Howard Bauchner: Hello and welcome to this author interview. This is Howard Bauchner, editor-in-chief. And I have the remarkable privilege of being joined by Maurizio Cecconi, from Italy. Maurizio is a colleague who I've known for the last 5 to 10 years via Derek Angus. Maurizio, thank you for joining me today.
Maurizio Cecconi: Hi Howard. Thank you for hosting me.
HB: So before we start, just a couple comments, and then we'll start the probably 30-, 35-minute interview. Firstly, from the JAMA family and Editorial and Publishing, and all of our colleagues in the United States, we know it's been an enormously difficult time in Italy, particularly in your area, and we wish you the best. And I thank you for taking some time out today. You're in our prayers.
MC: Thank you. We think it's important to share what we see here.
HB: So Maurizio, you've written a Viewpoint that's being released simultaneously with this livestream. It's entitled "Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy: Early Experience and Forecast During an Emergency Response." We're going to walk through the Viewpoint and some other things you've sent me, but before we start, I know you want to recognize your two co-authors, and the entire team of people providing care. So could you just talk a bit about them?
MC: Yes. I've written this viewpoint with Giacomo Grasselli and Antonio Pesenti, that are there on the authorship. But you know, this is an effort really that is being made available by the whole IC unit at work in Lombardy. And I think-- I will tell this probably later -- but I think the only way that we've been able to act so fast is thanks to the fact that Alberto Zangrillo from San Raffaele Hospital in Milan, and Antonio Pesenti from Policlinico Maggiore in Milan, they set up a network of intensive care that these always use to support patients with respiratory failure or with cardiac failure with the VV-ECMO, VA-ECMO. And the starting point was crucial for us to be able to manage the very, very first surge. So that was really the beginning of the framework of our network. And I think without these individuals, we would have been even in a much worse position than what we were on day 1.
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HB: So just to help orient people, where is Lombardy in Italy, and why is it so unique?
MC: Well, Lombardy in Italy is in the north of Italy. It is probably one of the richest regions in Europe, not just in Italy. It is where the majority of the wealth and global domestic product of the country is made. So actually, we're living in a unique situation here, because we're facing an outbreak in what probably is the part of Italy that has the highest concentration of resources and healthcare resources compared also to other parts of the country. And I would say probably also to some other parts of Europe.
HB: What are the largest cities in this area?
MC: So largest cities in this area of course Milan, and then other big hubs are cities like Bergamo, but we-- it's a very dense area. I don't know if you've ever seen those maps that come from satellites, where they looked at how Europe looks at night. And you can see that the density of light that we have in Lombardy, and going to Emilia-Romania, down to the east coast of Italy, it really-- it makes you understand how dense the population is in this area. And I suspect that probably was one of the reasons why we've seen these-- some of the outbreaks coming up here so fast.
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HB: You were kind enough to send me an infographic this morning, and I'll just tell people what's on it. I don't know if we can show it. As of yesterday, close to 14,000 cases: 13,882. 1,116 health workers have contracted COVID-19, and there's been 803 associated deaths, which is a case fatality rate of 5.8%. We will return to that, because I don't want to leave people with that figure. I think people need to really recognize the data from Italy are enormously consistent with the data from Korea and China, in the sense that people under 60 are at an incredibly low risk for fatality, so we'll return to that. The story starts February 20th. That's the first sentence in the viewpoint. On February 20th, 2020, a 38-year-old patient admitted to the intensive care unit in Lombardy had tested positive. So what happens after February 20th?
MC: Well, you have to imagine that after that moment, Italy was monitoring, as every other country in the world, very carefully, what was happening in China, and you know, every possible case that was identified through index cases was quarantined. You know, people were followed so that we were really trying to contain completely the disease. So that day is a very specific day, because one of the doctors in one of the hospitals that is being majorly affected, one anesthetist actually, realized that there was something different from a young patient that was not responding to typical pneumonia. And this young patient didn't really have the normal risk factors for which we would screen for-- you know, for the new virus. So anyway, they decided to send a swab for it, and the swab was positive. Now you can imagine that now we are in a situation in which a secondary transmission of a young patient that is so sick that is in intensive care, is Patient Number 1, and we have to try and find the trace back to whoever was in contact with this patient. That was really the beginning of us getting a little bit nervous. We are in Lombardy, and-- in Italy. And you may remember then during the next day, some other cases were coming up because finally we were testing more and more patients. So, the risk factor had changed. It was not any more traveled from China in the previous 14 days or being in contact with a confirmed case. It was actually being in contact with our patient, and in that area. And I do remember an anecdote of mine, that I was actually in Switzerland at the time, giving a talk for a symposium. And just by seeing the number of cases that we're ramping up, and being in contact with some colleagues there, I decided very quickly to come back to my hospital, because we realized we were having a secondary cluster, a secondary transmission cluster. And that is a key point to realize that this is very different from any other group of patients that was this COVID in Europe up to this time.
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HB: How many cases began to accumulate on February 21, 22, 23? And then, I know you have really reorganized your intensive care unit services. So how many cases were accumulating, and then how did you begin to think through the organization of your critical care services?
MC: So, difficult to give you the perfect number. But we were quickly seeing 5, 10, 14, and the number was going up, at a kind of an exponential way from the very first day. So very fast, and very fast increase. So, the same, on the Saturday, the network was called to get together. So, the network of the hospitals that I was saying before, organized by Antonio Pesenti and Alberto Zangrillo, we got together, and we said, we have a problem here. We have to act very quickly. Because it's very likely that the numbers we see are coming up. And the cluster has to be contained, at least try to be contained. It's very likely that we see more patients coming through. So, it was very clear from us. And we were not alone. We had to work with health authorities and with everyone else. But we worked from the very beginning on two principles. Give intensive care to every patient who needs intensive care, and at the same time, guarantee containment. Now containment, you can do it in the community with a series of rules and maneuvers that can be done by health authorities and government and so on, but what you do in healthcare is try to find a way that the infection will not spread also to other patients. So, we decided very fast that our only option at the moment was to ask hospitals, the first five hubs, to basically create some isolation units that could manage the initial surge. And at the same time, realize that if really we were in the middle of an outbreak, we should have planned immediately an increase in capacity to be able to give intensive care to whoever needed intensive care, and at the same time work on containment.
HB: How many hospitals exist in the Lombardy area? How many critical care beds were there? And then, a week later, how many critical beds were there?
MC: The total number of hospitals is not completely clear to me, but what I can tell you is that in this moment, hospitals that have an intensive care facility in which they're being able to create isolation units is more than 50. I think we're talking about 55 to 60 hospitals. Now you have to imagine Day 1, when the crisis starts, the total capacity pre-crisis of the open ICU beds in the region was about 720 beds. OK? So, we're talking about probably 8 beds every 100,00 population. And these are beds that are usually reserved for the very sick patients. So, in order to be able to manage the surge, realize also that if the numbers were going to come up, we should free capacity as much as possible. So, what we did was also, with health authorities, decided to cancel all non-urgent elective surgery, free some capacity, and work very fast to realize our contingency plan was able to bring more capacity to the system.
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HB: So, a week later, how many additional beds were you able to add to the area?
MC: So, within a week, we were able to add another 200 beds to the area. And that led us on the 7th of March, to have roughly 360 patients treated in an intensive care bed at the moment. I can give you unofficial news from this morning, just from the coordinating network, that we've treated more than 1,000 intensive care patients so far, since the beginning of the outbreak. And we are managing between 750 and 800 beds of intensive care patients occupied by COVID-19-positive patients in the moment while I speak.
HB: Now I know there may be some variability in this question. But the China data suggested that people could come into the hospital, and be hospitalized, and then deteriorate after 3, 4, 5 days. Is that what you're seeing? Or are people coming in through the emergency department, and are they sick immediately?
MC: Well, we are seeing a very high variety of cases. And indeed, you don't have to expect to increase your surge capacity just for intensive care. You really need to manage the outbreak. I can give you the example of what is being done in many hospitals was to create completely different pathways for respiratory symptoms patients, so that you could actually find a way to detect if the patient really is a COVID-19-positive patient or not. And you will see a lot of these patients coming through if you have a cluster. So, the majority of patients, they may come in with some mild disease, and in Italy we have a code in our emergency department. It goes from green yellow, and red, depending on the severity. The majority of patients would still be green. And now we are even able to send them home, and if they don't require hospitalization, but we know that they are positive, we will find a way for them to self-isolate. But they don't come to the hospital. For the ones who are kind of yellow, and they require hospitalization, well we see that these patients, they may require significant support.
And indeed, when I talk about intensive care beds now, we are basically talking almost entirely about patients that are invasively mechanically on ventilators. So, we're talking about a very sick group of patients. On top of that, to increase our capacity to provide total support, we have increased also the ability to provide a Level 2 organ support, like monitoring and non-invasive ventilation outside of a normal ICU area.
HB: There's a-- quite a few clinical questions coming in, and I'll ask the one that I'm asked every time, when I do interviews. Can you say anything about children? I've already mentioned that you were kind enough to send me the data from yesterday. And just to reassure people, case fatality rate for individuals from 40 to 49 is 0.1%, which is very similar to flu. Fifty to 59 is 0.6%. Those numbers look very much like Korea. And then the breakpoint begins to be 60, 70, and 80, and we'll come back to that. So that really is around comorbid conditions in the people who are older. But have there been sick children, and how have they done?
MC: So, two answers about ages you're asking me. Both about children, but also about younger patients.
MC: I'll answer first about children. In this dramatic situation, one good thing at least that we see is that kids seem to be infected, and we have some reports of infected kids. But it's almost 0, you know, the percentage of very sick kids that we see. So, we've not seen a significant surge of seriously ill kids. We don't know how that is happening. It's very consistent with the data that we were seeing from China, and kind of way in these very difficult situations is kind of reassuring. We don't know what's protecting them from getting very sick, but the good thing is when kids get infected, they don't seem to become seriously ill. On the other hand, while the percentage of people, you know that are younger, seems to be having a better outcome, remember that the mean age of our population in intensive care seems to be around 65 years of age. So that means that half of the population is less than that, and I would consider that still relatively young. And so even we've seen in our units now, considering the large number of cases, we still see some young patients coming through. The majority is people that are older. But we see some young cases come in, too.
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HB: Are the younger patients, you know, 30, 40 doing fine, doing well after they get the treatment that they need?
MC: Very early to tell you that. But that's what we are certainly seeing at the moment, and the reports that I can give you from my colleagues. You know, even Patient Number 1 had to go through quite a prolonged ventilation, but we now have some reports from some news that actually he's doing better. And that's what I'm seeing also in my unit. So, from that point of view, we don't see something very different from other types of pneumonia. The older, the more frail, the more comorbid you are, the more likely it is that it's going to be very difficult for you to come out well from intensive care. But the younger you are, with less comorbidities, well, if you come to intensive care, you have a higher physiological reserve, and the chances of coming out are probably higher.
HB: Yes, similar to data before, and similar with other respiratory diseases. Have you created separate ICUs for those that are COVID-positive versus those that are COVID-not positive, or need other types of treatment? Have you separated those types of ICUs?
MC: We've tried to do that as much as possible. But for two reasons. Because we wanted to protect other patients from you know, not being exposed to these patients, but also to maximize the way we're using our workforce. Remember that our mission, even if it's not written there, but is to provide an intensive care bed to whoever needs an intensive care bed, but we're not making any distinction between a COVID-positive patient, or a patient that is having a trauma, a patient that's in a car accident, a patient that's having an MI requiring emergency intervention. During these times, we were very focused on guaranteeing all the emergency that is needed. We're still doing that, so we wanted to protect with different flows of patient through the hospital, what was the surge of sick COVID-19-positive patients, and all the other patients. So, we separated the--as much as possible--the cohorts. What is being really overwhelming in this sense is that the number of patient has been growing day by day, and what we have found is for instance in my hospital, but I know it's common experience in every other hospital, every day you make the plan for the next two days, but you need to have a couple of options ready for the next five days. You don't have to leave anything to chance. You have really to be prepared for the next surge, and to guarantee everything because it's time-dependent and needs to come to your intensive care unit.
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HB: How are you protecting your staff? What have you done around staffing and protecting healthcare personnel? I think many people in the U.S. have talked about two groups that are critical to think about. That's the frail elderly with comorbid conditions, and it's critical that we maintain safety and health of our healthcare workers. So, what have you been doing around staffing and your healthcare workers?
MC: We've worked really, really hard from the very beginning, not just buying and stocking, you know, personal protection equipment, but also to do a lot of training. So, for instance, what we've done in many places is increase as much as we could education and simulation and training in donning and doffing procedures. Remember from previous epidemics, a very key point is how you protect yourself, not just while you're working, but for instance when you do the doffing procedure, which is where a lot of the contamination could be. So different solutions in different hospitals. What I've done in my hospital was to suit up a simulation team from the first day when we were trying to set up our first unit, and what we did was train very fast 80 people in working protected, and working in difficult situation that you're not used to before. We decided to go for a very high level of protection. Even higher than what the WHO was recommending. The reason was that the very first, the beginning of the outbreak in Lombardy-- remember the outbreak was found in this intensive care in the hospital, and we found a significant percentage of healthcare workers were affected, so were infected.
So, we really wanted to protect our intensive care, our hospital staff as much as we could. So, we decided to go for close contact of less than two meters for FFB2 and above, and N95 and above, and depending on what you do with the patient, different types of protection from full cover to, you know, to waterproof gowns and so on. In my unit, we are working with full protection now for these patients. That makes it difficult also to staff, because if you could imagine working for six hours-- it's very difficult to work for more than six hours in a shift with this. You cannot even go and have a rest. You cannot drink. You cannot go to the toilet. So, you know, we are basically drinking a little amount of water before dressing up. And then we try to work. And you stop and you do something else, and somebody else comes. And there are some more extreme situations where some people are not even able to do that, and people are really working very long hours, trying to protect themselves as much as they could.
But we do believe that it's so important to protect the healthcare workers, that we don't want to go down on this standard. We owe it to our healthcare workers, but we owe it also to the patient, to the outbreak. We cannot afford to actually have people in quarantine, or to go away from this. So, it's a very, very important topic, and I really would give the message to everyone is you have to start to think now, and make sure the training is in place. Talk is not just enough. You need to learn how to work with this protective equipment.
HB: Are you allowing the healthcare workers to go home from the hospital?
MC: Yes, we are, of course. It's very difficult to send them home, I would say. Because no one has been summoned to work yet, but really the sacrifice that people are seeing is something incredible. We are doing an enormous effort really to work and I would like to say this is not just about intensive care. To save a life of an intensive care patient now is the effort of the whole hospital, of the whole healthcare authorities, of everyone that work in healthcare. Everyone is working beyond what was asked of them. And so, we do very long hours to cover the shifts. But so far actually, it's incredible how united the group is, to try to work, to protect themselves, and to give everything that we can to our patients.
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HB: Now, Maurizio, this is a difficult question. There's been disturbing reports over the last day or two, in the American newspapers, about-- because you've run out of certain types of facilities, largely intensive care unit beds. You're having to make painful decisions about triage. Are those accurate, or has that not been your experience?
MC: The only thing that we decided to do was really, as I said before, to give an intensive care bed to whoever needs intensive care. And we don't want to do anything differently. Of course, we need to help the citizens and the government slow down the virus transmission because we could be on our knees very soon if we see more patients coming through. But at the moment, we are giving intensive care to whoever needs an intensive care bed. And indeed, every day we end up with more intensive care beds than what we could have done the day before. Remember that pre-crisis we had 720 open beds. Today we've exceeded, just with COVID-19-positive patient that total capacity. We're not giving up, and we are now thinking about even other possible solutions. So, while we're increasing intensive care in every operating room, we could do that. We're even thinking about building a fast-paced, a massive intensive care facility in the region where we could maybe bring some more capacity to the system.
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HB: Now you're an intensivist, and you take care of these patients. You know, most of it has been around respiratory disease, but there's a number of questions about have you seen the traditional other medical concerns? Hypertension, cardiomyopathy, you have a wealth of experience. Is there anything unusual beyond the respiratory disease?
MC: Let me first start with the respiratory disease, because it's very interesting. The pattern is very recognizable for these patients. They come hypoxic to the hospital, and there is very severe hypoxemia. But they seem to have a good compliance. So, they don't seem to be fatigued at the moment. They're able to breathe, and indeed, hypercapnia is not a problem. It's severe hypoxia. When we intubate, and we intubate, and we see that pattern carrying on, at least for the first days. And what we see is the hypoxia is very severe. We see PaO2: FiO2 ratios that are very low. But again, pH and hypercapnia is not usually a problem. Again the compliance seems to be pretty good. They seem really to behave really as pneumonias, to which we have to give a little bit of time to the lung to rest. In the large numbers that you said, you would start to see some other types of organ failure. For us it's too early to give you comments on other things as they may have seen in China. China, in a webinar that we did with [inaudible] for instance, was reporting a significant percentage of patients with myocarditis, or with cardiac dysfunction.
We don't seem to see that as much here. And indeed, I would say that the majority of organ failure is related to respiratory failure. Some patients may require renal replacement therapy, but we've not seen significant other organ dysfunction. Of course, as you would see normally in an intensive care patient with pneumonia, but really the predominant clinical picture is a severe respiratory failure from the pneumonia from this virus.
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HB: And any unusual therapies being tried? Or have you just tried to use the traditional approaches to acute respiratory failure, well-known, well-practiced for decades now?
MC: So I would say the only evidence that we have at the moment is that we can do supportive care for these patients. So that's why our mission is to provide a bed to whoever needs an intensive care bed. Of course, there are reports coming out everywhere. There is a lot of anxiety, understandably, in physicians. Everyone wants to find a specific drug for this patient. I say that probably I don't think there is any specific drug at the moment. I particular enjoyed, Howard, your podcast with Anthony Fauci the other day. It think it explained so well, that even in a moment of stress like this one, our enormous effort should be to do the things that have evidence, and to do the things that can really help our patients. So I can speak for myself, and for many people in the network. We believe that's where the effort has to be. We need to find ways to support more patients if they come. I don't think we need to take shortcuts in therapy, just using therapies that are available, just because they are there.
We don't know if they could be dangerous. So adjunctive therapies may provide benefit, but maybe they could even be harmful for our patient. I think especially with this volume of cases that we see, we need to do simple things that we know how to do well, and we know how to do well intensive care. We know how to ventilate our patients well. This is what we are best at. All other therapies are something that we would consider if we find ways to test them safely in a research fashion with rigorous methodology, then I think we should do it. And I don't think we should lose time to do it. But I don't think we should take shortcuts with adjunctive therapies that have no evidence.
HB: There are so many questions coming in. I think you know, you're such an astute clinician, people really want to hear from you. Do you have a few more minutes, Maurizio?
MC: I think this is important.
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HB: Thank you. There's been quite a few questions about re-infection. They've emerged in some of the literature. You know, someone who goes home, gets re-infected. Have you seen much of that, or is it too early to know?
MC: You know, it's-- what is being incredible about these events personally is, it feels like two months we've been fighting this, but actually it's not even three weeks. So, I think it's too early for us to talk about that. What we are doing to try to protect the population, we don't know what is the evidence out of it. But I come back to the question about labs. We used our labs in a way that we wanted to prioritize patients that need intensive care to be correctly identified. So, we had a protocol to identify them early, and to have a faster process on that. And at the same time, when people get better, in order to send them home, and to prevent them to re-infect maybe other people, we do two swabs. And if the two swabs are negative, we send them home. We really don't know if this is common sense and pragmatism. If there is any evidence for it, but this is what we are doing.
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HB: I'll return to some more questions, but I just want to make sure I touch on this. You now have as much experience with this as anyone in the world. What are your recommendations for the United States?
MC: I recommend everything we recommended from the very beginning to everyone. And we even sent a letter with the European Society of Intensive Care Medicine on this, is the-- don't underestimate this. This is not a normal flu. This is serious. The majority of people that get infected will go through it normally, but the percentage of patients that get infected and require hospitalization is high. And the percentage of patients that require intensive care admission is high. So do not underestimate this. Get ready. Get ready with your surge capacity in hospital. Make sure that you work on the protocols now. Make sure that if an outbreak comes, a cluster comes close to you, you don't lose time by putting the plan in action. I think that's very important. And do not think that you can win this battle just by increasing your capacity. Containment, mitigation maneuvers, slowing down maneuvers, are equally important if not more important than anything that we can do as doctors.
We want to fight. And I really think this is the-- this is something I would never have imagined to face in my life, but this is something that we are going to win with government health authorities, and with citizens. If the moment comes where your government in the U.S. or in any other country, mandates self-isolation or any other maneuver, I think it's really the personal responsibility of every citizen to do that, because if you don't take down the transmission of the virus, then the capacity of your system will be overwhelmed.
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HB: Do you have any sense over the last few days-- I mean the reports out of China, Korea, have suggested a waning of the number of individuals being infected. I think we can debate the aspects of the massive quarantine in China, but given that Beijing and Shanghai were generally spared, it's hard to imagine people not thinking it had worked. Even if it could be seen as Draconian, it appears to have spared over a billion people. Do you have any sense yet of what's happening both in Lombardy in terms of daily number of cases, versus the rest of Italy?
MC: Look we have to be realistic. The incubation period of this virus is up to 14 days. So, we are basically bracing for, you know, an even higher peak of what's coming here. We know we're expecting it. The lockdown of Lombardy happened a few days ago. The lockdown of Italy just happened. We have to be prepared for a peak that probably is not going to slow down immediately. So, we’re still expecting for the next two weeks to be ready to give any support to patients that may increase in numbers. And I believe, and I hope that after two weeks, we will be able to five you better news.
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HB: One more clinical question, then a couple other questions. You know, the type of ventilation for acute respiratory stress is highly variable. And sometimes you don't need the traditional ventilator. And there's now been concerns that the U.S. may not have a sufficient number of ventilators if we end up being faced with the same type of cluster outbreak that you've had. Has there been different approaches to ventilation, or just the traditional varying approaches, and see what works with each patient?
MC: So, I tell you what we've done here, which is basically using, you know, every capacity on ICU ventilators that we have. But remember that there are ventilators living in the operating rooms. And there are in many places more operating rooms than, you know, ICU beds. And indeed, the responsibility of the government was also to try to stop elective surgery. That allowed us to free ICU beds from surgical patients that need intensive care. But we also freed a lot of resources from our theaters, from our anesthetists that could help. We are also using non-invasive ventilation, and we try to be very pragmatic about it. I think a patient that responds to non-invasive ventilation, we don't see that they get tired, we will keep them on that. We don't want patients to get tired on non-invasive ventilation. The feeling is that if you exhaust someone on non-invasive ventilation, they may do longer-- they may require longer time on invasive ventilation, so-- but we have to use everything. And indeed, we have increased massively also the capacity of non-invasive machines in our hospitals.
HB: As you know, there-- you know, there was a back and forth last year, article in JAMA, the Bayesian analysis about ECMO following the NEJM report, and I think there's a general feeling that ECMO does work. Have you used it in many patients, or are you limiting it?
MC: Oh it's not that we're limiting, but what we are seeing is that this is a problem of volume, of respiratory failure that responds usually pretty well to simple techniques that have been studied and validated over the years. So, we're use quite a lot of proning and we use, you know, protective lung ventilation. With this, if a patient has some physiologic reserve, we see that they can do, they can do better. We are reserving ECMO just for very selective cases. We do believe that in this moment, the focus should be on providing high-quality volume therapy for the large volume of patient that we see.
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HB: And just returning to one question about healthcare workers, and in this case specifically, physicians and nurses, when you go home, how are you protecting your family?
MC: Well, I can tell you what I've done personally. When the outbreak started, my kids were on holiday. And then they stopped on holiday with my parents. And my parents don't live in the same region as mine. I thought, I am a doctor, I am a citizen as well. My parents are old. So, I decided, coming from Lombardy, I will not see my parents for a bit. So basically, I decided to self-isolate. For the people that live in the same place, there is no reason to panic on this. If you become in close contact, or you think you've been contaminated, there are some very robust policies that the authorities have put in place. For instance, if something like this, if you get symptoms, you will get a swab. If you don't get a symptom, they will ask you to spend some days trying to avoid spending time in close contact if you can, try to use a different bathroom, a different bedroom. Of course, we are concerned, but we cannot panic. We have to be sensible, and we have to use the recommendations. The recommendations may change over the days. The communication needs to be clear to everyone so that you can protect yourself, your families, and your patients.
HB: So Maurizio, I actually know who you are, since we're friends and colleagues, but can you tell our listeners who you are?
MC: So I am Maurizio Cecconi. I am the professor of Anesthesia and Intensive Care Medicine at Humanitas University in Milan. I'm also the Head of Anesthesia and Intensive Care at Humanitas Research Hospital. And I'm also the president-elect of the European Society of Intensive Care Medicine.
HB: From JAMA and the United States, all of our colleagues, we are praying for you. You have done extraordinary work. And I can't thank you enough for sharing the clinic experience you've had, the information about healthcare workers, and really an intimate view of what's been occurring in your area. You and your colleagues have done an extraordinary job, and you're saving thousands of lives. And obviously, you're to be commended for it. Mauricio, thank you so much for joining me. This is Howard Bauchner, editor-in-chief of JAMA. We will continue to bring you these podcasts, and everyone, thank you for watching and listening. Maurizio, be healthy, be healthy, be healthy.
MC: Thank you. We will keep sharing everything that comes out here.