[INTRODUCTION]
[0:00:04.2] LS: Welcome to the MedSoup Podcast, where we talk about trending healthcare topics. I’m your host, Laura Schumacher, let’s dig in.
[INTERVIEW]
[0:00:13.5] LS: Today, we’re here at Carolina Specialty Care in Statesville, and Carolina Specialty Care actually has an infusion suite. So we’re here today at Carolina Specialty Care and we’re going to talk with Cynthia. She’s a registered nurse and she’s also the manager of the Infusion Suite. Hi Cynthia, thanks for joining us.
[0:00:32.1] CR: Hi, thank you. Thank you for having me.
[0:00:34.0] LS: Can you explain to us a little bit about what your role is here?
[0:00:38.0] CR: Yes. Okay, so like I said, my name is Cynthia. I’m a registered nurse here at Carolina Specialty Care. I am in my 15th year here with the practice and I love infusion, so I’m an infusion nurse and so every day, I spend taking care of patients in our infusion center and giving them various types of medications for the diseases that they have. I love my job.
[0:01:00.7] LS: I would imagine you have to love your job because people probably come in very nervous or especially if they’re new to it.
[0:01:07.4] CR: Absolutely. When we have new patients, we always want to make sure that we’re taking extra time with them and explaining the process, and giving them a time to ask any questions that they have. We want them to be as comfortable as possible.
[0:01:20.2] LS: So what is the difference between infusion or IV therapy, is that the same thing? IV therapy.
[0:01:26.9] CR: Yes, yes.
[0:01:28.2] LS: And an injection because some people think, I’m going to get a shot, but it’s not.
[0:01:31.3] CR: Right, absolutely. Yes, so it is a little different. So if you’re getting a shot, it’s basically, you’re getting medication that’s drawn up in a syringe and then that is injected with a needle to – into your tissue or into your muscle in your body.
When you’re doing an infusion, we actually take a needle and we insert it into your vein, and then actually, the needle part comes out and what’s left is a small silicone catheter and it can stay there in your vein. And to it, we can connect tubing and we can give you medications into your vein and that goes directly into your bloodstream. So that is different than an injection.
[0:02:06.6] LS: It is and it – so it’s not painful?
[0:02:09.7] CR: Well, as painful as a needle going through your skin. So we can’t actually take away all the pain that’s involved in that but we try to do that as carefully as we possibly can. We use the smallest needles that we can in order to get the job done. So we don’t try to do anything big, large bore needles that you would see like in the emergency room and that sort of thing. Here at our office, we are able to use small catheters and they are maybe not quite as painful as some other types of injection or infusion procedures.
[0:02:38.9] LS: But definitely the benefit outweighs a little bit of discomfort there for a moment.
[0:02:42.7] CR: Absolutely, yes.
[0:02:43.9] LS: Because probably most people get comfortable after that first part.
[0:02:47.6] CR: Right. I mean, there’s a lot of people and myself included that don’t like being stuck with needles, that’s just not an actual process.
[0:02:54.3] LS: I don’t know anyone who does.
[0:02:56.0] CR: I tell people that I too, if I’m sitting in the chair, I’m going to be nervous as well, but we try to do that just as gently as we possibly can and once that part is over with, there should be no more discomfort. The rest of it is just smooth sailing.
[0:03:09.2] LS: They just kind of sit back and relax or read or –
[0:03:12.8] CR: Right, pretty much. We have patients, our room actually, set up with recliners so we have 10 recliners that have the automatic reclining on them. We have blankets and we just try to make them comfortable with pillows and blankets and whatever that we can do to make them as comfortable as possible while they’re here.
[0:03:28.1] LS: And I have seen that room. I mean, it’s beautiful because it’s very the windows and it’s sunny and you feel good walking in there.
[0:03:34.7] CR: Right, we love our infusion room. The windows are amazing, you always get to see what’s going on outside, the beautiful sunlight in the morning and lots of room. So we’re excited to have lots of room to get our patients in.
[0:03:47.0] LS: Well, speaking of the benefit of that, let’s talk a little bit about what you use infusion therapy for. So it’s for a variety of conditions.
[0:03:56.8] CR: Correct. So obviously here at Carolina Specialty Care, we are a multispecialty practice. So that means that we have different types of physicians that take your different types of disease states. Primarily here in our room are mostly rheumatology-type diseases. So we have a lot of patients that have rheumatoid arthritis, other diseases such as lupus, gout, osteoporosis, and also, we will do infusions for other patients maybe that aren’t necessarily primarily seen in our practice.
But we have patients that might have Crone’s that need infusions for their Crone’s disease, which is also an immune disorder similar to rheumatoid arthritis. Some of those patients have joined all our practice because they needed somewhere to go to get their infusions, so we were able to kind of adopt them into Carolina Specialty Care so they can continue their therapy here with us.
[0:04:46.9] LS: So, some of those patients who may not be patients of Carolina Specialty Care, they can be referred here and received their treatments here and then they go back and see their other doctors as well?
[0:04:58.3] CR: That’s exactly right, yes. So we have patients, primarily right now, we have some gastroenterology-type patients with Crones and other types of GI disorders, and they were desperately needing a place to do their infusions. So, we have partnered with several of the GI physicians and they do call us and ask if we can take on a patient for them.
Basically what that looks like is the patient gets set up as quickly as we possibly can, as a new patient referral to see one of our rheumatology providers, primarily, Dr. Wodecki if we can get them in with him. So he can give them a once-over and then at that point, we will collaborate with the GI doctors with whatever the infusion therapy is that they need the patients to get.
And as quick as we can get their insurance authorized, we are ready to resume their therapy here in our office or in some cases, start that therapy from the get-go. They may be starting with us new and have never had that therapy before, so we can do that as well.
[0:05:51.6] LS: Yeah, I mean, it’s nice to have a partnership like that.
[0:05:53.9] CR: Right, absolutely.
[0:05:55.0] LS: And that you’re being cared for by multiple medical providers, going to get you the right kind of care that you need.
[0:06:00.0] CR: Right. And then I can communicate with those doctor’s offices, they can contact me regarding the patients. If the patient reaches out to them or vice versa, we can communicate with different issues that are going on, and that way, we can keep that partnership going where they can collaborate with us and say, “Hey when you see this patient next, can you do some labs?” or “maybe let’s give them a little bit different medication,” and we can make that happen.
[0:06:25.2] LS: And that’s great. And then as far as the treatments, I mean, I would imagine that the condition dictates the treatment, like how often or how long it’s going to take. Can you talk a little bit about that?
[0:06:36.4] CR: Yes, absolutely. We have, on average, probably about nine or 10 different biologic medications that we give in our infusion room on any given day. Those medications can range from a 30-minute infusion up to at the most, like a five or six-hour infusion, and everywhere in between and each person or each therapy like you mentioned, I tell them, they all have their own recipe.
So this particular therapy, you might come every four weeks, another one you may come every six months or every eight weeks, and then we have some therapies that are actually every two weeks. So it really just depends on the condition and on the therapy that the provider orders.
[0:07:15.9] LS: And over time, would that change?
[0:07:19.0] CR: It can, it really just depends on the disease that we’re treating. Many of the therapies that we give from a rheumatology standpoint are what we call long-term therapy. So that means if the patient is doing well on their therapy and they’re responding to it and it’s helping them and they’re not having any ill side effects or whatever, they could continue that therapy for a very long time.
I have patients now who I’ve been treating pretty much the entire time that I’ve worked here at Carolina Specialty Care that are still receiving their therapy. Some of them, the same therapy they’ve been on for all these years. Others, they may switch to a different therapy after a while. It just depends on their overall health condition and how they’re feeling with what we’re doing.
[0:07:58.1] LS: And are those, you mentioned biologics, are those that drugs given in combination with pills or maybe in some cases, maybe not in other cases?
[0:08:06.4] CR: Right. So again, it just depends on how the prescriber has ordered their therapy. Some of them are given in combination with other medications whereas they may come here and do their infusion, and then in between their infusions, they may be taking medications at home that are in most cases, an oral medication or some pills or something that they might do once a week. or some of them maybe every day, and then they’ll come back and get their infusion when it’s time.
[0:08:32.0] LS: Okay. Can you explain what biologics are?
[0:08:34.8] CR: Yes, to the best of my ability. So we have patients that have immune disorder such as rheumatoid arthritis and in those patients, their immune system isn’t acting correctly. It’s – some parts of it is just doing too much and it’s overactive and that is what’s causing patients to have issues such as pain in their joints, swelling, fatigue, and just general, overall issues that they can have without just saying rheumatoid arthritis, for example.
Biologic medications are designed by scientists to be given to patients, and they are what we call targeted therapies. So basically, this medication goes into their body and it goes into their immune system and it just targets one piece of that immune system. So it’s not a full-on – we’re not zapping everything. Like, think about if someone’s getting chemotherapy or whatever, this is different. It’s very targeted.
So, we’re really just looking at one piece of the puzzle and if we can target that one piece of the puzzle and say, “Look, you’re doing too much, you need to stop. Let us calm you down a little bit.” By doing that, we can slow down the process of their disease. So, therefore, that means less joint damage, less joint swelling, less joint stiffness in the morning, and then just an overall better well-being, which is our ultimate goal.
We want to help patients live better, fuller, more productive lives. And if we can slow down the process, we can keep things from getting worse, that means that we’re doing what we need to be doing.
[0:09:59.4] LS: Yeah, and with that targeted therapy that means that “Hey, we’re not going in there with this medication and we’re messing with a bunch of different things.
[0:10:06.6] CR: Exactly, exactly. So yes, what we tell patients is, we have various different medications that we give and each one of them potentially can work on a different part of the immune system. So they’ll come into the ivy room and they’re like, “Well, why is this patient only here for 30 minutes and I have to stay for two hours?” or three hours or what have you. I explained to them that the different drugs and the way that they’re made dictates, one, how they work in a system, and how quickly we can give them their medication.
But yes, at the end of the day, we’re working on just this one little piece of the puzzle and if for some reason, that therapy doesn’t work, well, thank goodness, in a lot of our disease states, we have another choice. So if that medicine doesn’t work, that doesn’t mean that there’s nothing we can do to help the patient. It just means we may have to go back, the provider’s going to have to decide, “Is there another medication we can give them that will help them?”
[0:10:57.2] LS: So it’s just like anything else. I mean, everybody’s body reacts differently, things like that.
[0:11:01.2] CR: Absolutely.
[0:11:02.4] LS: And what are some of the side effects that you see?
[0:11:05.2] CR: So the number one concern that we talk to our patients about when they are on biologic therapy is that because of that immune system disorder and how we’re going in, and we’re looking at their immune system and then we’re working on that one particular piece, every patient is cautioned and educated on the fact that there could be an overall risk of infections.
Meaning, if they get exposed to someone that has an infection, they might get sick. The biggest takeaway is that if they become sick, you do like you normally do. You go to your doctor, you get an antibiotic or what have you. The biggest thing that we are concerned about is when it’s time for them to get their infusion again, we want to make sure that on that day, that they show up to see us that they’re well. That they’re not sick in any way.
If they’re sick, are they on an antibiotic for some reason or they maybe need to be, then that’s a reason for us to step back and take a look and say, “Hey, maybe we need to wait and give you your infusion when you’re better.” So, we want the sickness to be gone, we don’t want to make them sicker by giving them the biological on top of that. That’s usually a conversation that we have with the patients upfront.
We screen all of our patients when they come in and we ask them, “How are you feeling today, are you sick in any way, or have you been sick since we’ve seen you?” So we can keep a record of that. But if they had a sinus infection or something and they’ve been off of their antibiotic for two or three weeks and they’re feeling better, we have no issue with that. It’s when it becomes a pattern or when it becomes a problem or if they show up and they’re actively – they have an active infection.
If they have an active infection, we are not going to treat them because that’s how we’re going to keep them safe.
[0:12:37.4] LS: Yeah or someone’s had the treatment and then over time if they’re noticing they’re getting more and more infections.
[0:12:44.2] CR: That’s true too. So that’s going to be – yes. So that’s when we’re going to send them back to the provider for an office visit so they can sit down with the doctor or the physician assistant and go over, “Here’s what’s been going on” so then they can decide what we need to do next.
[0:12:57.8] LS: Yeah and I guess the key point is that every patient is monitored, whether they’re sick or well and everything, those side effects, whatever’s going on with them.
[0:13:07.4] CR: Right, and with each time we have a new patient or every time a new therapy is started, there’s a consent process. So actually sit down with all of those patients on the very first day of that infusion or on another day if we happen to get a chance to do that before the IV day. But on that very first day, we do a consent and I’ll sit down and go through all the information about the medication, talk about what the medicine’s going to do.
Talk about what the potential side effects are, which of course could be infections and that sort of thing, and how we will move forward and keep that from being an issue by not treating them and then we do talk about, “It’s a medicine that’s going into your system, so it’s new. We don’t know if your body is going to like it or not. Here’s what we’re going to look out for” things such as itching, hives.
If they have any issues while they are in the IV room, such as difficulty swallowing, trouble breathing, chest pain, we monitor their vital signs throughout the whole process, so we are looking at their blood pressure and different things like that but essentially I tell the patient, “If you don’t feel well, you tell us and as soon as you tell us, we’re going to intervene” and that’s typically how we deal with those type of situations and thank goodness, by following all the safety guideline as far as how quickly you infuse the medication, if they require any other medicines upfront.
By following all the safety rules, it’s not common that we have to deal with hypersensitivity reactions or allergic reactions whatever. But just like you said, every patient is different, every person is different. So you just don’t know, that’s why they’re here so we can monitor them during the process.
[0:14:37.4] LS: Yeah and a lot of the medications that you use, they have been around for a really long time.
[0:14:41.8] CR: Right, yes.
[0:14:42.6] LS: So I think that is important for people to know that it’s not just new things coming in the door all the time.
[0:14:46.9] CR: No. Yeah, I mean, we thankfully, research is great and new medications do come out but we also have those, many of which have been around for many, many years prior to me coming here 15 years ago, and we do have new medicines that will come out over time but again, they’ve all been through the clinical trial process. They have been tried and true and they’re all FDA-approved and we’re using those and following the safety guidelines.
[0:15:12.6] LS: Are these medications are typically covered by insurance?
[0:15:16.5] CR: So yes. So what we will do is every time a patient has a new order or the patient sees the provider and the physician sent it where to start an infusion. Before anything is done with that, it is going through a whole insurance approval process. So we actually have a whole department of people who are actually – well, one person and myself, an infusion coordinator and she works with the insurance companies.
She gets all the paperwork submitted, make sure the prior authorization is complete and at that time, we get information from the insurance on whether the medication is covered and also how much the patient may owe. So before the infusion has ever been started, that has all been taken care of. The patient has been contacted and told, “Your insurance is covering it, here’s what you may owe as a copay or out of pocket, depending on which insurance plan that you have.”
But in a lot of cases, we can get full coverage through the insurance plans and through copay programs and things that the other – the pharmaceutical companies offer through the medicines that are made. And absolutely, we’re able to give patients these drugs at very little cost to them obviously with their insurance company’s help. So in doing that, we don’t want to burden patients by having them come in and have to pay an exorbitant amount of money in order to get these medications.
[0:16:32.9] LS: Well, Carolina Specialty Care is a private physician practice?
[0:16:36.1] CR: Correct, yes.
[0:16:37.2] LS: So there’s got to be some sort of cost savings too that they are not going into like a hospital system.
[0:16:43.0] CR: Right. So we are an independently owned practice, which means we do not have that umbrella of a big mega company or a big mega health group. So we do try very, very hard to make sure that all of those things are looked at and that each patient that walks into the door, we’re doing everything we can to make sure that they get their medications covered at little to no cost for them.
[0:17:03.9] LS: The other thing I’ve noticed, I have seen a lot of the comments from patients who come in here and there is just so many comments about being so well taken care of and made them feel comfortable, and I think that is important.
[0:17:17.0] CR: It is absolutely the most important for me. As a registered nurse, I mean, that’s what I have strived my whole career to do is to take very good care of the patient. So treat them like they’re potentially my family member. I want to treat them the way I would want my mother to be treated or the way I would want my siblings to be treated or my children. I feel like we try very hard as an entire group to make sure that we’re accomplishing that each day.
I know in the infusion room, every time I get a chance to have a patient in front of me and to have that time with them where I can talk with them about what’s going on with their disease, “How are you feeling? Are we getting better? Is it getting worse?” And if things are getting worse, “When is your next office visit? Do we need to move it up sooner?” I feel like when you are in the infusion room, we have that time that we can spend that’s a little different than when you come in for an office visit.
You come in for the office visit, there’s a process you go through and they have to do that. That’s how we have to get in and get the patients in so we can see them, so then we can get to the next patient. In the infusion room, if the patient’s here, they may be here for hours and there may be time that we can discuss those types of things. So some days are busier than other but we do try to really focus in on the patient and how they’re doing.
As registered nurses, picking up on if there’s issues and things like that going on, we can be a go-between for them. So I can step over and speak to the providers and say, “I have this patient and this is what’s going on with them today. I need to know what you want me to do in addition to what we’re doing with the infusion. Is there something different we can do? Do we need to order some more labs today?”
What are the things that we can do while we have them in the infusion room to help better take care of them? So then when you get them for the office visit, you have what you need to take care of them.
[0:19:00.4] LS: Yeah and probably during some of those conversations where they’re just, they finally relax and then they’re remembering something or thinking about something that may be a clue to you.
[0:19:10.2] CR: They forgot, yeah.
[0:19:11.2] LS: That they just haven’t talked about before.
[0:19:14.0] CR: Yeah and it’s different. I mean, a lot of these patients I’ve been taking care of for many, many years so they do become like your family.
[0:19:19.8] LS: You know your history, their history.
[0:19:21.6] CR: We have a history together. They know me, I know them, they can get a little bit more comfortable as far as asking those questions and things that they may not even realize tie into their disease. And it may just come up in conversation and then I can say to them, “When you go and see the doctor, we need to talk about these things that you’re telling me because he may be able to do something about that.” So it’s a great opportunity.
[0:19:43.1] LS: Yeah and it’s this big deal because a lot of these medications can be life-changing.
[0:19:48.3] CR: Right, absolutely.
[0:19:49.5] LS: So if someone is interested, I mean, I know that there’s lots of commercials out there about this condition, that condition and say somebody has never tried it before. They have never tried a biologic and they think, “Well, maybe that might be right for me” where do they start?
[0:20:05.3] CR: So obviously it’s going to start with the office visit. When you get in to see the rheumatology provider, if it is a rheumatology disorder that we are going to be treating, that is kind of where the initiation of this process is going to start. They’re going to talk with the patient as far as which therapies are out there and which one they feel like are going to be best for them.
If it is going to be an infusion-type therapy, then if the patient is extra nervous and really has a lot of questions, they will try and pull me in on that day and I can come over and actually speak to the patient while they are in the exam room before they even hit the IV room ,and go ahead and start that conversation like, “Here is what we do in the infusion room.” And start planting those seeds as far as “Here are the things that we’re going to be doing and here are the reasons why that we want to make you feel better, and it’s going to be a process.”
But we are all going to work together to do it and then if they’re extra nervous and they really want to know more, I’ll say, “Come on, let’s go on into the IV room.” I can give them a tour, show them what the IV room looks like because if you don’t know, the fear of the unknown I think is the strongest thing, and they go home and they start reading through the pamphlets of these medications, they have to tell you about all the side effects.
[0:21:11.5] LS: They read all the scary things.
[0:21:12.8] CR: All the things that might potentially even though hardly ever happened happen and it can really get overwhelming. So, those patients can call me. They can call me on the phone and I’ll say, “Look, let’s talk about what is appropriate for your disease” versus “Maybe something in this literature is for a different type of disease that we are not even – that’s not even what we’re treating for you.”
So sometimes you can just take a couple of minutes and just get down to what’s important to that particular patient, and really alleviate a lot of fears. And then the other thing too, when the patients come in for the first time for their infusion and you know they’re nervous and you know they just really don’t know what to expect, or maybe they’re thinking about their mom or their grandmother had cancer and had to go through chemotherapy and they’re thinking about that, and it is hard to shift into something that’s a little different.
Then that type of experience, I always just explain to the patient, “Look, let’s get the first treatment behind you.” You know that fear of the unknown is so strong, but if we can get the first treatment over it, you are going to find out, “Oh, you know what? It really wasn’t that bad.” It’s basically just sitting here and we’ve got some music playing. The nurses are in here doing their thing and if we’re having a crazy day, we may be laughing and joking and whatever.
But we just try to make patients as comfortable as they possibly can, that’s what we want. We want them to come in and feel at ease and feel good about what we’re doing and feel good about what they’re doing for their treatment.
[0:22:33.8] LS: Yeah and to come in and feel comfortable and be able to talk about these things.
[0:22:37.4] CR: Right, absolutely.
[0:22:38.1] LS: You don’t have to sit over there and be quiet and worried.
[0:22:40.1] CR: Yeah, no-no-no. And the other unique thing about our IV room I think is that we have – they’re chairs that are close to each other and so sometimes you might have a patient that is sitting very close to you that might be going through the exact same thing, and that can strike up a conversation. I’ve seen some of the greatest conversations happen between patients where you may have someone that is a veteran that’s been doing this for a really long time.
And there is a patient right next to them that’s brand new, scared to death, and hear it from a patient’s perspective versus me as a nurse telling them, “This is what I’ve seen.” Obviously I’ve been around infusions for most of my career, but to have a patient share with them and to have that little connection that they can make, they may never see each other again and then in some instances, I’ll have patients that they come repeatedly together.
I’ve seen friendships form in the IV room. It’s the neatest thing where you have the slow group of patients and they seem to be on the same cycle and they’ll come in and they’ll be like, “Well, where is so and so?” And for HIPAA reasons I can’t really go into that, but they know when their IV buddy or possibly is not there.
[0:23:42.8] LS: If they choose to talk about it.
[0:23:44.3] CR: If they choose to talk about it that is totally on them. So it is very, very interesting to see those relationships that can develop and how patients can actually help each other just by sharing their experiences, so yeah.
[0:23:55.5] LS: Oh, that’s fantastic. So if someone who doesn’t have a rheumatology condition, maybe they don’t come here as a patient, they should talk to their provider, whether it’s their specialist or their primary care provider and they can just start asking questions because they can be referred here.
[0:24:12.4] CR: Absolutely. I think that’s the best place to start is that if you have a condition that may require some type of infusion or like you said, maybe you saw something on TV, maybe you saw a commercial about something and you are thinking, “That might be something that might help me” definitely talk to your doctor and see if you can get them to investigate that for you.
Is that an appropriate med for you and if so, let’s start that process because if it’s available and we can do it in the infusion room, here on special care, we want to make sure we do every effort to do that.
[0:24:42.0] LS: Yeah, I mean because they’ll still continue to see their own physician. I think they need to understand yes, that’s just here for a treatment and they can go back and see their providers.
[0:24:50.9] CR: Yeah, we are not taking those patients away from them. We just want to be able to collaborate and offer them the treatment or the therapy that they need.
[0:24:58.6] LS: Yeah, it’s an amazing facility and it is beautiful and it’s very open. It’s very bright and it feels very happy in there.
[0:25:05.6] CR: Yes, it’s very happy in there. That’s a requirement.
[0:25:08.6] LS: It’s a great way to feel –
[0:25:09.4] CR: For coming in, so yes, we have a great time in the IV room. I tell patients but also tell employees that are in other parts of the practice, especially new employees, they’ll come in, they’ll go for their tour and they’ll bring them into the IV room and I’ll say, “You know, this is the fun room. We have a lot of fun in here.” But we work very hard but we do have a lot of fun. So we can be super busy but we do try to keep it fun at the beginning, yeah.
[0:25:30.5] LS: That’s good. So if someone wants more information, they can go to the website, carolinaspecialtycare.com, and all the information is on there, where you can find the office, the office phone number. There is a form on the website and you can even request an appointment and someone will call and talk to you about that and just make sure that they have the appropriate information to get you seen. Is there anything else you can think of?
[0:25:54.2] CR: I don’t know if anything else I can think of, I’m sure there’s plenty of things I could talk about. I can talk about IVs all day long. But I would just like to say, if you are looking into coming to our office or if maybe you already have an appointment and you think that infusion’s maybe coming up for you, we look forward to having you and we will try to do everything we can to make you as comfortable as possible. We want this to feel like a normal part of your day and not like a really stressful thing.
We want to make this nice and easy and hopefully accomplish the goals, which are helping to treat the disease and helping you to feel better.
[0:26:29.2] LS: That is so nice because healthcare can get so complicated. I mean, just getting in the door sometimes.
[0:26:34.4] CR: Right, absolutely. Yeah.
[0:26:35.3] LS: I’ve noticed that with the staff here, that everyone is trying to help you get where you need to go, help you get to feeling better, whatever care you need that’s what you get here.
[0:26:44.0] CR: Absolutely, that’s right.
[0:26:45.0] LS: Wonderful. Thank you so much, Cynthia. I appreciate it.
[0:26:46.7] CR: Okay, thank you. Thanks for having me, absolutely.
[END]
