Speaker 1 00:05 Lange, welcome to HelixTalk, a podcast presented by the Rosalind Franklin University College of Pharmacy. Narrator - Dr. Abel 00:11 This podcast is produced by pharmacy faculty to supplement study material and provide relevant drug and professional topics. Speaker 1 00:19 We're hoping that our real life clinical pearls and discussions will help you stay up to date and improve your pharmacy knowledge. Narrator - Dr. Abel 00:27 This is an educational production copyright Rosalind Franklin University of Medicine and Science. Speaker 1 00:32 This podcast contains general information for educational purposes only. This is not professional advice and should not be used in lieu of obtaining advice from a qualified health care provider. Narrator - Dr. Abel 00:47 And now on to the show. Dr. Sean Kane 00:51 Welcome to HelixTalk. Episode Eight. I'm your co host, Dr. Kane, and I'm Dr. Patel, and today we're talking about the hospital acquired pneumonia guidelines, also known as the healthcare associated pneumonia guidelines or the ventilator associated pneumonia guidelines. Speaker 2 01:05 And similarly to the community acquired pneumonia guidelines, they were also approved and published in about 2004 2005 so we can imagine, it's about a decade old, just like the community acquired pneumonia guidelines. We're expecting an update in summer 2015 but as you can imagine, with the guidelines, delays that we have experienced recently, we don't know if this is going to be something on schedule. And just Dr. Sean Kane 01:29 like the community acquired pneumonia guidelines, these are released in collaboration between two different organizations, the American Thoracic Society, or ATS and then the Infectious Disease Society of America or IDSA. Previously, they had their own guidelines, but when they created these, they formed the collaboration. So there was one guideline for hap VAP and H cap. Speaker 2 01:49 Got it and talking about hap VAP and H cap, there's just a lot of acronyms. So I think we can start by defining maybe these acronyms. So what does hap stand for? Dr. Sean Kane 01:59 So hap is hospital acquired pneumonia, and that means that you've been in the hospital for at least two days and then you have new onset pneumonia. And the reason that we classify it that way is that the type of bacteria that you would get is different if you've been in the hospital for a few days and then get a pneumonia, as opposed to a pneumonia, let's say out in the community, which we call community acquired pneumonia. Speaker 2 02:19 And we're going to talk about the common pathogens that are associated with this hospital acquired pneumonia too. And then the second acronym we have is VAP, and which stands for ventilator associated pneumonia. And again, this is after two to three days of a patient who has been intubated. So again, this is a little bit different definition than just the hospital acquired pneumonia. Dr. Sean Kane 02:42 Then our third classification is called H cap, which is healthcare associated pneumonia. This is kind of a combination of hap and cap, which is why we have H cap. And the reason that it's different than community acquired pneumonia is these are patients who came from the community but have healthcare exposure significant enough that the type of organisms that they can have from their pneumonia are worse than community acquired pneumonia, and are actually fairly similar to hospital acquired pneumonia, but they're not necessarily inpatient in the hospital setting. Speaker 2 03:12 So you're saying those people who live in nursing home or other long term care facility, or patients who are on long term infusion treatments or dialysis treatment. Is that correct? Dr. Sean Kane 03:23 Exactly to me, the classic healthcare associated pneumonia or H cap patient is going to be that hemodialysis patient or someone who lives in a nursing home or a long term care facility. There are also a couple other criteria that qualify someone to have healthcare associated pneumonia or H Speaker 2 03:40 cap, the healthcare associated, the ventilator associated, and the hospital acquired pneumonia. They're all kind of grouped together in the one guideline when you look at these three combined versus the community acquired because again, the microbiology and how these pneumonia occur, the pathophysiology is different. So if you can imagine, as we mentioned earlier, when the patients are acquiring any of these three pneumonias, the bugs are a little bit more aggressive than compared to the patient who are coming in with community acquired condition. Dr. Sean Kane 04:13 So thinking about the types of bugs that we would see, gram negatives are one of the more common types of infections that we'll have for H cap, hap and VAP, and that would include things like pseudomonas, E coli, Klebsiella, Proteus, Haemophilus, Moraxella. These are all gram negatives, and it can even be something as serious as Acinetobacter, which is one of those gram negatives that we don't see very often, but when we do see it, it has pretty mean resistance patterns that it displays. Speaker 2 04:43 And when we look at the gram positive suspects, we're looking at Staph aureus, mainly the MRSA, and then some strep pneumo is there as well. However, as we discussed in the community acquired pneumonia guidelines, that there are atypical organisms. They're kind of a major component of cap. However, the atypicals are not common in this healthcare associated pneumonia. Dr. Sean Kane 05:08 So Dr. Patel, because we're not worried about atypicals, we probably won't be adding things like azithromycin, other macrolides or doxycycline to these regimens, right? That is absolutely correct. Great. Then on top of this, in terms of the types of bacteria, we'll talk about some risk factors that these bacteria or these bugs can get even meaner. So, you know, not all healthcare associated pneumonias are created equal. Sometimes we're even worried about kind of multi drug resistant healthcare associated pneumonia. And we'll talk about, you know, what criteria are risk factors for that, and then how we would treat those differently. Speaker 2 05:43 So before we dive into the actual medications and how we can treat these patients, what are some of the options that we have as a hospitalist or as a clinician who is working in the hospital to decrease patients risk of getting dyspneumonia in the while they're in the hospital, Dr. Sean Kane 05:59 by far the easiest thing to do is to wash your hands between patients. So almost every hospital room should have some kind of hand washing station or a foaming station outside the patient room. So anytime any provider touches a patient or visits the patient's room, they should be hand washing Speaker 2 06:15 and I'm assuming if the patient has caught one of this multi drug resistant pathogen, it would be a good idea to kind of isolate them, so the spread is not as prominent, exactly. Dr. Sean Kane 06:27 So depending on the institution you work at, oftentimes there's carts with gowns in front of them, and in order to enter the room of someone who has displayed MDR, let's say MRSA, or MDR pseudomonas, or other, you know, transmissible infections. Oftentimes, it will be a requirement of the hospital that every provider, including family members that enter the room, have these gowns that they wear. Speaker 2 06:50 And like we talked about, the definition of ventilator associated pneumonia, usually it occurs after two to three days of being intubated. So what we want to make sure is that we reduce this time of mechanical ventilation, or even re intubation, because again, those organisms are highly associated with the intubation. Dr. Sean Kane 07:10 Then finally, for both intubated and non intubated patients, it's a good idea to keep the head of the bed elevated anywhere from 30 to 45 degrees. And what that means is that the patient is kind of in a sitting position rather than a lying flat position. And the reason is that many of the bugs that we worry about coming from the mouth, if a patient is lying completely flat, it's more likely that they'll aspirate that bacteria into their lungs than if they were lying in a semi recumbent, recumbent position. For that reason, we can prevent aspiration by keeping the head of the vet a little bit higher. So Dr. Patel, what are some things that you think about in terms of clinical presentation when you think of a patient who presents with H cap, Hap or even VAP? Speaker 2 07:51 So again, these patients are not coming in with the symptoms. These patients will develop the symptoms after they have been hospitalized for at least after two days or so. So first thing we want to look at is their x ray. Plus we can look for other signs, such as fever, again, any signs of infection would emerge as a fever. We can also do blood count to see what the white blood cell count is, and then things like, you know, productive sputum, if there are any other purulent secretions that are coming out of the lungs. And it's Dr. Sean Kane 08:23 always a good idea if you can, to get a culture of, you know, the sputum, if they're if they have productive sputum, get a blood culture to see if there's any bacteria that have made their way into the blood, because that can absolutely help direct your antibiotic therapy. And as we'll talk about later, we really start fairly broad with our antibiotic regimen, and if we have a positive culture early on where we haven't killed off most of the bacteria with our empiric antibiotics, and we can de escalate to something that's narrower spectrum and potentially even less toxic, then you know, these broad spectrum agents. So getting that initial culture is a really good idea. Speaker 2 08:55 Yeah, and like we talked in the cap too, we need to start the antibiotics empirically as soon as we can, and like you just mentioned, Dr. Kane, then we can go ahead and de escalate the therapy or reassess in two to three days and see where patient is lying. So how are you going to reassess the patient? What things are you going to look at? Dr. Sean Kane 09:12 Yeah, so for me, in the ICU, oftentimes we're initiating antibiotics in patients that we're not completely sure have a pneumonia. So it's really important, after a day or two or even three days of empiric antibiotic therapy to re evaluate and see, you know, did this patient truly have a pneumonia, or were there other factors that may be played into their respiratory status, for example. So was it CHF, or was it a pneumonia? So after two to three days, we should be looking at things like our blood and sputum cultures. We should be looking at, did they have a fever? Did their white count improve? Was it bad? Is it still high? Did their chest X ray improve? If it improved dramatically over a period of a few hours? It was probably pulmonary edema caused by something like CHF, as opposed to a pneumonia that takes time to resolve. We should also be looking at, you know, does their oxygenation improve? Has their sputum. Production diminished? Is it less purulent? Are they hemodynamically stable? So were they on pressors, and now they're not? Or have we started pressors because now they're hemodynamically unstable, then really any other organ dysfunction? So as an example, fairly commonly in patients who have a gram negative bacteremia, for example, they'll commonly have things like low platelet count, they may have acute kidney injury, other organ dysfunctions because of the body's response to the infection that they're having. And if we see signs and symptoms of other forms of instability of the body, then we probably don't want to back off on our antibiotics. But if things are looking much better, then maybe we do want to back off. Speaker 2 10:38 So we mentioned cultures. Let's say the culture results are negative. What happens? Then do the most of the clinicians then continue the antibiotic, or do they go ahead and Dr. Sean Kane 10:48 discontinue it? Yeah. So it really depends on what the patient's looking like after that two to three day period. Oftentimes, you know if you're if you don't trust the culture results that you got, for example, or if they still don't look very good, if they look toxic, these patients will probably be treated for an empiric seven to eight days of therapy. But it really depends on what the patient's Speaker 2 11:07 looking like. And obviously, if the culture results are positive, then we're going to look at to see maybe whether this culture is truly pathogenic, or this is just the colonization, or just pure contamination. Once again, if we have the cultures, we can run the sensitivities, and instead of giving empiric antibiotic therapy, we can do a little bit more targeted therapy, and then we can treat most of the non MDR cases for seven to eight days. Dr. Sean Kane 11:35 So Dr. Patel, can you give me some idea of a reasonable, empiric regimen? How do we pick that initial regimen before we even have our culture results back. Speaker 2 11:44 So again, we want to look at patient's risk factor. Okay, we talked about the multi drug resistant versus non multi drug resistant. If you suspect the patient does not have multi drug resistant factors, then we can start out with limited spectrum antibiotic therapy. Once again, we mentioned atypicals are not very common, so we're going to target our therapy at gram positive and then gram negative coverage. Dr. Sean Kane 12:09 So Dr. Patel, you said multi drug resistant risk factors, so that really determines whether we're going broader or narrower. So what are some of those risk factors to help us decide if we go big guns or if we go smaller guns? Speaker 2 12:21 So there are a few things that we need to keep in mind, things like, if patient had any antibiotic use in the last 90 days, okay, if the if there is a local antibiotic resistant rate. So you're going to look at your hospital's antibiogram, maybe your community resistant rates as well, to see what the what the pattern of these bugs in the community is, or in the hospital community is, then we're going to look at the hospital acquired or healthcare associated pneumonia risk factor. So if the patient's been the hospital for more than 48 hours, patient has a history of, you know, going in and out of the nursing home or long term care facility, or if they truly reside in one of these facilities. Patient is on IV antibiotic or other infusion therapy like chemotherapy. They're under wound care or currently going under dialysis, especially within last 30 days. Or patients who are immunosuppressed, whether they have a condition that makes them immunosuppressed, or they're taking the medication that can suppress their immune system. These are all the risk factors for MDR bacteria infection. Dr. Sean Kane 13:25 So what you're really saying is that if you don't have any of these risk factors, so you don't have H cap, and you don't have any of these other risk factors, like recent antibiotics, then we don't have to pull out our huge, you know, canon of antibiotics. We can go with the smaller pistol hand pistol of antibiotics, if you will. So give me an idea of what are some of these more limited spectrum antibiotics that would use on a patient who, let's say, doesn't have these MDR risk factors, are not h cap and have been in the hospital for less than five days. What kind of thing would we give them? Speaker 2 13:58 So one of the agent is the third generation cephalosporin, ceftriaxone, like we talked in the community acquired pneumonia guidelines. Then we have our standard fluoroquinolones, the respiratory fluoroquinolones like levofloxacin and moxifloxacin. Interestingly enough, the guideline also recommends Ciprofloxacin. However, it is a non respiratory fluoroquinolone. Agents such as Unasyn and ertapenem are also recommended. Ertapenem because it still doesn't give it that anti pseudomonal coverage. And like we said, we're not yet worried about the MDR pathogens here, so we can use that ertapenem agent. Dr. Sean Kane 14:35 So in looking at the recommendations, and again, these are decade old guidelines, the two that I take away from this are ceftriaxone and urtipinum. Those are two reasonable recommendations looking at the quinolones. Generally, I prefer to use these less. I think that they cause things like altered mental status in the elderly. You know, we worry about things like Qt prolongation with other medications. So for me, they're not my favorite, but if we were. Use those. Levofloxacin and moxifloxacin are reasonable, but again, decade old guidelines are recommending things like ciprofloxacin, like you said, doesn't have good strep Pneuma coverage, it's a non respiratory fluoroquinolones, then unison, about half the time. Unison misses E coli, which is a pretty predominant pathogen for things like hospital acquired pneumonia, so I personally don't find Cipro or Unison reasonable recommendations, even though they are listed in the guideline. Speaker 2 15:26 So I think the proper choice for the non MDR pathogen, H cap would be things like ceftriaxone, or we can even go for the artpenum. Dr. Sean Kane 15:37 So what about those patients where they've been in the hospital more than five days, or if they have H cap, or if they have any of the multi drug resistant risk factors that we talked about, primarily being the antibiotics in the past three months. What do we do different for those patients that we didn't do for our limited spectrum antibiotic therapy patients? Speaker 2 15:55 So here is where we're going to pull out the big guns. You know, the pistol might not work, just enough so we're going to do double gram negative coverage using one of those higher generation beta lactams, plus adding one of the fluoroquinolones or aminoglycosides, and then adding a gram positive coverage using vancomycin or linezolid. Dr. Sean Kane 16:15 So going through that a little bit, the beta lactams that we're going to pick are going to be anti pseudomonal Beta lactams. So when we say anti pseudomonal, it also means that we're covering a number of other pathogens. But we use pseudomonas, kind of as the prototype to help describe whether it covers these multidrug resistant gram negatives or not. So when I think of an anti pseudomonal Beta lactam, the two most common that you're going to be seeing are Zosyn and cefepime. Zosyn is piperacillin/tazobactam. But there's a number of other ones that are out there that you may or may not see, and those would be ceftazidime, which is a third generation cephalosporin, some of our carbapenems, like imipenem, meropenem, doripenem, then aztreonam, which is kind of the anti pseudomonal monobactam, so it's similar to a beta lactam, but doesn't cause cross reactivity. That isn't as good as some of the other agents that are beta lactams in terms of Pseudomonas coverage, but it's good enough that we'll throw that on for those who have penicillin allergies. Speaker 2 17:11 So the second gram negative agent that I mentioned was adding a fluoroquinolones. The recommendation part of the guidelines, again, is Ciprofloxacin or levofloxacin, or adding in aminoglycosides such as amikacin or gentamyosin or turbomycin. Again, note, Cipro over here is non respiratory thoroughquin alone. We already mentioned about increased resistant rate to strep pneumo, or less coverage to strep pneumo, but if you can think about it, zosin, we already mentioned, is a beta lactam which covers most of the gram negative and if zosin is not going to cover the bacteria, then most likely that SePRO is not going to cover those bacteria as well. So if you highly suspect that the patient really needs double gram negative coverage, the better option of the two would be aminoglycan, using one of the aminoglycoside. Dr. Sean Kane 18:02 So in addition to that, we also talked about agents that we could add for MRSA coverage. Really, the two main ones that we'll see for MRSA pneumonia are going to either be vancomycin or Lange lid. If you look at the guidelines, they say that you should be considering anti MRSA coverage if the patient has risk factors or you have a high local incidence rate of MRSA, but they don't really give you any guidance in terms of what is a risk factor for MRSA or not, aside from what we already know in terms of multi drug resistant risk factors, so oftentimes, patients will have this added empirically, and it's removed after a couple days if the cultures are still negative. I did want to mention that it's very common to do MRSA nasal swabs that is not diagnostic for saying the patient does have an MRSA pneumonia. In my mind, it only says that they're at risk because they're a carrier for MRSA, but it doesn't mean that that's a positive culture for an MRSA pneumonia, and that's a very important distinction to make. So in my mind, that just tells me, yeah, it's probably a risk factor, but it has a high false positive and a false negative rate, and I just view it as a risk factor, not a definitive yes or no whether the patient has an MRSA pneumonia. Speaker 2 19:10 So now we talked about how the double negative coverage is used empirically, and plus, you throw in the MRSA coverage depending on the risk factors, I've heard a few things about using this combination double gram negative coverage? Do all the clinicians start patients on double gram negative coverage? Dr. Sean Kane 19:27 Not at all. So it really depends on your institution and how sick the patient is. The argument to give double gram negative coverage, and when we say that, we mean a beta lactam, like an anti pseudomonal Beta lactam, let's say zosin, plus something like an aminoglycoside. And the thought is that if you give two maybe you can kill the gram negatives better. If the gram negative is resistant to one of the antibiotics, you at least have a second one to kind of make up for the fact that you missed with the first one. But it's not all benefit. So there are some negatives to it as well. Speaker 2 19:57 And from my practice as a resident, what. What I have noticed in the institution that I had my residency, that most of the clinicians just started out with single gram negative coverage and one gram positive coverage. However, if your patient is very sick, meaning patient is in ICU, or patient has severe sepsis, or the pneumonia is pretty severe, then these patients can be considered for using another gram negative coverage, like gentamicin or amikacin, exactly. Dr. Sean Kane 20:24 So really it's a pro con debate. So I've discussed the pros in terms of maybe you get better coverage. The Con, though, is that you have toxicity from the agents that you're adding, and there's a cost component too. And probably the biggest argument against doing double gram negative coverage is that we don't have any studies that show that patients do better when we give them two gram negative drugs. We just have data that shows that we're more likely to cover a gram negative pneumonia if we do have two agents depending on the local resistance pattern. Speaker 2 20:54 And not to forget, these aminoglycosides also come with the high requirement of monitoring for the peak and trough levels, right? Dr. Sean Kane 21:01 So at least in my shop, in my institution, if we were to do double gram negative coverage, the typical thing that we do is to have that anti pseudomonal Beta lactam and give one nice big five to seven milligram per kilogram dose of tobramycin or gentamicin, and then we reassess in a day or two and see if we want to continue a potentially toxic regimen with the aminoglycoside if they're really sick, maybe we should if they're getting better, maybe we can see how they do with just the monotherapy of the beta lactam. So what about patients who have an aspiration event? So let's say they need to be intubated, and during the intubation, they vomit everywhere, and they aspirate all the vomit into their lungs, so we know that they've aspirated. What do we do for those patients that might be different than what we would do for our hap, VAP and H cap patient? Speaker 2 21:46 So with aspiration pneumonia, one thing we need to keep in mind that most of these organisms are anaerobic organisms. They go into the lungs and basically form pockets. So we need medications that a have good anaerobic coverage, and B can penetrate the lung tissue as well. And so we have the options of using carbapenems, like ertapenem, doripenem, imipenem or meropenem. Or we can use the combination, such as ampicillin/sulbactam, amoxicillin/clavulanate or piperacillin/tazobactam, which is your standard zosin. Alternatively, you can do another type of anaerobic coverage using clindamycin. The guidelines also mentioned using penicillin G or penicillin V, and tigecycline is also an option. And one thing that we missed is using some of the second generation cephalosporin, which also have some anaerobic coverage. So agents like cefotan or cefoxitin are also used or mentioned in the guidelines. Dr. Sean Kane 22:45 So one thing that you can remember in terms of our penicillins, whether they have anaerobic coverage or not, is if a penicillin has a beta-lactamase inhibitor with it. So that's your sulbactam, your clavulanate, your tazobactam that adds your anaerobic coverage to it. So if you have that, you're good to go with anaerobic coverage, and then also our carbapenems, and like you said, clindamycin, penicillin, and only two of our second generation cephalosporins have that anaerobic coverage. So now that we figured out how is the patient presenting, we've established the potential diagnosis for hap, VAP or H cap. We've started our empiric antibiotics. Maybe we've got a culture. Maybe we've been able to de escalate. How do we know when we're done with our antibiotic regimen, how long are we going to continue these big gun antibiotics for? Speaker 2 23:28 So it's a it's a very interesting approach. If you treat the patient for too short, you don't kill all the bad bugs, and patient might relapse. If you treat it for too long, maybe you will encourage colonization with certain MDR bugs, or you can create opportunistic infection. Again, long term antibiotic treatment is a risk factor for developing other super infections like C diff, Dr. Sean Kane 23:53 so really it's a Goldilocks approach. Then you don't want it too short. You don't want it too long. So where is that sweet spot for hap, VAP in each case, Speaker 2 24:00 so most of the antibiotic, we've seen a good clinical response within about seven to eight days. And so that's what we're going to go for. Unless we see patient has Pseudomonas or Acinetobacter growing in the culture, which is highly MDR type organism, then we're going to continue the therapy for 14 days, and once again, this is just to make sure that or the patient doesn't relapse. Dr. Sean Kane 24:26 This comes out of a study called the eight versus 15 study, where they looked at patients who had hospital acquired pneumonia, and they saw that it was okay to give these hospital acquired pneumonia patients eight days of therapy unless they had the Pseudomonas or Acinetobacter, in which case they had a pretty high relapse rate. So it's an evidence based guideline for the length of therapy. And actually, most of infectious disease doesn't have such a good evidence based duration of therapy. Typical answers are seven to 14 days. You pick a number between there. This is actually a fairly good evidence based recommendation in terms of how long you should try. Read it classically, these infections would be treated for two to three weeks. So seven days is very different than a 21 day course. So we've really come a long way based on that. It was a 2003 study, I believe, and in doing so, we've done a lot to make sure that we don't promote multi drug resistant colonization of these patients by giving them three weeks of zosin, for example. Speaker 2 25:20 So make sure, if you're working in a multi disciplinary team at your hospitals, you know antimicrobial stewardship program, remind the clinicians about this duration of therapy, because again, not only it would be cost effective, but we will be preventing further MDR, about colonization or other opportunity opportunistic infections. So to summarize today's podcast, let's just go over really quickly what type of bugs we are looking at. Okay, most likely we are looking at the gram negatives, which is your E coli, Klebsiella, Proteus H influenza, Moraxella. And then if you look at a little bit aggressive bugs we got our Pseudomonas and Acinetobacter, there are some risk of patient acquiring gram positive such as MRSA or strep pneumo. Remember, atypicals are not very common. If you suspect the patient has aspiration pneumonia, you want to think about some of the anaerobic bacteria as well. Dr. Sean Kane 26:16 So in terms of the treatment regimens, there's really two different buckets that a patient can fall into. One bucket is what's called the limited spectrum antibiotic therapy. These are our smaller gun antibiotics for patients who have hap or VAP who have been in the hospital less than five days, they're less at risk for MDR bugs, so we're going to be able to use things like ceftriaxone, levofloxacin and erdopenem in these patients, the guidelines recommend a few other options, but we don't feel they're appropriate for this decade anymore. Maybe they were more appropriate a decade ago. Then the other bucket that a patient can fall in are our broad spectrum big gun antibiotics. These are going to be our H cap patients, and they're going to be our hap and VAP that have other risk factors, like recent antibiotics, if we have a local resistance pattern that's very worrisome, or if the patient has any of the H cap risk factors, but also are normally in the hospital. So the antibiotics that we're going to use for these broader spectrum patients is going to be an anti pseudomonal Beta lactam. So again, that's going to be things like cefepime, imipenem, aztreonam, zosyn or piperacillin/tazobactam, there's a few others as well. Then we're going to either pick a fluoroquinolone, which is less likely, or an aminoglycoside more likely. The fluoroquinolones that we could pick are Cipro or levofloxacin, and then the three main aminoglycosides that you'll see in clinical practice are amikacin, tobramycin and gentamicin. And then there's not good guidance on when to add that anti MRSA coverage, but if you are to, then it's vancomycin, or less likely, linezolid because of cost. Speaker 2 27:49 Last, but not the least, let's focus on the duration of the therapy. Like we said, we have a really good evidence based approach, or we do have a really good recommendation and the guidelines that most of the patients who do not have the MDR bugs should be treated for seven to eight days. But then if you if the cultures are growing Pseudomonas or Acinetobacter, then we should go ahead and complete 14 days of treatment to avoid the relapse. Dr. Sean Kane 28:13 So that concludes episode eight of this HelixTalk podcast. If you'd like to visit us online, you can find us at HelixTalk.com we'd really appreciate a five star iTunes review. With that, we wanted to give a shout out to Dr. Schuman, who's in Honduras right now. We're sorry he can't make the podcast, but we'll hope that he'll be on the next one. Absolutely, with that, I'm your co host, Dr. Kane, and Unknown Speaker 28:33 I'm Dr. Patel, and as always, study hard. Narrator - Dr. Abel 28:37 Thank you for listening to this episode of HelixTalk. For more information about the show, please visit us at HelixTalk.com you.