Transcription:

Dr. Weis: All right. Well, welcome. Hey, it's another Get Wise with Weis podcast. I am very excited today and we're very fortunate to have a special guest. I have Dr. Brad Trinidad. Now, it's interesting, when I was growing up thinking about being a doctor, you know, certain doctors, you know what they do. They say, "Well, he's a brain surgeon." You go, "Oh, I know what brain surgeons do. They must do surgery on brains." But Dr. Trinidad is a vascular surgeon, and I didn't know what that meant until about five minutes ago. But anyway, Dr. Trinidad, tell us what does a vascular surgeon do and what did it take for you to get here to be a vascular surgeon?

Dr. Bradley Trinidad: Yeah, sure. So, that's been one of the common questions that I get since I've been here. Like you said, what is vascular surgery? Well, the way I answer that is I say that a vascular surgeon essentially is a surgeon of the blood vessels of the entire body that are not within the heart or the brain. I operate on any other blood vessel anywhere else. What I like to also say is I'm kind of a mixture of things, right? So, I'm a surgeon first and foremost, but I'm also an interventionalist. And in some weird way, I'm also kind of a primary care doctor, right? I'm prescribing medications and following medications and seeing patients for other issues, right? Because, you know, inevitably, the vascular system is all related, right? So if I'm doing vascular surgery on somebody, they probably have issues with blood pressure or, you know, peripheral arterial disease, you know, atherosclerosis, et cetera. So, that's kind of the short answer.

Of course, the long answer is quite complicated as far as what I do, but it's a little bit of everything, But again, blood vessels throughout the body. So, you know, it used to be in the-- not the old days-- but back maybe about 10 to 15 years ago, if you wanted to be a vascular surgeon, you had to do general surgery first, five years, and then you would do two years of vascular surgical fellowship.

About 10 years ago, 15 years ago, they started a new paradigm, the integrated vascular surgery residency. And so, I was actually the first person from my medical school to go through one of these integrated vascular surgical residencies in which you really start your training, your residency training with vascular surgery and you kind of build from there. And that was important because at that time, vascular surgery was undergoing a big change.

So, you know, the old school vascular surgeons, you think of fem-pop bypasses, open aneurysm repair, open carotid endarterectomy, which are all still things that we do today. But new vascular surgeons also not only do that, but we're doing the angiograms, minimally invasive procedures, right? Stenting, endovascular aortic aneurysm repair, right? So, that's right around the time where vascular surgery started changing, and that is what led to this training paradigm. And so, that's what I went through. So, I went through five years of vascular surgical training. My first surgery as an intern was actually a leg angiogram. And then, my second one was an amputation. And then, the third was a carotid endarterectomy. So, I started very early in my training doing minimally invasive, you know, endovascular work.

Dr. Weis: Yeah. So, it's interesting to say I'd seen that when I was young. You know, the vascular surgeons with all that training, they would finally graduate about age 55. So, these programs are really nice now the way they consolidate some of them. But you made some great points because certainly, many, many years ago when I was a medical student, and I would have to, you know, go into vascular surgeries and, you know, kind of helped them as a medical student or be there. These surgeries were typically no shorter than eight hours. You dreaded being called into vascular surgery because you knew it was going to be an all-day affair. But you've talked about this revolution in vascular surgery. You know, you made mention of open versus kind of maybe, you know, minimally invasive. Tell us a little bit more about that. What do you mean by open versus minimally invasive?

Dr. Bradley Trinidad: Sure. Yeah. So, what I mean minimally invasive, I mean endovascular. So if you look at cardiologists, you look at some of the interventional radiologists, right? They do interventions, and that's what I mean, right? So, leg angiograms, angiograms of different vessels in the body, that means minimally invasive, percutaneously accessing an artery or a vein with a needle; advancing a wire, some catheters, basically some long tubes; getting to where you want to go and then, performing the intervention within the body, right? So, I don't have to make a large cut. It's really all through a single access point, maybe two access points. And that has really changed the paradigm as far as vascular surgeons.

And it's interesting because at that time, you know, vascular surgeons were really willing to adapt. If you look at some of the troubles with some of the heart surgeons these days, right? I mean, they don't typically do a lot of endovascular surgery. Right now, that's changing, right? They're trying to now. But that's because at that time, they weren't as willing to learn the innovations. Vascular surgeons were very willing to learn these new techniques. And I think that's really benefited the field. And now, if you look at, you know, the areas of, you know, peripheral arterial disease, carotid disease, aneurysms, you know, vascular surgeons really are at the forefront and kind of the lead specialty for these typical areas. And I think that that's due in credit to the earlier vascular surgeons who are willing to accept minimally invasive endovascular procedures.

Dr. Weis: Thank you. I mean, you kind of mentioned a word in there and I think, you know, certain words that stand out in medicine that everyone knows, that strikes fear in them, and one is aneurysm, right? And you know, you used to hear people, "Oh, but my uncle died of an aneurysm." So what is an aneurysm? In particular, which aneurysms do you work on and how is it different today to fix those than, oh, let's say 20 years ago?

Dr. Bradley Trinidad: Sure. So in short, I fix aneurysms in any part of the body. Again, not in the hearts or the brain, but, you know, in the belly, in the leg, et cetera. But an aneurysm, all it really is, is it's a weakening of the wall of the artery. And so, typically the most common cause is smoking, but also high blood pressure. Believe it or not, diabetes actually has a protective role, but that's an interesting topic in and of itself. But particularly, you know, for instance, the cigarettes, they have these chemicals which have known to cause breakdown of the certain proteins that lead to breakdown then of the wall of the artery. As the wall of the artery gets weaker, it's like a balloon, so it gets bigger. And as we know, eventually the balloon gets bigger and bigger and bigger, and then it pops, right? And so, that's always the risk with aneurysms that we worry about, is rupture.

And so, the most common typically is an infrarenal abdominal aortic aneurysm. So, it's usually in the belly and, again, mostly found in smokers, older populations. The second most common would probably be behind the knee, believe it or not. And there's also aneurysms in the groin and then along some of the visceral vessels in the stomach, you know, typically. But by far, the most common is those infrarenal abdominal aortic aneurysms and so, we like to screen for those.

Dr. Weis: That brings up a good point. So, you know, because if I'm worried, gosh, could I have an aneurysm? Because in my understanding is you don't know you have it a lot of times until it does pop and then, it's a disaster. Who should be worried about being screened for an aneurysm? And what do you mean by screening? What do you do?

Dr. Bradley Trinidad: Sure. Yeah. So, the big one, and this is what I try to relay and I'm trying to relay to our primary providers, our cardiologist, you know, the moment that a person is diagnosed with one of these aneurysms, and I'll go over the diagnosis here in a second, but really they need to get that patient to a vascular surgeon, right? There's no too small or too large of an aneurysm. Once one is identified, a vascular surgeon needs to be on that patient's care.

But to give you an idea, the most common patients we see aneurysms in are smokers. So, actually, if you look at, you know, Medicare and the guidelines, so any patient that's over 65, particularly any male, is supposed to get a diagnostic ultrasound to look for an abdominal aortic aneurysm. Anybody that's over 55 with a smoking history also under Medicare gets a free ultrasound to look for an abdominal aortic aneurysm. And then, most importantly, and this one's often forgotten, is anybody who's got a family history of abdominal aortic aneurysm, those patients should definitely, sooner rather than later, get with a vascular surgeon for an appropriate surveillance and at least a diagnostic ultrasound. An ultrasound is just a minimally invasive way that we can look into the abdomen to identify one of these aneurysms. So, there's no invasiveness to it. It's very simple. It doesn't take very long. And it allows us to get a lot of key information which can save your life.

Dr. Weis: Yeah, very good. So, you know, great. When I think about my patients, you know, I have a lot of older gentlemen who have a significant smoking history, and they get this ultrasound. As you pointed out, it's quick, it's painless, it's noninvasive, and yet we can measure how wide that aorta is and then whether or not it's dilating out, because that's a concern as you pointed out. Now, in the old days, people used to panic because that meant you had to open the patient up and kind of almost fortify that aorta. What do you do nowadays to fix someone with a dilated aorta?

Dr. Bradley Trinidad: Sure. That's a great question. Now, to answer the first part is that, believe it or not, we still do that sometimes, but it's not the most common way we treat them. I think what you're referring to is something called an endovascular aortic aneurysm repair or EVAR. And so, this is going back to what I was saying earlier as far as really embracing the endovascular techniques. So an EVAR, essentially, all it is, is allowing me to exclude that aneurysm in a minimally invasive way, meaning two groin sticks typically. I put the wires up, I put the catheters, these tubes, and then I'm able to put the stent graft inside the aneurysm to exclude it from the blood flow. And that has been really a game changer as far as treatment. If you look at the open surgery, again, the open surgery really is the gold standard. With that said, it is a very large surgery, as you mentioned, right? Those are probably those eight-hour cases you were talking about earlier. But, you know, as long as the patient gets out of the hospital, they do pretty dang well.

Well, the problem is you got to get them through that postoperative course, which can be challenging, particularly with patients with a lot of comorbidities. So, an EVAR really allows us to expand the number of patients that we can treat, you know, for these aneurysms and particularly some of those patients who are not as healthy and may not be able to get through one of those open surgeries. So, it's really allowed us to do that. So, we bring them in, I do the repair, and then they go home the next day. So, that's pretty good.

Dr. Weis: Fantastic. Yeah, absolutely. And, again, the whole idea is to get on top of that aneurysm before it causes trouble.

Dr. Bradley Trinidad: Absolutely.

Dr. Weis: You know, and trouble as you pointed out, whether it bursts or ruptures, dissects is another term, and oftentimes that's an emergent situation at that point.

Dr. Bradley Trinidad: Right. Usually, what I recommend is any patient who's got a history of a known history of abdominal aortic aneurysm. If you have any sort of abdominal pain and it's pretty severe, you really need to keep that thought in the back of your mind, particularly some of the larger aneurysms. You know, anything over, you know, three and a half, four centimeters, you know, it's something to think about. And also, if you're somebody and you have a primary care doctor or a cardiologist right now, and you've got an aneurysm that you've been told about, you really should talk to them to get them to call your neighborhood vascular surgeon and get them to evaluate the patient as well. Because as you mentioned, the most important aspect of care of these aneurysms is prevention. So if you get them before, they do very well. It's the patients that you find when it's too late, when they rupture, the patient does tend to not do as well.

Dr. Weis: Absolutely. Thank you. You know, that's great. Let's switch gears a little bit. You know, we've been talking about big blood vessels, the aorta. But, you know, you hear a lot of people talk about peripheral arterial disease or peripheral vascular disease. You know, I guess we want to think about the fact that, you know, blood's got to get all the way down to the tips of our toes. And when that doesn't happen, then that causes problems. You know, and most of them, there's some kind of disease of those blood vessels that's supposed to carry that blood to the toes. What are some of the risk factors or what damages the blood vessels that would cause that to happen where the blood can't get down that far anymore?

Dr. Bradley Trinidad: Sure. Great question again. Probably one of the things that I treat the most is peripheral arterial disease. So, I think it's a very important topic. The most common comorbidities I see with these patients, smoking is one. Again, I go back to the smoking a lot. Smoking. Diabetes is also very prominent, any problems with the kidneys. And so, essentially, in these patients with peripheral arterial disease, there's different levels of peripheral disease, right? So, there's probably patients out there that are walking around Amarillo and the panhandle and all over the world with peripheral arterial disease, and they don't even know, right?

So, I think that's one of the things that I think is important when you're trying to see these patients and treat them, right? Not every patient that has peripheral arterial disease requires an intervention, right? So the question is, who does and who doesn't, right? So if you look at a patient who's got what we call claudication, claudication is just some pain on ambulation, right? Those patients, there's different outcomes for different patients, meaning if a patient has peripheral arterial disease and they can walk half a block before they have pain, then it's probably a patient you want to try to be very conservative with, right? You can only make them worse if you start intervening on them too much. So typically, that's a patient you want to, you know, if they're smoking, promote smoking cessation, good diabetic control if they're diabetic and then making sure they're on optimal medical management with aspirin and statin, right? So, you take that and then you go to a different patient who's got something called life-limiting claudication, right? So, "Doc, I can't go grocery shopping because my legs hurt so bad." "Doc, I'm getting ready to lose my job because my legs hurt so bad because of this peripheral arterial disease." That's a patient where you are maybe a little bit more aggressive on your treatment, right? Because if you have a patient that's going to lose their job because of their peripheral arterial disease, then that's someone you want to treat, right?

But again, the idea is that you want to treat them when they need to be treated. And that's something I try to stress to all my patients with peripheral arterial disease. The likelihood of a patient with claudication and peripheral arterial disease of losing their leg in one year is probably less than 2%. And so, that's one important concept that I think the patient should know. Now, a patient who's got rest pain, right? So, that means that their occlusions and their stenosis in their legs are so bad that they do not have enough blood flow to even feed the muscles at baseline at rest, and it hurts even just laying down. That's a problem, right? Then, you talk about somebody who is at high risk for limb loss. And then, somebody who's got a wound on their foot, right? And that means that their perfusion is so bad to their foot that they do not have enough blood flow to heal the wound, and that's a serious issue and that needs to be addressed very quickly.

Dr. Weis: Yeah. Thank you. Just from my understanding, so when you talk about this claudication, this pain, so that's due to the muscle not getting enough oxygen under the stress or demand.

Dr. Bradley Trinidad: Correct. And that's like exercise. Yes, it's just like exercise, right? You know, when we push our bodies to the limit, you start getting that cramping-like pain, some of burning-type pain. Well, it's the same thing in a patient with claudication, right? Their muscles are not getting enough blood flow and that in turn leads to some of that cramping-like pain much sooner than maybe like an athlete.

Dr. Weis: Gotcha, absolutely.

Dr. Bradley Trinidad: Right. So, that's basically similar. That's what I like to compare it to, because that's the type of pain you're usually feeling. And it's usually in the buttocks and the thigh and in the calf. Those are the most common places.

Dr. Weis: Fantastic. And then, you kind of alluded to it, I thought it was interesting, so let's say maybe I have diabetes, maybe I have a smoking history, I've got some of those risk factors you've talked about. You know, maybe I'm not having necessarily pain or at least pain that doesn't bother me until I walk, you know, two or three blocks. But then, are there any outward signs on my skin or anything that would say, "Boy, maybe my legs are not getting enough blood flow?"

Dr. Bradley Trinidad: Sure. Yeah. I mean you start looking at your feet and you lose your hair. That's a big deal. Usually, there's this sort of, we call it independent rubor in the feet, right? The foot is red when you look at it or when they're laying down, but then when you elevate the foot, it turns white, right? So, those are signs. But, you know, believe it or not, like for me, you know, history and physical are the most important part of diagnosis, as you know. But when it comes to claudication to me, history is more important than any physical. To me, it's more of how far can this patient walk, how can they live through it. Is it life limiting? And do I find any other thing in their history, which made me suggest that this patient would likely do better with intervention versus conservative management?

Dr. Weis: Great. You know, you brought up wounds because that's a big thing. You know, people don't realize the extent that people suffer with chronic wounds. And, you know, a lot of times they are on the legs, you know, around the ankles or the feet, some of that. And, you know, we have a wound care center. You'll find a lot of these wound care centers, but they work hard at trying to help people heal these wounds. But your point is well taken, if you don't have sufficient blood flow beneath that wound, it's just not going to heal. You're not going to get the immune system there to help. You're not going to get the scar tissue forming. And so, I assume you probably work pretty closely with doctors who take care of people with wounds.

Dr. Bradley Trinidad: I do. And you know, I work closely with doctors who do the wounds, but also I can do wound care myself. So, wounds are very complex. As you know, there is multiple different possibilities as far as what's causing somebody to have a wound, right? Perfusion is definitely one of them, right? Arterial blood flow, but that's not the only, right? There's patients that have issues with not necessarily the blood getting to the foot, but blood going back to the heart and you get venous insufficiency and causing wounds, that's another one. You've got patients who just have infections that are not being treated appropriately. You've got patients who've got wounds with good blood flow. But they're not doing appropriate offloading of their foot and they keep walking on it and it never heals.

So, it's complex. And that's why I think you really need like a combined, I like to call it a limb salvage team, you know, comprehensive wound care team in order to really give the patient the best opportunity to heal. And I think we do do that well here, you know, with our wound care center. We are able to get these patients in very quickly. If they need perfusion, you know, any sort of revascularization, we get them in quickly. We do that. If they need any sort of, you know, wound debridements, et cetera, we do that quickly, we see them frequently. And I think that the outcomes have been pretty damn good. But the only way to do that is to have a complete team. And I think we're fortunate enough to have that here.

Dr. Weis: Great. Yeah. And, you know, say you find someone that does have blockages in those arteries down the legs, I'm assuming you have the same options of maybe minimally invasive versus open procedures.

Dr. Bradley Trinidad: Yeah, I always go minimally invasive first, endovascular first. So, just very similar to maybe like a cardiologist or a radiologist, I do the same thing. I will tell you sometimes in these more complex patients, you know, sometimes they require an open surgery, right? So then, I might do something like a hybrid surgery. A hybrid surgery is just a minimally invasive surgery that's combined with an open surgery, right? So in the old days, a patient who had lack of blood flow to the leg would just get a bypass. Now, I can do maybe a small, you know, revascularization open above in the leg, maybe in the thigh, and then I can do the rest minimally invasively, right? Or I can do the entire thing minimally invasively, which I pride myself on. I really try to push-- I don't want to say push the boundary, but I'm aggressive with endovascular therapy. That's just how I was trained. I come from a limb salvage program in Arizona, we wrote all the textbooks on it, right? So, that's what we do. And so, I'm very serious about offering the patient the best treatment therapy for them. But with that said, I always try to do minimally invasive first, endovascular.

Dr. Weis: Fantastic. I do remember a lot of those patients, those eight-hour surgeries, not only was it a long surgery and they were miserable, but they were left with some pretty gnarly scars, you know. And I think just using catheters now to go in there and be able to open up these arteries with, like you said, just a little tiny incision to get the catheter into the artery and then do all the work inside that artery.

Dr. Bradley Trinidad: Yeah. It's fantastic, you know. But I'll tell you sometimes cold steel treats everything, you know? And, you know, you might have a scar, but you're feeling better, you know. So, that's the beauty of it.

Dr. Weis: Absolutely. Fantastic. And then, obviously, you know, I think another thing is, you know, for us to have a true vascular surgeon. Talk a little bit about what's your role in our trauma team? People obviously get injured by trauma. And what kind of things do you do to help that team?

Dr. Bradley Trinidad: Yeah. So, you know, before I took this job, obviously, I was told that we have trauma. But that's a bigger part of my practice than I think I even was expecting. And I think a vascular surgeon really is vital, you know, to any sort of trauma program. And, you know, you talked about patients who are coming in with, you know, blunt aortic injuries. You've got severe injuries to the extremities, you know, leading to cessation of blood flow. You know, you've got patients that are bleeding who need emergent coil embolizations. So, these are all things that I see on a fairly routine basis, and I'm able to really offer either an open endovascular combined approach for these patients. And so me, in conjunction with our trauma team, I think we've really opened the amount of patient, so we've really allowed more patients to stick around here in Amarillo, right? That was the problem, was a lot of these patients tended to potentially be shipped out for some of these more complex traumatic vascular injuries. And now, it really allows us to keep them here and treat them here, which I think is ultimately the best interest of the patient.

Dr. Weis: Absolutely. Anyone who's ever spent time hanging out at a major trauma hospital like Northwest, you know, you realize that we have the gun and knife club that normally happens on Friday and Saturday nights. You know, people getting shot, people getting stabbed. But your point is well taken. A lot of times before we had a doctor like you, you know, if there was a large blood vessel that was cut, then you put a tourniquet on that extremity to try to stop that bleeding. And depending on the time to transport that patient to an appropriate level of care, that could really risk damaging that extremity, if not a total loss, because of the fact that you're trying to stop the bleeding and spending that time. So, vascular surgery, there's a lot of situations that are very time-dependent. I mean, the faster you fix it, the better.

Dr. Bradley Trinidad: Yeah. I mean, there's, you know, difference between life and death sometimes in some of these patients. And, you know, speaking to your tourniquet issue, you know, you really only have less than six hours before that's a pretty much a non-viable limb, right? And sometimes, as you know, it can take a while to transfer patients out, especially with the bed situation that's been going on in the last couple years. It's a serious issue. And so, if you can treat them here, that's important. You were talking about the knife and gun club, you know, I remember on New Year's, I was on call of course, and I told my wife, I was like, you know, "I'm going to be up late tonight a bit," right? So I go to bed at 9:00 PM. And, of course, like clockwork, 3:00 AM comes, we've got a traumatic gunshot wound. New Year's Day, I just knew it. And it's just is what it is, you know? And you have to have somebody to treat that, right? And those patients deserve the best care. Everybody deserves the best care no matter the situation. And so, I was glad we were around that day.

Dr. Weis: You know, it's part of every major holidays, people shooting each other. So, absolutely.

Dr. Bradley Trinidad: Especially New Years. I just knew it. The funny part is I just told my wife, "Yeah, I know for a fact I'm getting called tonight," and I was.

Dr. Weis: Just set that aside.

Dr. Bradley Trinidad: I went to bed early because I knew. I'm not staying up tonight.

Dr. Weis: Well, I'd say it's been a huge difference to have you here and know that, again, a lot of times we can keep these patients here, fix them in a timely manner and save just the possible loss of limb, possible loss of life from the bleeding.

Well, good. You know, in terms of just wrapping things up, I'm thinking so I'm an individual that maybe has some of those risk factors you've talked about, diabetes, maybe high blood pressure, smoking history, and I'm concerned that, "Gosh, could I have vascular disease that needs to be addressed?" What do I do? Do I go to my primary care doc? Do they then do some workup? How do I navigate healthcare as to where I get to the right person at the right time?

Dr. Bradley Trinidad: Sure. Well, I mean, as you know, things are variable depending on insurance status, et cetera, et cetera. But in general, I think that the person you should always start with is either your primary care doctor or your cardiologist, right? So, either one of those providers should be able to get you in touch with me or any other vascular surgeon that the patient would like to see. But I think that the primary care doctors are usually good. They're good at ordering the ultrasounds, you know, for these duplex, you know, for these aneurysms. Cardiologists can also do the same thing. But yes, I would always recommend starting there because really-- And I always mention this, and I think it's important that I say this, that primary care doctors don't get enough credit these days. You know, really like they do the hard work, right? I mean, we're fortunate as specialists, like, you know, for me, right? Patients, you know, come to me with typically one singular problem, you know, a primary care doctor these days has to know so much. And so, sometimes I just need somebody to assist, right? And so I'm always available and that's what I really try to stress. And so, if a primary care provider, you know, wants me to see their patients, I'm always available to see them no matter what. But they're usually the starting point. And so, I would direct any questions to them, any concerns and then they can usually go and start the process from there.

Dr. Weis: Fantastic. Well, I think we covered a lot of topics.

Dr. Bradley Trinidad: We did. Yeah. That was a lot.

Dr. Weis: So, I really appreciate your time.

Dr. Bradley Trinidad: Rapid review.

Dr. Weis: Yes, exactly.

Dr. Bradley Trinidad: Much more too. I can go on for days on venous disease. You know, the magnitude of the things that we do in vascular these days is just incredible. We'd be here for hours, so I can go over everything.

Dr. Weis: So, I guess the take home message I'm hearing is that the vascular system's pretty important.

Dr. Bradley Trinidad: Yes, it is. Yeah. And the vascular surgeon is important, I think. I think that we're coming around. You know, I think that I like to call us the firemen of the hospital where we put out fires.

Dr. Weis: Yes, you do. Yes, you do.

Dr. Bradley Trinidad: So, everybody calls us.

Dr. Weis: Yes. Well, fantastic. So, any other messages you want to give or anything you think we missed that just ought to be said?

Dr. Bradley Trinidad: No. No, I think that that was great. You know, again, I just want to reiterate, you know, we're here to help out. You know, like I said, there's a lot of things I treat. If there's ever any questions, you know, people can call my office. They can get in touch with me. I'm very reachable and I'm always here. And so, I'm always happy to discuss things with providers and patients. And I think that having a vascular surgeon around is really important for the community. And so, I'm just trying to do the best I can to help provide the necessary things that this community needs. So, I'm always around.

Dr. Weis: Fantastic. Well, I know with you here, we are really working hard on getting the education out to the community about, you know, what are those warning signs, who are those people at risk. And if you do see those warning signs, then what do you do? And education's always the best thing for people in terms of their most powerful tool.

Dr. Bradley Trinidad: Yeah. If you're over 60 and you smoke, come see me. Just come see me.

Dr. Weis: And please quit smoking.

Dr. Bradley Trinidad: Yeah. Please quit smoking. Exactly.

Dr. Weis: I think that that's still the best thing you do for yourself.

Dr. Bradley Trinidad: Yeah. We'll get you quitting.

Dr. Weis: Absolutely. Well, fantastic. Again, appreciate your time. And I think this concludes another Get Wise with Weis podcast and we'll see you next time.

Dr. Bradley Trinidad: Thank you.

Dr. Weis: Thanks.