Hello, this is Charlie Krasner. I’m here with Amy, Jessica and Mike. How pretty. (laughs) I got crazy with this design idea on powerpoint, it’s just great, it makes your slides look great. That’s half the fun of doing these talks. Anyways, First of all, you guys have any questions or any issues that have come up that you’d like to discuss with us -we’re all ears. Any cases? Cases? The weather, ha. Well, as we go along, if you have any questions… So, this is a more very relaxed talk today, I wanted to go over some cases of community acquired pneumonia, basically how we make the diagnosis and if you ever wondered how to read an x-ray too, so, make it a little bit more enjoyable. Alright, so, this is – So I’m going to talk about community acquired pneumonia and community acquired pneumonia basically as you know it’s pneumonia which is acquired outside the hospital in a healthy post. But most the time when we see them in the hospital these patients have co-morbidity. So it’s very unusual to see a healthy person in the hospital with pneumonia. Actually representing a healthy person that’s the next case but usually it’s because they have co-morbidiy whether it’s things like heart failure, diabetes, COPD, kidney problems or strokes. So it’s hospital-acquired Usually in a patient with multiple co-morbidities who ends up in the hospital does not have any exposure to a healthcare system. So like cancer patients or dialysis patients, they’re basically just people admitted with pneumonia. It’s important to – why do we classify people as community acquired pneumonia? Because – The treatment of pneumonia, as you know is imperative most of the time. You don’t get results for 2 or 3 days and so deciding if somebody’s been healthcare exposure or whether they just got community acquired, it’s very important because oftentimes the pathogens that we treat are very different. So when you’re treating empirically as opposed to the time we do, you really wanted to have an idea of what the most likely pathogens are. And so we talked about that and x-ray findings which may point you in the direction of what the pathogens are. Alright so, case 1 is a community acquired pneumonia, and this is – Joe Camel he allowed me to put this picture on for the talk. Mr. Camel is a 73 year old patient, he presents to your primary care office 3 day history of productive cough, wheezing, fever and confusion. And again, he’s got co-morbidities, history of COPD. Diabetes, heart disease, and was recently treated for sinusitis with azithromycin pak a few months prior. Alright, so he comes in with a cough, wheezing, fever and confusion. And, on exam, he has a temperature – 100.8. He’s a little bit tachycardic. His pulse ox is a little bit low. And when you examine him, he looks short of breath. He’s a little bit confused. He’s coughing up goobers which he shows you very nicely. In the back he has a wheezing and rhonchi lung exam. So smoker, diabetic comes in with fever, cough, confusion and productive phlegm. Alright, so question for the audience. As you consider always presenting symptoms – You decide that the most likely diagnosis is either asthma, chronic bronchitis nosocomial pneumonia or healthcare-associated pneumonia or community-acquired pneumonia What would be – What would be your most likely choice and why? Anybody? Jesse or Joy or Christine? A chronic bronchitis or a pneumonia – community pneumonia. And why would you pick between those two? Without a chest x-ray, listening to the chest, how far down the breath sounds are and what quality the breath sounds are. So, I think that’s a good call. The only thing is about chronic bronchitis, you should have a fever. Chronic bronchitis, you usually a fever, so I think most likely you’re gonna be looking at a community acquired pneumonia. Obviously asthma, again, should not have a fever associated with it. (inaudible) chronic bronchitis or community acquired ammonia – very good. What test would you order next for Joe? The chest x-ray. Alright, you can go home now. (laughs) According to the latest American Thoracic Society, community choir pneumonia guidelines, all patients with suspected community acquired pneumonia should receive which test to establish the diagnosis? Chest x-ray, blood cultures, blood gases, sputum cultures or Legionella and Pneumococcal urinary Ag So, as you said its chest x-ray to make the diagnosis of pneumonia really need a chest x-ray. The other stuff would be nice but doesn’t help you make the diagnosis of pneumonia so, clinical production of sputum again suggests a bacterial infection and the fever and the wrong kind exam so (inaudible) now a community acquired pneumonia, very good. Alright so, I’ll show you x-rays. I’m sure some of you know how to read x-rays, some of you don’t, so this is a normal chest x-ray. And we’re gonna compare, we’ll get some x-rays just to compare what a normal one looks like, so… So, this is the heart. This right there, you have the spine behind it. And all these things here are the ribs. And the diaphragm them on the bottom. So the rest of this are lungs, so the left lung the right lung, and everything is basically black. Except when you have the ribs and the scapula. So this is a normal lung. And the lugs are broken up into lobes. So like in anatomy class, the right lung has three lobes and the left lung has two lobes and you’ve all heard of people saying you have a lobar pneumonia. Okay, so clear x-ray down here is the gastric bubble, the diaphragms, the heart, spine, the ribs, but this is a clear x-ray, normal chest x-ray. And so, this is just an example of the right side of the heart. – Or the right right side of the lung. So the right lung is – you can see his is made up of three lobes, here on the right upper lobe. And then you have the on the lateral view so, looking straight on the lateral view, the whole upper half of the right lung is right upper lobe, in the middle you can see over here is the right middle lobe so it’s sort of like a triangle between the right upper and the right lower. And in the front it looks you see it straight on okay, so you have the right upper taking up the upper half of the right lung and then the bottom half of the lung is divided into a right middle lobe. Which looks like a triangle. Straight on, it’s right in the middle. Or you have the lower lobe. So you can see, right upper is our lateral view. Right middle or right lower lobe. And so, when you have a lobar pneumonia, you basically have a Infection which is basically localized to one of those lobes. So it’s like saying ‘Oh I have a lobar pneumonia’, You can be saying right upper lobe, right middle lobe, or right lower lobe pneumonia. Okay, so these are much – these lobar pneumonias, are typical, typical bacterias – Klebsiella. Strep pneumo. And when we see lobar pneumonia, often times we know what feelings of bacterial – standard bacterial, typical bacterial, pneumonia – like Klebsiella or strep pneumonia. So the left side is also very similar, the left upper left lower Okay, so we’ll refer back to this – this chart. So, next x-ray. Alright, so, This is not our patients x-ray, but this gives you a better idea, so. On the left side over here we again – I haven’t shown you the anatomy of the left side but this is a low bar consolidation. It’s – this is localized to the left upper lobe. There’s a left lower lobe, but we can tell it’s left upper because it’s the upper side. It’s not touching the diaphragm, the heart the of the edge of the heart is not touching the diaphragm. So this is a lobar pneumonia So we don’t have a lateral on this but typical lobar pneumonia. If you contrast it on the left side, you have patchy infiltrates throughout. it’s not localized to one lobe of the heart – of the lungs – not the right middle. Bilateral dispatch infiltration of cavities. So, the left said I’d call a typical lobar pneumonia, in the right side I’d say it’s probably a pneumococcal or Klebsiella. On this side This is a very atypical presentation. This doesn’t look like a lobar pneumonia. So I’d be thinking of other things like viral, mycoplasma atypical infections universal infections -something that doesn’t restrict itself to the lungs. And so, when you see that Joe Camel is coughing, and you look at his x-ray, you definitely want to see what pattern you see on the x-ray. Alright, so this is a – this is Joe’s chest x-ray. Question – true or false: Joe’s chest x-ray shows our right upper lobe pneumonia Okay, so this is the lateral, and this is the front on. And so, What – did anyone see what they see? Say what they see on this. Alright, so remember if you look in the lateral, we – the long is Yeah so, you go down here, you have the right upper, the right middle and right lower. Alright so, actually – right upper, right middle is the triangle here, and this right here’s two right lower. So we can see here, right here is the line between the right lower and the right middle. So this would be – this is the right middle – this is the right lower. And it’s touching the diaphragm. Okay so if we go back, we see it’s touching the diaphragm and we see it’s – what looks like the right lower. So we go back. So right here, we have a right lower lobe infiltrate, so, it’s down here. It’s touching the diaphragm It’s not filling completely the lobar, (inaudible) This is a typical right lower lobe consolidation. So again, we see that it’s right here, just the right lower, it’s all over here. It’s touching the diaphragm. So when you look right on it, you can’t see the diaphragm because you’re full of fluid and pus. So the diaphragm is very obscured over here So you know, it’s touching the diaphragm, and you know it’s in the lobe, so I would call this a right lower lobe consolidation. – or pneumonia. Okay it’s not like this -this x-ray, which is crazy looking, this is a lobar, this is a lobe pneumonia, so… He coughs up, he’s wheezing. He’s got bronchi, he’s got temperature. It’s got gross sputum and now he has a lobar consolidation. Again, It’s really staying in the lobe, it’s not going everywhere. Just in there, so, again you think of a typical bacterial infection. Alright so, gives you a good idea of what you’re probably dealing with. And so, if you look at – next question, the most common cause of hospitalized – hospitalized not outpatient – cases of community acquired pneumonia is it… E. coli, is it Klebsiella, is it mycoplasma, is it RSV, pneumococcus or MRSA? Any thoughts? Strep-pneumo? Yes, it’s always strep-pneumo until proven otherwise, and so… But I can tell you, even it it’s not strep-pneumo, you’re probably doing like a Klebsiella (inaudible) it’s a lobar consolidation, okay. MRSA is horrible cavities. RSV is diffused infiltrates. E. coli doesn’t cause community acquired pneumonia (inaudible) healthcare associates. So, I’d guarantee and say this is a typical community acquired pneumonia, most likely strep. Possibly Klebsiella or H flu and I would direct my therapy towards that. Okay, so x-rays would be really helpful in terms of coming up with a diagnosis. And this is – okay, strep-pneumo is always the answer. It’s strep-pneumo until proven otherwise. From mild to severe cases, number one, And what is the arrow pointing to? This is a gram stain. (inaudible) What are you seeing on that gram stain? Tell me two things you’re seen about where the arrow’s pointing. (inaudible) Yes, and what else, what’s around it? It’s encapsulated. Yeah, so you see the clearing around it. So, Pneumococcus has capsules remember when your vaccination’s with the prevnar (inaudible) you’re vaccinating against the capsule, so, the capsule is, you know, it’s like the clear space around so every one of these, you can see it clearing around it. You also see that they’re pointed like little sort of bullets towards each other. Like over here. So this is classic pneumococcal findings. First of all, these are white cells, you want them pink like this, to tell you the slides been done improperly. But these are classic pneumococcus facing each other with a clearing around it. And you can see the capsules everywhere. So this is you know, if you have, you’re able to get a sputum on a guy’s culture, or you get a report from your micro lab, this is encapsulated diplococci, which is a pneumococcus. And again, Very consistent with Joe Campbell’s presentation with coughing, phlegm, fever, bronchi, and a lobar consolidation on his x-ray. It’s nice, all you see is – you don’t see epithelial cells (inaudible) and you don’t see like all different types of organisms. It’s not a good sample so a good gram stain can really point you in the direction. So, other common causes of community acquired pneumonia, one is typical. Typical means that they present like Joe. -Joe Campbell They have respiratory complaints, they don’t have extra pulmonary complaints like diarrhea and stuff like that. They complain – they say I’m coughing, I have a fever, I got phlegm. And on the chest x-ray, you see lobar consolidation, and when you look at the gram stain, you can see these organisms, these are moraxello, hoemophilus. Or strep-pneumo. So I’d say this is a typical CAP infection. The term atypical usually is not with a lobar infiltrate, they usually have patchy infiltrates. And these bacteria when you do gram stains, they’re picked up by the cell wall. Things like mycoplasma and chlamydia don’t have cell walls, so you don’t see them on the gram stain so you have a gram stain of water bacteria while the white cells have no bacteria so they point you in the direction of an atypical infection like (inaudible) chlamydia, mycoplasma. As you know, it has a gram, gram-negative, but it’s interstellar, so it doesn’t come up on the gram stain. So typical means typical presentation, a lobar consolidation on chest x-rays, (inaudible) sputum and typical bacteria. Atypical Often times extra pulmonary complaints may be ear rash, pharyngitis, etc. Plus a gram stains are negative and x-rays are not typical low bar consolidations. Again, this is a picture that shows causes of pneumonia in different age categories and yellow is strep-pneumo. So even in the young people strep-pneumo’s not uncommon but it gets particularly common as you get older. Mycoplasma is also very common. I think it’s more common than strep-pneumo in young people. It’s usually the person in the back of the hallway (inaudible) can’t stop coughing and that’s 102 degrees, so that’s mycoplasma. And then you have Legionnaries, we don’t that much Legionnaires here and chlamydia. But again, whenever you’re treating someone from pneumonia Unless you already know the cause the infection, you always want to cover strep-pneumo. And so just talk about if you antibiotic therapy for community acquired pneumonia, You always want to cover the possibility of strep-pneumo. And as I said, you know, Beta-lactam antibiotic, penicillin, cephalosporins, only work against bacteria that have cell walls, so, penicillin, cephalosporin are great against strep-pneumo (inaudible) But they don’t have activity gets atypicals where they do need other mechanisms to knock off the bacteria. For example the quinolones are DNA gyrases, an inhibition and other ones are ribosome inhibitors, etc. So penicillin works great against strep cephalosporins. The macrolides have been so overused that there is some resistance against pneumococcus. Unless you’re sure that’s not pneumococcus pneumonia, you probably wanna add something for atypical (inaudible) You should put something in the – when you’re hospitalized somebody either like rocephin and unasyn. with the pneumococcus then you add the macrolides for atypical coverage But you want to hospitalize someone just give them (inaudible) And the quinolones work against the DNA and so they’re effective for all types, and doxycycline has some activity against pneumococcus but again, it has atypical coverage. Okay. Alright, so this, this is a case I just saw a week ago in the hospital. This is a 25 year old, otherwise very healthy young lady. She was seen a week early, in urgent care. Came with myalgias headache, fever, and the flu season was still going on so she tested positive for influenza. I was surprised that you know, I wouldn’t normally give a healthy 25 year old person Tamiflu, but she was given Tamiflu anyways. Usually Tamiflu is expensive and toxic so usually you try to save it for patients who have more comorbidities and more likely ending up in the hospital. Anyway, she was given Tamiflu, but she continued to have a cough, started developing some chest pains. She was feeling worse despite the (inaudible) from the fever. First she started feeling better then she started developing this hacking cough and left sided pleurisy. So when she coughed she had pain in her chest. She had fever and rhonchi on exam in an emergency room, she looked ill and she had sputum and x-rays obtained and she was admitted to the hospital. Alright so, woman getting over the flu started feeling worse with (inaudible) she had not had the flu shot – I should add. And this is her chest x-ray. It’s not the most dramatic x-ray, but you can see down here, there’s simply something going on here. But there’s also some changes over here. And there may be some changes up here, and over here, so, this is not a classic lobar consolidation. She was having some Pleurisy on the left side, so, you’re wondering about what may be going on there. And so they did a cat scan of her chest and these are two levels through your chest. This is the left side of her lungs and this is a 25 year old girl. She should have healthy lungs. She’s got big cavities. This is just one of many views, she has multiple cavities on her chest x-ray, so this is a narcotizing process. Regular bacteria like pneumococcus, H flu, (inaudible), do not cause these problems. And this is a nasty, narcotizing process. How sick was she? (inaudible) Over here, you can see over here on this side, these are her ribs and her chlora. And over here again, you see it down further, it still looks good, but here we see this – this fluid collection and you can even see some enhancement of the lining of the pleura. So this looks like week-old loculated effusion, so she has fluid and it’s her – pasted in there. So she had these large cavities and then she had this large pleural effusion, so, there is a pleural process going on. So this is a narcotizing pneumonia sick girl post influenza. And this was her sputum, What is the likely cause of this young lady’s pneumonia? Staff. How can you say it’s staff? They look like gram positive cocci in clusters. Classical teaching is post influenza pneumonia. It’d be staff. Yes, very good So she read the textbooks. So, her x-ray actually looked better before she came in. These are, what happened, she had an -this fluid is like very thick and has to come out, so basically pus. So the surgeon had to take her to the operating room and you can see this thing here, these are chest tubes to help drain the pus out. So they they they open her up, they wash it out and then they put these drains in. (inaudible) And there’s actually some air here in the lung tissue. So these are like basically if you can imagine to garden hoses in your chest, it would probably hurt like hell. I’m sure that does so, but this is what you have to get this this stuff is so thick and gelatinous that it just has to come out. And it has to be drained. So she was – she grew up MRSA, and was treated with vancomycin. And – She went home, it was susceptible to clindamycin So we sent her home on clindamycin to complete her treatment for a few weeks and then we’ll be getting – She’ll be seen in the clinic in a week or two with follow-up chest x-rays and make sure she’s doing well. Alright, so this is a again a community-acquired pneumonia, MRSA in a healthy young lady. Not typically seen in young people, but it is known for post influenza complications. So get the flu shot. Alright, so these are some -some of the pointers that I use. if you’ve got a young healthy person, mild disease, coughing, febrile, you know, they’re not bringing up sputum, It’s almost certainly an atypical pneumonia. So like mycoplasma pneumoniae or chlamydia pneumonia, are very very fine. You could probably just you know, give them like a Z-pack. It’s not great for pneumococcus but Unless they’re really sick (inaudible) pneumococcus. But if it’s really severe. Then you worry about pneumococcus And if you treat as an outpatient, you may add like amoxicillin. to the Z-pack. And, even consider MRSA as a complicated pneumonia when you get your chest x-ray. If they’re smokers, just like Joe, – Joe Camel, I think pneumococcus, H-flu, Moraxella. As the causes of acute exacerbation of chronic bronchitis as well as pneumonia. Depending on the how sick they are, you can either treat them with like a box of augmentin or a similar drug. Alright, some suggested community-acquired pneumonia regimens not set in stone. Healthy outpatient, no prior to antibiotic use, just think about Z-pack or doxycycline. Basically a healthy person. Outpatient mild to moderate disease prior Z-pack. You may be worried about some resistant strep pneumo. So levofloxacin is a generic for how many days? Five days? No more than five days, yes. I just saw somebody getting a prescription for ten days I’m not so happy about that. And then for inpatient, again, Inpatient wards -you definitely – if somebody’s sick enough be in the hospital, you need to cover pneumococcus empirically so either ceftriaxone or unasyn for that coverage and then atypical coverage, either IVs, erythromycin, IV or oral doxycycline. And then you can based on culture results or you’re not sure of the results – transition to oral levofloxacin. If somebody’s sick enough to be in the ICU, there’s two reasons they’re gonna be in the ICU, one they may just have such bad commodities, you know, they basically (inaudible) barely functioning, and something like a pneumococcal pneumonia Pushes them over and then it’s still pneumococcus, but if you see cavities on the chest x-ray, which is not a common finding for someone standard. You might want to think about adding vancomycin for the possibility of (inaudible) And then, you may have somebody on the right treatment, but empyema is our common complication. So if somebody is you think has pneumococcal pneumonia they’re doing good and after 2 or 3 days they’re getting worse, don’t go vanco zosyn. Get an x-ray, because they can develop exudative effusion empyema that needs to be drained. You don’t need to change antibiotics, so One of the things that we’ll do for outpatient mild-moderate infection was comorbidities when they’ve had the Z-pak prior. If they’ll do amoxicillin or with or without a z-pack prior we’ll do amoxicillin plus atypical coverage. So high-dose amoxicillin two grams, PO twice a day, plus the atypical doxy or asythro. We’ll do that – we prefer that over levoquin a lot of times, but the duration would be very similar to 5 days or less in some cases. If anti doxy or azithro for atypical coverage is – doxy has some activity preventing C. diff. (inaudible) Doxy’s a good choice for atypical coverage. We try to encourage people to use it orally in the hospital. I remember that case, we had a case when I was with you, patients had strep pneumo pneumonia and we came back, we were looking at it and all of a sudden the right side – remember that – we could see nothing. And we were like what is that? That was one patient who got an empyema? -Yes. Just amazing. Don’t go vanco zosyn, get the x-ray think about empyema. Alright. Let’s see who’s been listening. This is the 62 year old smoker with chronic bronchitis, comes in with fever, cough, productive green phlegm, shortness breath – sounds like Joe Camel. What is the pneumonia pattern on chest x-ray? Lobular? Very good, so, it’s actually – we haven’t talked about the left side, but you can see how the left side is actually just two lobe so it goes down here, and this is the left upper lobe and this is the left lower lobe. So this is a lobar consolidation and you know it really it doesn’t break that line there. MRSA, staff, (inaudible) You know, Klebsiella and pneumococcal doesn’t do that. Okay, so then you can see it over here, So this is the front for you, but this is a left upper lobe. Pneumonia, which typical pattern, typical presentation, so what’s the most likely cause of this patient? Strep-pneumo. Yeah, very good. And again, strep-pneumo (inaudible) but you’re also going to cover Klebsiella, (inaudible) treated very good. And empiric treatment in hospital – what would you do? if you admitted this patient in the hospital? We would either do unasyn, azithro, (inaudible) and you’re doing the azithro, primarily because you have to. Historically you have to, yes. Yeah. So why are we treating atypicals when we know it’s pneumococcus? But there were some studies that the years ago suggesting that azithro may improve the outcomes of pneumococcus maybe because that’s anti-inflammatory activities (inaudible) but that’s questionable. And what would you use if he was penicillin allergic? I’d asked him what his allergy was. (laughs) Very good. We had an uncle who – In the old country – (inaudible) Alright. Anyways, so now, you know the terms and if you look at x-rays you can see what they’re talking about. You know, if it’s a lobar pneumonia, (inaudible) vanco zosyn, okay, it’s usually typical bacteria (inaudible) Alright. I have a case that I forgot about until just now, it’s not a pneumonia case, it was A gentleman, I believe it was a gentleman with a pacemaker pocket infection. No.. blood cultures were not positive. The pocket they swabbed the (inaudible) out of the pocket, showed Staph aureus, this is that our facility Renown. (inaudible) That was negative. So I had them deescalate vanco to cephacillin. Then today, I got a fax from another facility saying that they cultured the exact same pocket and it’s MRSA. When I look at the actual sensitivities, it’s – the MIC’s it’s less than or equal to on the amoxicillin and the resistance would be amoxicillin. So it’s labeled MRSA. Have you seen that before? You should report that case. That doesn’t make sense. It doesn’t, it doesn’t. And so, We’re still waiting on our final susceptibility patterns here off the micro scan. But I was tempted to have them run it on the PCR machine to see if… Did you have oxicillin resistant here too? (inaudible) It should be up later today. Unless it’s somewhat a mix thing or – Yeah, well I said MICU is less or equal to but resistant because they change (inaudible) What the Pacer has to come out. Pacer came out already. Yeah. (inaudible) No additional guidance for that. (laughs) Any questions or comments? My question is, how do you know when to test for Legionella A lot of people say it’s part of the routine presentation, but you know if you have a.. I would be concerned about Legionella, you know, there’s some things that will tip you off. Have they been on the East Coast, in Pittsburgh places like that. Butwhen they have a lot of things that don’t fit, you know like whenever I’ve seen Legionella, you know like Joe Camel; he’s coughing and short of breath. (inaudible) Interesting things about Legionnaires is that they oftentimes only complain that don’t even know they have a lung infection. They complain about diarrhea, headache, confusion, and we actually had a patient about two years ago. He went to an emergency room and was very upset because he was told he had pneumonia when that wasn’t his complaints. (inaudible) So Legionnaires should anytime you hear extra pulmonary complaints think about Legionnaires low phosphate, (inaudible) And then you can just order Legionella antigen, it can be helpful. And also, if the x-ray does isn’t nice and lobar, you think about Legionnaires. But it’s just it’s just a constellation of lab abnormalities and extrapulmonary complaints. They can often have high attempts to (inaudible) Yeah, sometimes yeah. Temperature, the pulse is not as fast as their temperatures. Yeah. And so, it was really interesting, All the patients I’ve seen, you know, they’re always surprised to be told they have pneumonia, the doctor said I have pneumonia but that wasn’t my complaint. So anything that doesn’t fit with a typical presentation You may want to go off to Legionnaires and you know any of the levofloxacin azithromycin, or doxy has pretty good activity against Legionnaires disease. (inaudible) Since I’ve been retired, have we had a Legionnaire case that was originated here? No, we’re probably missing it though. Yeah, not that we know of. Yeah, that’s a good question, but, I just think the CDC recommendation is – and for NHSN – they want you to do a urine antigen respiratory culture for Legionella, and the respiratory culture for most places is probably a send out to the state lab, so… Does that recommend everybody with pneumonia being admitted? No, just if you suspect. So, you know, if it doesn’t make sense, and you start thinking about the weird stuff like the mycoplasma (inaudible), chlamydia, (inaudible) Legionnaires, then you should order that. If it’s not a typical presentation, and it’s not obvious then forget it. That’s a good question, thank you. We hardly ever test for it. So, yeah, we don’t actually know I guess. (laughs) It’s big on East Coast though, right? Yeah. (inaudible) The VA is fixated on national so they have committed hundreds of hours (inaudible) but hundreds of hours of talking about Legionnaires disease. They have to take all the water pipes out It’s like oh, you know I get a life. Well, they actually had an outbreak at – was it in Phoenix? At a nursing home or somewhere. I don’t see Beth on there but Carrie is on there right. Yes, Carrie. Alright, thank you all. Thank you.