Speaker 1: 0:41

If on the dice they do see large lingual tonsils or something more like a soft tissue contributing factor, typically then does the ENT go and address that before even prescribing the Inspire.

Speaker 2: 0:54

Sometimes they do, sometimes they do, or what they do with a couple of the guys that I work with, one in particular probably did more than anybody that I work with, so we got pretty close and he says, look, let's see how than anybody that I work with. So I got, you know, pretty close. And he says, look, let's see how you do with the Inspire. If your first study comes back and it's suboptimal means it doesn't didn't get us where we want. Then, because he didn't want to put him through yet another surgery, okay, wait and see, let's wait and see, let's see if this goes great for you for four years and then maybe, if you put on a little bit of weight, we might revisit that in the year. So I think minimizing time under anesthesia, minimizing time for recovery and more surgery, trying to do that, is really a good idea and that's a prudent way to handle it.

Speaker 1: 1:42

How do they determine, though, that? What if they just remove lingual tonsils and address soft tissue? The patient wouldn't need the inspired treatment? Perhaps you can?

Speaker 2: 1:51

always try that, but most of the time children, when you remove tonsils and adenoids, they tend to have their sleep apnea resolve to a large extent. Not always, not always and not always perfect. Then that's why expansion and all of the good work that I've reunited her people are doing comes in play. And early, earlier the better, earlier the better, and that's one piece of it. Soft tissue resection, remember. Anything that's you take away can come back or it doesn't make a difference. So you can't guarantee none of this. You can guarantee this is that you're going to be perfect at the end. None of it. Yeah, it's really good therapy. However, it's not just monotherapy, at least not in my book.

Speaker 2: 2:40

I use inspire. You know patients who've had maximum mandibular advancement surgery and they can't. They come back and they want to be treated 10 years, 12 years later. Maybe they've gained a little weight, maybe their synaphyse come back, whatever, they can't be advanced anymore. That's not appropriate. That's not appropriate for them, even if they wanted it. That's not appropriate care for them.

Speaker 2: 3:04

Inspire is a great way to use combination type therapy. Okay, we have patients that use inspire and their c-pap. Okay, because some folks can't. The stimulation levels are tolerable for most folks to a point with somebody who maybe pops away. You're at step number five and you're doing great, but your apnea is not really fully controlled. You go to set and you go to step six apnea is fully controlled, but you can't tolerate it. Okay, what do you do with that? What do you do with that? Well, as far as I'm concerned, if they haven't had any previous craniofacial surgery, I'm okay with putting an oral appliance in with somebody with Inspire Dial. It very just basically, put their teeth end to end, put their teeth end to end, put their Inspire on. See how that goes, Because you'd be surprised. All of a sudden they're getting everything.

Speaker 1: 3:58

So when the machine stimulates the nerve, where exactly is the tongue going? It goes out into the, it goes out into the Between the front teeth.

Speaker 2: 4:10

It doesn't go to Cleveland. It's not going out to Cleveland, it goes out to the border of the teeth, just outside the border, a slight interdental thrust. There are some people that it goes to Cleveland, others say it doesn't. It's a gentle thing. You're not whipping the tongue out like a snake.

Speaker 1: 4:28

It's not like just knocking across the room, so um tongue is thrusting straight forward.

Speaker 2: 4:35

So here's your tea, and it kind of goes.

Speaker 1: 4:38

Okay. What if somebody okay Benefits sleeping with the lips closed versus lips open with Inspire? So if your lips are closed, is that going to negatively or positively impact the treatment and what's happening?

Speaker 2: 4:58

Yeah, you know, it kind of depends. A big part of sleep apnea treatment in general is trying to train people to breathe through their nose and not through their mouth, and that's hard. It's really hard for a lot of people. That's why they have full face masks, I mean, that's why. So it makes it very difficult, but I would say people get creative. I even had patients who insisted on continuing doing their lip taping with their Inspire and they managed to make it work.

Speaker 1: 5:27

So I remember a sleep physician, yeah yeah, he said that there was a patient that they could not, the voltage would just maxed out and the patient was still having apneas. And they brought the patient in with the ENT and I guess they were doing a dice and they're just trying to figure out what to do. And they brought the patient in with the ENT and I guess they were doing a dice and they're just trying to figure out what to do and they closed the lips, held the mouth closed and everything resolved. And he was like what I'm like hello, that's what we do in myofunctional therapy. We know if the lips close, that helps support the jaw and the tongue. So that's just an interesting concept, though, because the tongue is thrusting forward between the teeth. Does the occlusion change? For someone who's been on Inspire for a while, it can.

Speaker 2: 6:12

It absolutely can. We had a couple of patients who said that they felt like there was pressure on their lower front teeth and that they were proclining a little bit. I have never seen any huge occlusion changes, not like you see with oral appliances. People's teeth go really. Their bites change in. Their teeth move lots with oral appliances, even though they use their am programmers, deprogrammers and all that. You do see tooth movement. You do see diastemas open up. They didn't have before. Tooth movement by changes. That that's pretty common in those kinds of therapies.

Speaker 2: 6:44

But you just it's part of the thing that you have to tell them. Look, I can't tell you this is or isn't going to happen. Statistically we say yes, it's going to happen. We just don't know when. You can do whatever you can to avoid it. Continue wearing your retainers. Let's say they still have retainers. You want to wear your Invisalign trays or whatever you can do. That I mean. I fully feel like if patients are going to use Inspire, keep your Invisalign trays and keep wearing them, because it makes the slide smoother over the teeth anyway.

Speaker 1: 7:11

For the top, Right, and probably if you've gone to the level where you've selected Inspire as your treatment I don't want to say it's like a last option, but sort of kind of is then you probably don't care as much if you're going to have some dental tipping because it's not on your list of priorities, probably.

Speaker 2: 7:35

So communication you have people who do inspire and care for inspire patients. I say to my patients a lot, you know, because a lot of them are getting surgery, and I said be very careful what you're reading on the blogs, facebook, twitter, all that stuff. Please be careful, because you're getting a skewed opinion on a lot of things. You're getting information that's half true, half emotional, half didactic, half whatever. And when we're talking to the patients who want to get this kind of hyperglycemia therapy and they come in and they failed or they've been told they failed all these other therapies, first of all they've been told they failed. Okay, nobody wants to hear that. Okay, nobody wants to hear you failed anything. Okay, and a big part of what I found myself doing was saying letting them talk before you even get started about it.

Speaker 2: 8:32

You know why for sure. Why do you want this? And then see do you want to? Do you want me to fix this issue? Do you? You know it's. Do you want me to help you? Do you want me to hug you or do you want me to hear you? Three different conversations which conversation would you like to have first? Because then I think we can find a pathway for you to be successful From a provider standpoint. Those are my first three questions. Do you want me to help you, hug you or hear you? And you can put them in any order of preference.

Speaker 1: 9:09

Yeah, and probably some people need all three and don't know which one they need. Right, which order?

Speaker 2: 9:17

Yeah, there is no order for sale.

Speaker 1: 9:19

There is no order for sale. Wow, well for ENTs. Is it specific ENTs that provide this treatment?

Speaker 2: 9:28

The ENTs install. Do the surgical installation? Okay, they do the procedure.

Speaker 1: 9:34

Is there any specific obviously training Like how would you find?

Speaker 2: 9:37

No, there are inspired. All you have to do is Google inspired in my town and they give you a whole list. You can even contact somebody directly. They've been trained. There's surgeons have been trained. They've been through extensive training. They have a lot. They partner with sleep doctors. So the ENTs are surgeons unless they are both asleep and an ENT which there are a number of them that I worked with, so they kind of did the whole thing front to back. Then the front piece is the sleep doctor sending you to the surgeon. Surgeon does his thing and then sends you back to the sleep doctor to be followed. You don't go back to the surgeon unless you have a problem, and so the sleep doctors are managing it and some of them are really, really adept at it.

Speaker 1: 10:29

Okay, so how is this effectively monitored in each patient? Is their utilization as part of their apnea?

Speaker 2: 10:42

No, their utilization is monitored. Every time they turn their remote off and on, that information goes into the cloud and the doctor has access to it. So every time you turn it on and off, as long as you sign the sheet that says you're going to participate, so they know you're using it or you're not, but your actual apnea, what the levels of the apnea are, that's the doctor's going to have to order a new study Because, unlike a CPAP machine which shows you in the morning that a little green, happy face on your button and then you can read your report that says what your AHI was, this doesn't do that. Oh wow, so it just tracks the technology.

Speaker 1: 11:17

It just tracks that you used it. So at what level? Yes, and a patient would probably need to go back to the doctor if they're not feeling well. It would be based on symptoms or snoring. They shouldn't be snoring using this treatment, right, I mean, except until it turns on. But when it's on, snoring is greatly reduced.

Speaker 2: 11:37

But remember, there are stuff, people who throw up their nose, so they have other things going on in their nose, but snoring is. If you look at all of the studies that have been put out, snoring is tremendously reduced. So people who've been kicked out of the bedroom for years and years are now back in it. Okay, because they're quiet. They're quiet. Yeah, snoring is tremendously reduced in general.

Speaker 2: 11:59

So a change in symptoms would trigger someone to go back to the sleep doctor to get their we have to put a sleep study done after they've been on a therapy and they start you at a very low level of voltage and then the button. You have the plus button and every number of days you go up to the next level and you stay there. You acclimate, just like you're going to Everest, right? You don't go to the top the first day, you go a little bit. You wait, see how you do. You go to the next step. Wait, see how you do. You go to the next step and you're like, eh, that kind of woke me up. So then you go back and you stay at the level down below for a little while longer and then you try again. And then, when you start having your symptoms resolving, you start feeling better.

Speaker 2: 12:40

And, let's say, you make it to level eight. You're sleeping all night long. Instead of getting up eight times to pee, which people do, all of a sudden you're getting up once in the night. Then that's a good indicator that you're ready for a sleep study that will at least tell us how well it's doing. Where are you Now? It can tell you that your apnea went from 60 to 20. It's not perfect and you may need to go up two more levels to get it down under 10. It gives you an idea of where you need to go.

Speaker 1: 13:11

And to go up to the level, the doctor is the one that changes that. He's the one changing that.

Speaker 2: 13:15

Well, you're doing the remote control. You can go up and down at home. What they do is program in the remote control 10 steps, oh, and so you can go and you start them at level three. So you give them two to go backwards, just in case they were over ambitious in the office.

Speaker 1: 13:31

Okay, so they can adjust. They can adjust the start time, but they can adjust on 10 levels. Yeah, oh, that's, that's interesting. Are there any problems with this treatment, or side effects or negative things that could happen?

Speaker 2: 13:51

Well, with any surgery there's always complications of surgery which everybody knows. There are Infection, nerve damage, neuropraxia. Used to happen in the very early days when people had numbness and their tongue didn't work real well on the right side. Afterwards I think that's hardly ever happens anymore. You know hospital infections. You can't do anything about that. Stuff like that. Problems that patients report would be intolerance to the stimulation. That would be one thing, intolerance to the stimulation.

Speaker 1: 14:21

Can I just ask for so would that be when you inhale and it triggers a nerve and it causes you to wake up, Right?

Speaker 2: 14:28

That's kind of intolerance, intolerance, right, pop you awake. I can't go to sleep with it, insomnia. They wake up, they can't go back to sleep, soreness on the tongue itself. So those people you just a bite glide, a tooth glide or a lower Invisalign tray kind of solves that problem. I found when I was up at the VA in San Francisco doing some cases, a lot of those folks the lower teeth are pretty ragged and rough and just make them an Invisalign tray from first bite to first bite and then the tongue split right over it, no problems. So I think I've read them somewhere else here I had a list of a couple.

Speaker 2: 15:11

You know, patient complaints are patient complaints, you know, for a number of reasons. If you don't mind looking at that, let's see. Let's see dry mouth. Some patients complain of dry mouth and, um, let me see. Sometimes they say they can feel the generator moving. That that bothers them. Headache, coughing, choking, anything like that. Some people have reported that. But for the most part the biggest thing is that it wakes them up, keeps them awake, or it wakes them up. The worst one.

Speaker 1: 15:45

What about going through x-rays, like going to the airport or something? When you have the health plan, you can go through the airport.

Speaker 2: 15:51

You can go through regular standard x-rays. You need to let them know that you have it, the old 3024, which was the very original generator that was put in that long ago and far away. They haven't used this for years. Those were not mri compatible. The new ones are mri compatible. The ones that have come out, the 3024s are compatible. You just have to have the right kind of tesla machine, which now most most hospitals have a tesla machine, so it's not a problem, okay and then inspire is the main brand, but you said there's other brands around it's I would say it's.

Speaker 2: 16:24

It's more than a couple of furlongs ahead of everybody else out there. It's more than a few furlongs out there. And Nixoa is the next one coming in, very interesting in that it has put in both sides of the hydroglossal nerve, so for people who have the concentric collapse that they have better, since they're accessing both sides, they think it's better, might be better for treatment for patients who have concentric collapse, which is that's a great subset of patients that need to be treated. And, interestingly enough, the generator is external. It's external, so you take this little thing under your chin, looks kind of like a hockey puck, okay, and then it goes on in it. That's how it works at night. So those have been. I know that a couple of my friends are putting them in.

Speaker 1: 17:13

Like magnetic or something Like how does it connect?

Speaker 2: 17:18

I think no, you have a control that turns it off and on, but the actual generator is not inside, it's outside. Use it. It's got the sole tape you tape it okay. It's on your neck. I think the idea of having bilateral stimulation if you have concentric collapse, it's really a great idea, because then you're getting it on both sides and the whole idea is the whole tongue coming forward. That would be great.

Speaker 2: 17:41

Okay, because in the typical inspired the tongue will come forward and go out in one direction. It's only on this side. It's on this side, but what they do is lots of times nerve fibers cross over, and so it does get some bang for your buck on both sides, but not just not like having it on both sides.

Speaker 1: 17:58

So they implant it on the right side, usually on the right, usually on the right, because then it comes out on the right or it comes forward on the left Opposite. So if you're stimmed on the right, usually on the right Because it comes out on the right or it comes forward on the left Opposite.

Speaker 2: 18:07

So if you're stimmed on the right, it goes this way, okay.

Speaker 1: 18:12

Interesting. So you got to see which side your bed heart rate is on. In case they over-stimulate you, you're going to lick them, okay, so that's interesting. So how did you get started working with Inspire? What do you do? Were you part of the surgeries or what was your role?

Speaker 2: 18:30

I was one of the lead clinicals for the West Coast, so when I first started I could be in four states in four days going to cases. I did a lot of traveling the first few years and then, as they started to grow, then more feet on the ground and I didn't have to do so much traveling to grow, then more feet on the ground and I didn't have to do so much traveling and went to cadaver labs, helped to train the physicians and then go in the surgeries and be with them and support them and testing the equipment. When you're in the OR you want to make sure everything works properly before you send somebody home. So doing that. But my favorite piece of all of it was something that they don't do as much anymore, at least the same way.

Speaker 2: 19:07

I think the inspires changed since, since I retired, is that I like the one-on-one care with the patient afterwards because sometimes they're coming in and they're saying they're not doing well and and they don't like it and whatever. And just by virtue of active listening and trying and asking those kind of, in a nice way, asking those same three questions, I was actually able to realize that the global piece sleep is so global and it's so different for every individual. I could pull one of my other very disparate tools out of my bag and use it in connection with their inspire appointment to help them turn towards being successful for themselves, and and so something as simple as okay, well, let's try. How about we add this? How about we try that? Because it's not, maybe not the inspire, but you're focusing on that because that's what you have.

Speaker 1: 20:04

I mean, it's so important to get someone who knows so much about sleep, all the different treatments, who's well-rounded like you, or somebody who thinks of all these different options, because if there's somebody doing the procedure and just recommending inspire but not looking at all the other pieces to the puzzle, then the success rate is going to be a problem right it can be, and I know I have.

Speaker 2: 20:32

Of course, we all have our favorite people that we worked with at least my group of surgeons and friends so we did a lot of cases together just because we don't work together so much and I love that. And it's frustrating and disheartening from the physician's point of view when some of the providers refer you at a patient that they're just frustrated with and they're sick and tired dealing with this person that's complaining and like, okay, fine, just go get Inspire, but you're sending me somebody who has rampant insomnia. Yeah, this is not the right therapy for somebody with rampant, untreated insomnia.

Speaker 1: 21:11

And what about patients being missed for maybe non-airway related disorders like restless legs syndrome, plmd? You know, other things might be playing a role, you know beyond. It's not narcolepsy, well, and that's the big deal.

Speaker 1: 21:23

That's my big war cry against having HSTs, because you find so many people have limb movement issues and the ferritin, vitamin D, restless leg syndrome and, yeah, I keep mentioning, we keep talking about this because this can be missed and it's a big piece of the puzzle and I was talking with Dr Simmons and Stacey Ochoa other people that, like a lot of kids, get diagnosed with ADHD and they might actually be having restless leg syndrome and periodic limb movements in their sleep. That's affecting the quality of their sleep. So I feel like it's so important with any sleep apnea treatment to look at all the other components and to have a well-rounded breadth of knowledge, to think outside the box, think outside the box.

Speaker 2: 22:24

Well, right, and I think part of this may not be inspired related per se, but it's very difficult when a patient goes in and they have multiple things that they need to talk to you about. They have multiple issues, multiple problems that are. They're very disparate and they kind of can't collect it all. They almost don't even know themselves, but they know that there's more than one thing. But I have actually heard a nurse seating a patient who says, well, I want to talk about this and this, and she's like you can only talk about one of those today Pick one Pick one, pick one.

Speaker 2: 23:00

And I'm like no, no, no, no. I said you. I tell the patients you have your grocery list. You think about something. I want you to write it down at home.

Speaker 2: 23:09

I don't just keep the list going because you're going to bring that to your appointment and you're going to say this is my list. I want you to because half the time their backs are turned to the patients and they're typing into the computer. They're doing their electronic health note, they're typing into the computer. So they're really glancing over here at Mary, who's like literally sobbing her guts out, trying to tell you what's wrong with her. Instead, because you've got to get this note done and push send before you walk out the door, You've made up your mind what already is going on with this lady and then you've kind of given her a cursory, whatever it is. And, yeah, the patient has to say stop, excuse me. Excuse me, this is my grocery list. Please type this in. You're typing. You're typing right now, sir. Please type it right in, because you now have to. Now that I tell you to type it in, you are bound legally to do something about it.

Speaker 2: 24:06

It's called that.

Speaker 1: 24:08

Once you type it, you own it, I guess, right.

Speaker 2: 24:10

It's called. Once you type it, you own it, I guess, right? Well, it means you are. Now you must take care of it. And the reason why they don't want you to talk about more than one thing. Do you know why?

Speaker 1: 24:18

Why they have to treat her Coding. Oh, okay.

Speaker 2: 24:23

I can't code for those two things on the same day. I only get paid for one.

Speaker 1: 24:27

Yes.

Speaker 2: 24:43

That's why the medical system is just kind of ridiculous. Right appointment with the ENT to put the scope in while the thing is on and see what's going on. That's important too. So it requires precise follow-up. It requires longitudinal follow-up. Patients many of the early patients that got Inspire they felt so great. They're like oh, I feel great, I've gone on in my life. They come in for something else and you interrogate their device and say did anybody tell you you're supposed to get this thing checked every year? And say did anybody tell you you're supposed to get this thing checked every year? Oh, it's a piece of hardware in your purse. You get it checked at least every year minimum. So it does need to be.

Speaker 2: 25:21

Require some fine tuning and maintenance. The batteries are about 11 year lifespan, which is pretty darn good. It's no more difficult than changing a pace maker battery. It's no big deal. No big deal Cause the wires technically should be lifetime. So it's a matter of tiny little incision pop the battery out, unplug, plug the new one in, close it up. You're in and out of there in half an hour.

Speaker 1: 25:44

Okay, this has been so informative and educational. I feel like I knew about Inspire. I knew what it was, but I did not know all these details and it's so important for us to all be aware of this as another treatment option that some of our patients may choose to do. I don't believe there's much, if any, research on myofunctional therapy in combination with Inspire. Are you aware of that? If there, is.

Speaker 2: 26:08

It's pretty limited.

Speaker 1: 26:10

If there isn't, you've got to get that going. Are you aware of that? If there is, it's pretty limited. If there isn't, you've got to get that going. That would be great to have some research on combining those, because we know pretty much adding myofunctional therapy to any treatment will have the potential to make that treatment more effective, and it would only make sense that it would. So I want to. Before I thank you for all of your time, I want to kind of summarize everything as best I can.

Speaker 1: 26:33

I take a lot of notes and it's interesting to me that Inspire just got FDA approved only 10 years ago. So this is, you know, a pretty new treatment but pretty prolific in its use. Hundreds of thousands of patients around the world are using this, so it's an internationally used treatment. Inspire is the brand name in the United States, but there are other ones, or the main brand name in the United States, but there are some other ones around and by pushing or thrusting the tongue forward, by stimulating the hypoglossal nerve on inhalation so when the patient inhales, it's going to stimulate the nerve to push the tongue straight out forward between the front teeth. That's how it's opening up the airway Out to the side, out to the left typically, and it's a one-day installation procedure. It's a surgery. They're in and out in the same day. How crazy is like modern medicine. I mean, when you just think about this, it's just really, really amazing.

Speaker 1: 27:31

After that feeling time of a month to six weeks, then they go back to the doctor, it gets calibrated and every year it needs to be checked back on. Patient has a remote control. They turn it on when they go to sleep and it has a set amount of time it takes until it turns on, because we don't want to start it too early when they're not fully asleep. And then the patient can adjust settings. There's about 10 settings on the remote. They can adjust that on their own and the efficacy is sort of monitored by patient symptoms, how they're feeling and if, if I'm and stop me if I'm saying anything wrong but if the patient is having like a relapse, not feeling well, getting up to use the bathroom 10 times, whatever, they might go back to that doctor for a sleep study. Um, and typically it's ent's or oral facial, max, oral facial, oral maxillofacial surgeons that might be installing this um, this treatment.

Speaker 2: 28:24

A couple things, a couple things, one is. There's also a pause. There's a pause on the remote control.

Speaker 1: 28:30

Oh, okay. You could get up and use the bathroom.

Speaker 2: 28:32

You could get up and use the restroom.

Speaker 1: 28:35

It's like 50-50. That's a really good point If someone needs to drink water or something that could be actually scary.

Speaker 2: 28:44

I think the longest the pause can go is a half an hour. They might have changed it, but it was a half an hour. 10-50 is usually what most people need. Definitely Do you go to the restroom get a drink of water.

Speaker 1: 28:55

Okay, that's really good to know. And for qualifications you need to be 18 years old or older with moderate to severe sleep apnea. Age high 15 to a hundred. But if someone has down syndrome, they can qualify age 13 to 18. Um, there's sort of uh, certain things that will prohibit you from being able to get this treatment if you're obese, your BMI is greater than 40, you have more than 25% central apneas. We don't use it on neurological degenerative diseases and patients must have tried and failed CPAP or like intolerant to CPAP. Yeah, it's covered under healthcare insurance for most insurances, and we also don't want concentric collapse. That was another important thing. This is so great when you said every day, you are a day older. That's interesting. Never thought of it that way. That's depressing.

Speaker 2: 29:47

I mean that's my life, that's what I do.

Speaker 1: 29:51

Let's not think about that. Let's just ignore that. But I do love a couple things you also said.

Speaker 2: 29:58

Go ahead One population, though that we need to remember also is excluded from it or might need to stop using it for a short time, is they would prefer it's not indicated for pregnancy? Oh, good thought, yeah, or would you be in a position where you would become pregnant? However, I do know of one of the patients in particular, at 46, who ended up having a surprise of life pregnancy and, um, she went on during that pregnancy and then went back on the spire after she died.

Speaker 1: 30:30

Okay, okay, and they don't have to remove it, they just don't Interesting Okay, and all patients with sleep disordered breathing. There's layers, like an onion, you said, to this diagnosis. And a good question to ask patients because oftentimes they're overwhelmed is do you want me to help you, hug you or hear you? And that helps us kind of break down. And that means as a provider, you probably have a lot of time scheduled with that patient because that's going to be a long appointment. So actually think before you ask those questions. Typical medical providers.

Speaker 2: 31:07

You don't have to phrase it quite that way.

Speaker 1: 31:09

And typical. Many medical providers might say do you want me to hear you and you only have one thing you're allowed to say? Right, okay, but that was. That was so wonderful, so interesting. I really appreciate all your time. I do want to mention Airway Circle is a great community. So if people who are listening are not members, I really urge you to become a member of Airway Circle and there is actually a code to get a free month's membership Airway Answers if you just enter that code.

Speaker 1: 31:42

Airway Circle has over 200 recorded lectures In addition to the podcast I do, the rest of the ladies do Thursday Night Lives every Thursday. Over 200 of them are recorded and they spend every single Thursday, every single week I think they've maybe missed a couple from holidays interviewing people all around the world, and it's just so educational and informative. They also have research folders, private Facebook group, member highlights, global directory of professionals, so it's a wonderful group to be part of. So I really urge everyone, if you're not a member, to consider and look into that membership.

Speaker 1: 32:18

And again, I want to thank you so much, dr Pat McBride, for being here. It's just so wonderful to be able to talk to you, learn all about other treatment options for patients. You're so informative, so smart, like I know, I'm going to think of more questions. So next time I see you at a conference I'll have a list, no problem. No problem. Well, we'll see you at the PMD coming up pretty soon PMD coming up, which is always so much fun. So I can't wait to see you then. You too, take care. Thank you so much. All right.