 2002-2003, or MERS (Middle East Respiratory); those two were also coronaviruses. [04:51]

Why did they call this the novel virus?

It's novel because it's new. So, they discovered it around the third week of December 2019. Now they have moved away from calling it coronavirus 2019 to COVID-19, which means “CO” for coronavirus, “VI” for virus, and “D” for disease, and then dash 19 because of the year it was discovered. [07:11]

Where did it come from?

In most cases, coronaviruses are easily carried by bats. They don't know exactly how that interaction took place between a bat and a snake, and how it resided in that snake but I have heard and have seen information on from both WHO and CDC and it's been reported to us that if we're going to prevent it and we're going to create a vaccine, we have to know where it started, we have to know everything we possibly can about that virus. So, that's why we try to find out exactly where it was coming from, and how that transmission went from animal-to-animal to animal-to-human. So in this case, we suspect that the market that had snakes, somehow by handling those snakes, a human was able to get it. Well, that happens that we can get something from an animal, we pay attention to that, it's a concern to us, but the main concern is when it goes from human to human because of how mobile we are. So, if you think about if we do confirm that it was transmitted from snake to human, that snake it's already in the market, it's not that mobile but we are absolutely that mobile and especially we're global. And it concerns us when it goes human to human because of how fast we can spread it. [08:03]

Are the symptoms just the same as the flu?

Absolutely, almost identical. In fact, even when it comes down to prevention, almost exactly like the flu. So they're very similar to that general malaise, fever. That's why you might see them using thermometers on the forehead to look and see if a person is already experiencing a fever, and that's where they've been stopping some people from leaving certain areas of China or before they enter certain areas. That's their quick way of doing it, and only other way of doing would be, of course, doing a confirmed lab test. [11:04]

Not really, it spreads the same way. So, if we are infected, we cough, sneeze those droplets; a person is very susceptible if they're within about six feet of a person that’s sick. So that's actually that's pretty far away when you think about what six feet is. So, the flu and coronavirus can be spread easily from human to human because of those droplets. And also, those droplets: if they land on a surface or if a person uses their hand and they cough into their hand, that virus then gets transferred to that surface. It's viable for quite some time and that person that comes in behind it, and touches that surface, whether it was a door handle, a phone, computer, keyboard, and if they touch that to their mouth in any way, they can then get sick, they can transfer that virus to themselves. So, it can either be human to human through the droplet in air or human to human through the droplets that have landed on a surface; so from surface to human. [16:17]

Coronavirus vs Influenza vs SERS vs MERS

If we look at MERS (Middle East Respiratory Syndrome), that has about a 35% fatality rate. So, that one is very extremely high. If we look at SARS, it was about a 9% mortality rate. Right now, coronavirus has actually gone down a little bit from its original to about 2%. It was at around two and a half percent. So there is a live feed so we can track this. And right now there's a total overall 64,000 cases, so a little over 64,000 and 1,300 deaths. And the recovery rate is starting to go up. So, if we just looked at the flu, last year alone in the United States killed a little over 30,000 people. So, it’s with millions of people, approximately 32 million people affected; 16 million people go into the hospital, meaning that about 16 million people stayed home with symptoms. They didn't seek out care. Hundreds of thousands of people are being admitted to the hospitals, with flu. With coronavirus it's so much less. Now, I don't say that to be able to say, “All right, let's not pay attention to it.” If anytime that we have a virus that we don't know a ton about that has the ability to go human to human, we want to know everything about it. The mortality rate is unknown in a population, so the more information we can gather about an illness and how it affects the population will provide better protocols for containment and treatment because it always has that potential to have an impact. A virus is no different than us: we change. Our genome, or every time we have children, they take on traits of both mother and father. Viruses do the same way: they change. And when they do that, they can adapt, and they look a little bit different in their next version  [19:51]. So, we want to know everything about it. That's why we want to know where it came from, what animal it started in, and how it was able to get transmitted, we can stop it there first, before a vaccine. And then after the vaccine, if we need to produce a vaccine, then we get a vaccine. [17:29]

What are the precautions?

Few precautions should be taken whether you have caught coronavirus or the flu: 

●      If you're sick, stay home. If you're a business owner and you have the ability to allow sick leave then allow it, encourage it; you don't want to infect the rest of your workforce.

●      Avoid close contact with people who are sick.

●      Avoid touching your eyes, nose, and mouth with unwashed hands. So, regardless of if you are healthy or ill, wash your hands using soap and water: 20 seconds, some people use the alphabet, there's other ways of doing it but just soap and water. A lot of people think that you can actually overdo it with alcohol. Soap and water is perfect.

●      If you do cough or sneeze do so in a tissue and discard that tissue. Don't keep it or put it in our pocket. Try not to use a handkerchief where it's multiple use, that virus just sits in there, and it just becomes this active biohazard that you're going to keep in your pocket, on your personal self. [26:18]

Do you really need a facemask?

I know that a lot of people are watching the news and they're seeing facemasks. There's no need to go in and do a rush because the same continual snapshots of people wearing facemasks end up on TV or whatever source that you're getting your news from. And then that starts saying, “Well, if I'm not seeing people without facemask, maybe I need to go get a facemask,” that is just not the case. [27:17]

What are the reliable sources of information?

Many nations are becoming educated on YouTube, and pretending to be professionals after we read something on YouTube. We're making YouTube lawyers now, we're YouTube public health people. And we've really got to get away from those types of sources. While they are some things that are fun to watch, we really need to get a reliable source.  If it's going to concern coronavirus or flu, I promise you the only place that's everyday updating where their surveillance is coming from, where they're getting information from, it's going to be cdc.gov, or the Ohio Department of Health at odh.ohio.gov, or your local health department: at Canton it’s cantonhealth.org, at Henry County residents in Napoleon it’s henrycohd.org. So, we're posting information every day on it, as most every single health department in Ohio is. We're on conference calls with the Ohio Department of Health; every day we receive an updated information packet from the Ohio Department of Health with what's currently going on, and it usually gets produced and sent out prior to midnight. So, we have very active surveillance measures that are not being covered everywhere else. Our job is to spread as much information that's true, and it's data oriented, not feeling oriented. So, I'm hoping that people can see the difference between how they feel about something and what they're actually getting data on, and go to those sources. And always double check what you're reading and say, “Can this even be real?” [34:06]

Summary

Finally, to summarize, we started with Mark giving his brief introduction and background. We then discussed coronavirus: it’s name, origin, symptoms and precautions. We compared coronavirus and some of its types with the flu. We also discussed the significance of facemasks. And lastly, we looked at some reliable sources of information to stay updated.

Health Matters is a weekly radio show sponsored by the Medicine Center Pharmacy on WHBC 1480 AM in Canton, Ohio. This episode pharmacists Brad White and Paul White discuss the role of a Hospitalist with Dr. Michael Linz, Chief of Inpatient Medicine with Mercy Medical Center in Canton, Ohio.

You can find all our Health Matters Podcasts here: iTunes Google Play Stitcher

Hospital stays can be full of surprises; one might be that the doctor who shows up in place of your personal physician. Hospitalist medicine is the fastest-growing medical specialty in the United States. Demand for this specialty was initially fueled by managed care efforts to bolster efficiency, cut costs, and improve care. Today, patients admitted to the hospital tend to be more severely ill. Hospital-based doctors can better attend such patients, respond to their problems and navigate the hospital’s increasingly complex systems.

Today we're going to talk with Dr. Michael Linz and we're going to talk about what a hospitalist is and how during a time, when a patient might feel vulnerable, they are there to manage their care and work with their personal physician.

We'd like to remind our listeners today that our program's also available on our podcast. You can just look for Health Matters with the Medicine Center Pharmacy in your favorite podcast app, and listen to any of our programs anytime. You can also post up questions on our live Facebook feed today. [00:42]

What is a Hospitalist?

Quiz Time!  Choose your answer from the possible answers below:

1. A groupie of the TV show “House”, who's obsessed with the smell of hospitals, and hangs out in the waiting room all day, talking with the ladies at the information desk, drinking day-old coffee, and eating packages of stale Graham crackers.

2. The real application of Bill Murray in Groundhog Day, waking up every morning and perpetual training in the residency program, being on call 24/7, no patient cap and no duty restriction hours.

3. Your third choice is, not actually a physician at all, but an undercover administrator hired by the hospitalist to control utilization management, kind of like Undercover Boss that infiltrates the medical staff and reports all rumors back to the CEO.

4. The last potential answer is the main cog in the fastest-growing specialty in American medical history, boasting more than 50,000 physicians in a mere 20-plus years, transforming itself, not only into an indispensable part of the hospitalist patient's care and management team, but the key driver in future health systems delivery and payment reform. [01:56]

The answer is D.

History of Hospitalist Concept

Interestingly, this is a concept that started in California in the early 1990s. It was first brought into play by the Scripps Clinic in La Jolla, but it really first became its own entity in 1996, where Paul Wachter, who is known as the father of hospitalist medicine, coined the term “hospitalist” in the New England journal article in 1996. So, it actually started in earnest and the University of San Francisco, California. So, it's only been around for 20-plus years. [03:20]

Can Smaller Hospitals Do This?

Hospitalist programs can be anywhere from 30 or 40 docs up to three, four or five physicians. A union hospital in Dover, which is a relatively small hospital and an access hospital has hospitalist program. They have programs out in Coshocton and in some of the critical access hospitals, much smaller in size than sometimes you may have just one hospitalist working as an admissions position for the day, but it can be anywhere from one to a hundred. [05:32]

What are the Pros of Hospitalist Medicine?

Well, that's the premise; it's easier said than done. The advantage of the hospitalist model is you have physicians that are hospital-based, 24 hours a day, seven days a week. So, you have immediate access to care at the bedside. You have efficiencies in moving through testing procedures, working with consultants. You have protocols that are in place for managing length of stay, and efficiencies of transfers of care. And so you have somebody who is there, basically, at all hours of the day, and we really work as an extension of the primary care physician as far as communication and interaction with them as well. [07:03]

Availability of physicians 24/7

Mercy not only has a hospitalist program, which is medicine and whatnot, they also have an OBGYN hospitalist program as well. So, OB-hospitalists that, again, are there 24/7 and help with the deliveries and whatnot. There are hospitalists in pediatrics, neurology, and also in the post-transitional care in the nursing facilities as well. So it's really a continuum of care that's being developed and integrated. [08:27]

What if you want to see your own doctor instead of a hospitalist?

Normally, your primary care physician notifies their patient population that they don't go to the hospital regularly, and that they're being cared for by hospitalists. So, we have an understood relationship with which physicians that we take care of their patients or not. And so I've really never had anybody say, “I don't want you to take care of me”. I've had instances where we'll get the primary care physician, maybe on the phone, and we have a three-way conversation. But, generally, it's been a smooth process, and I think the population understands the changes in healthcare and how medicine works. [09:15]

How do we become a Hospitalist?

The majority of the hospitalists, probably 90% of hospitalists, are graduates of an internal medicine residency program, which is a hospital-based program. So, you have to have a residency graduate training, just like you would in any other primary care specialty.

There's a growing number of programs that are actually having different tracks where you can go into the training program and move as an inpatient track, really moving as a hospitalist or an outpatient track where you're going to work in the outpatient setting. Family medicine, which traditionally has always been an outpatient practice, now also has an inpatient track as well, and I have to my physicians or family medicine grads, who did an intensive inpatient program, and so it is definitely stratifying to its own drummer. And I think eventually there will be specifically categorized programs in hospitals medicine as more of the teaching programs are overseen by academic hospitalists. [10:37]

What are the work models for a Hospitalist?

There are various work models for the hospitalist system. The most common or traditional is what's called a “seven-on seven-off model” where a physician will work seven days in a row and then have seven days off. The shifts are usually 12 hours, seven in the morning till seven in the evening, and then seven in the evening till seven in the morning, depending on what your work shift is. Other models are a “Monday through Friday model” where a physician will work Monday through Friday at various times, and then weekends are done on a rotational basis.

The seven-on seven-off model has various mutations as well, where people work part of a week, especially if they're part-time, or they have families at home and they want to work just X amount of shifts per month, there are swing shifts that come in throughout the day. So, there are all these machinations off this model, but that's the traditional model that works. [15:24]

What type of patients do you care for?

Our hospital is a team that cares for all patients that come through the door that have medical issues. So, we take care of patients who are co-managed with the intensivist and the ICU, with the cardiologists in the CCU, with cardiovascular surgeons. We admit all the normal traditional health issues to the hospital: pneumonia, congestive heart failure, infections, abdominal pain. We also work on a consultant role for the trauma program. So, a patient comes in with trauma we’ll handle their medical issues, or we'll do consultant work for orthopedic care or rehab care.

So, we really run the entire spectrum. And again, there are specialized physicians within their same disciplines. So, in internal medicine, we don't see young children, and we don't do any OB. So, the obstetricians have OB hospitalist, the pediatricians have a pediatric hospitalist. So, it's divided based on training. [17:49]

Tell us about Sound Physicians

Sound Physicians, it’s a very cool story. It was founded in 2001 by a physician by the name of Rob Bessler, who's from Ohio, grew up in Berea, did his medical education at Case Western and his residency at Cleveland Clinic. He ended up on the West Coast in Tacoma, Washington, and with eight or nine other guys started a hospitalist program was one hospital in Tacoma with nine doctors in 2001. So, fast forward, 19 years, and Sound Physicians is the largest hospital management group in the country. They are 42 states, 3,500 providers, over 350 hospitals, and all physician-run, physician-led, physician-managed, which is very comforting to myself knowing that I have a physician at the top of the chain who is making decisions based on safety and quality of health care. [20:52]

What other advantages are there of the hospitalist model?

Well, there are a number of advantages:

1. The data is pretty strong as it reduces the cost of care, predominantly, by being able to reduce length of stay, improve efficiencies, have testing done in a timely manner, getting results back, co-managing with the consultants, discussing with them, working at the bedside with the patient and families, working with the case management department, and moving people through in a timely manner; not rushing people through their hospital stay, but working efficiently.

2. The other important thing is, even though it decreases the length of stay, it does not affect; we never allow patient safety and quality of care to be superseded by time. So, that's very important.

3. The other advantage is quality of care and patient satisfaction scores are higher in the hospitalist medicine model. Again, because you're there, you can go back and see the patient two or three times a day, meet with the family, discuss things, meet with the consultant. So, it's the ability to have one on one open communication that is really, really a key.

So, our model allows us time at the bedside rather than having us have to go into the computer and have our head buried in a laptop. We actually sit down at the bedside and talk to the patients and comfort them, and actually provide them the time that they require. [25:27]

The other advantage to the program is what we call work-life balance. It's bantered about a lot but is a real entity. Young physicians coming out of training, like the idea of time-working, time-not-working ability to have time with a family to do other things. Sometimes physicians who may want to go on to further specialty training will take what's called a gap-year or two, work as a hospitalist either to solidify what they want to do long-term, work on research projects on the weeks they're off or pay off debt. [27:41]

What are the disadvantages of this model?

The main disadvantage, in my opinion, is that the model itself purposely creates a discontinuity of care. Again, not having your primary care physician take care of you, who you may be gone to for 20 years and they know you like the back of your hand, and so you're meeting somebody who you don't know, who's going to take care of you and have to figure out everything in a matter of day if they're in for an observation; a matter of hours. We have physicians that come and work a couple of days here a couple of days there. So, there's maybe one physician that you have Monday, Tuesday, and then maybe another physician Wednesday, Thursday. So, there's some disconnect there as well. There definitely is not an optimal model for communicating with the primary care physician and having their input as well. So, these are our definite disadvantages to the model itself. [28:43]

FAQs on Coronavirus

We see the trends just based on our patient population because we take care of 150 people or more a day on my service. So, we're seeing what's coming through, and so we'll see trends in different viral infections, different bacterial infections, as well as infections that set people up for secondary pneumonia. In general, the influenza virus has not had a big impact this year. We guesstimate on our service that we’ll probably see that rise in March. Now, we're seeing mostly RSV (Respiratory Syncytial Virus) which is a virus mostly seen in children, and then Rhinovirus and Enterovirus, and human metapneumovirus which sets people up then to secondary pneumonia, which is probably still pneumococcal pneumonia.

Coronavirus is not caused by drinking Mexican beer by the way, and coronavirus has been around for a while and we've had patients intermittently with coronavirus here. What's different is the virulence or nastiness of the strain that mutated in China, and it's, obviously, become epidemic and pandemic. The protection is basically no different than protecting yourself from getting the flu:

• Good handwashing technique

• Prevention of droplets that spread by covering your mouth and nose when you cough

• Again, washing your hands if you are ill

• Not going to work, not going to school, staying home and staying isolated

• Again, having an influenza vaccine is still a very important thing as well as a pneumonia vaccine, if appropriate.

We have not seen too much of the coronavirus yet, but it will come. I was speaking with one of my good friends who live in California and the folks in California are definitely on edge because of the amount of international travel and international folks that live in that part of the country. I know there's a recent question from students from Miami of Ohio.

So, the CDC is on top of things, our infection control department has a protocol already set up, I'm definitely sure that other hospitals would have the same protocol. So, I think the potential for any type of epidemic or significant exposure in Canada, Ohio is going to be fairly small. But again, any anybody who has flu-like symptoms should definitely see their primary care physician. [44:49]

This episode is sponsored by Mercy Medical Center and Studio Arts and Glass.