Q&A with Parkinson's Disease Experts

Dr. Sneha Mantri 00:00:04
Hi everybody. Thank you for joining us for today's Parkinson's Foundation Q&A. My name is Dr. Sneha Mantri. I'm the chief medical officer of the Parkinson's Foundation, and I'm here today with Dr. Ray Dorsey and Dr. Michael Okun to talk about their new book that just came out last week, The Parkinson's Plan: A New Path to Prevention and Treatment. Dr. Dorsey and Dr. Okun, thank you for joining us.

We're delighted to be able to have this time to sit down with you and talk about the origins of this book, the impetus for writing it, and what you would like people with Parkinson's disease and the people around them to know about prevention and treatment of the fastest growing neurodegenerative condition in the United States and in the world. I'll maybe just start there. What was the impetus for you guys to come together and to write this book? And how does it build off your previous book on ending Parkinson's disease?

Dr. Michael Okun 00:01:18
Yeah, I'll start by just saying, first, thank you so much. It's great to be here with the Parkinson's Foundation and with everybody. It's really important that we have these dialogues, so thank you so much for having us.

It really all started for me back in 2012 or so, when we wrote the Ten Secrets to a Happier Life book and I used the words "the Parkinson pandemic." Everybody said, "You're an alarmist," and, "You're nuts," and, "You're crazy," and all those things were probably true. But still, as we continued to go through the years and then reach 2020, when Ray Dorsey, myself, Bas Bloem and Todd Sherer wrote the book Ending Parkinson's Disease, Ray is the wizard and he smashed together all the numbers from the Global Burden of Disease study and estimated about 12 million people would have Parkinson's by the year 2035.

Well, we're at 2025 now. We've just written this book, The Parkinson's Plan, and we're at 11.8 million. We're growing faster than Alzheimer's disease, and that should be the shocking fact for everyone. This is something we need to really double down on and lean in to, and that's one of the major reasons and the drivers. We shouldn't leave this for this generation and for the next.

Dr. Sneha Mantri 00:02:45
Dr. Dorsey, anything to add?

Dr. Ray Dorsey 00:02:47
First of all, thank you very much, Sneha, for hosting us. Thank you very much to the Parkinson's Foundation for all you do to make the lives of people with Parkinson's disease better. This is a picture from the book. The book has lots of pictures, and this is a picture of what Michael was saying. In 1990, the Global Burden of Disease Study estimated 2.6 million people had the disease. Thirty years later, it's quadrupled to 11.8 million. This is not a natural consequence of aging. This is an unnatural consequence of aging. That graph, I think, is the report card for Michael and me. In the book we say, that doesn't look very good, right?

Here we are, two prominent Parkinson's specialists, and Parkinson's is one of the world's fastest-growing brain diseases on our watch. Clearly, what we have done for the last 20 years has been insufficient. Michael and I even say we're failing the Parkinson's community, and we want to rectify that failure. We do that by writing this book, which gives you a proactive plan for what you can do as individuals with Parkinson's, what you can do in your communities, and what we can do as a society to prevent, treat and end this disease.

Dr. Sneha Mantri 00:03:56
Wonderful. The whole book really is going through all of these different potential risk factors and toxicants and so on. The whole first chapter is really about pesticides and all of the chemicals in our food and our water and in the air.

Can you tell us a little bit about how pesticide exposure is linked to Parkinson's disease and Parkinson's risk?

Dr. Ray Dorsey 00:04:21
Pesticides, many pesticides, work by damaging the nervous system of insects, for example, and we've known about the link between Parkinson's and pesticides for at least 40 years. In the 1980s, Dr. Bill Langston described people who were exposed to MPTP and developed acute onset of parkinsonism. It turns out that the chemical structure of that chemical is almost identical to a weed killer called paraquat, and research done by Dr. Caroline Tanner showed that farmers who are exposed to paraquat have a 150% increased risk of developing disease.

Research done by Kimberly Paul and Beate Ritz at UCLA showed that simply living or working near where paraquat is sprayed is associated with a doubling of the risk of Parkinson's disease. Dr. Andre Barbeau, in 1987, demonstrated that pesticide use in rural parts of Canada has a near-perfect correlation with prevalence of Parkinson's disease. The more pesticide is sprayed in rural parts of Canada, the higher the rate of Parkinson's disease. That study has been replicated in France and replicated in Israel. The evidence linking certain pesticides to Parkinson's disease is overwhelming, both from epidemiological studies and from laboratory studies where mice, rats and rabbits exposed to these pesticides develop the features of the disease, including even a tremor.

Dr. Sneha Mantri 00:05:51
Yeah. I mean, that's very compelling evidence, I think, for the impact of pesticide exposures on Parkinson's. We also know that many people with Parkinson's disease, about 15% or so, have a genetic risk factor or genetic component to their Parkinson's. Can you say a little bit about the interplay between environmental factors like pesticides and genetic risks or genetic forms of Parkinson's?

Dr. Ray Dorsey 00:06:24
I'll start and then Michael will chime in. Thanks to the Parkinson's Foundation, we know the answer to what portion of Parkinson's disease is due to genetic changes. This great study called PD GENEration, shout out to Jim Beck and the Parkinson's Foundation, has enrolled, I think, tens of thousands of people with Parkinson's disease in the United States and Canada.

Dr. Sneha Mantri 00:06:49
Across the world, actually.

Dr. Ray Dorsey 00:06:50
Across the world now. For the first 10,000 participants, they were able to get genetic results for 8,000 individuals. Of those 8,000 individuals, 12.5% carry a genetic cause or genetic risk factor for the disease. Some of these genetic causes or risk factors are known to interact with pesticides. For example, the most common genetic risk factor for Parkinson's disease is a mutation in GBA, which affects about 8% of Americans.

Research done by Caroline Tanner again, and colleague Ethan Brown at UCSF, have shown that people who carry a GBA mutation may be at heightened risk for Parkinson's disease when exposed to pesticides. But the flip side is that 87% of Americans carry no known genetic cause or genetic risk factor for the disease. For the overwhelming majority of individuals with Parkinson's disease in the United States, the cause lies not within us, it lies outside of us. It lies within chemicals in our food, water and air, and therefore we can take actions to prevent this disease for future generations.

Dr. Michael Okun 00:07:58
I'll just add to that from the scientific perspective, too. I think folks who are listening should just remember that when you get exposed to a pesticide, it has a tendency to affect some things in your cells. There is an energy-producing part of the cell called the mitochondria. In particular, we're learning more and more about this with animal models and with humans. We now know that these pesticides go directly to many of the areas that are important to Parkinson's, sometimes right even to the dopaminergic cells.

That damage is absolutely critical. We also know in laboratory animals that it seems to be additive, that when you add, let's say you have a genetic risk factor and then you add the environment onto it, those two things sum up and add, and they might even be greater than one plus one equals two. We don't know that yet from the science. The last point is that if you have a Parkinson's gene like LRRK2, you may only have a 30% chance to get Parkinson's. If you have GBA1, these are two of the most common ones picked up in PD GENEration, 90% of people may not get Parkinson's with that mutation. So what is it that's pushing these people over? That's what we're beginning to study.

We really need to think about that because it might dramatically reduce your risk not to be exposed to the thing that's turning it on. It might be the pesticides, chemicals and other things that are turning it on.

Dr. Sneha Mantri 00:09:27
Yeah. I think that's a really key fact for listeners to be aware of. As you say, not everybody who has a genetic risk goes on to develop Parkinson's. The environmental trigger, if you will, might be the thing that sort of tips people over the edge and leads to manifest Parkinson's disease, as we sometimes call it.

Dr. Ray Dorsey 00:09:50
Just like not everyone with a genetic risk factor develops the disease, not everyone who's exposed to the chemical develops the disease. There have to be other factors, dose, duration, timing of exposure, interactions and modifiers that explain who among the exposed develops the disease, just like who among the GBA carriers, for example, or LRRK2 carriers, for that matter, develops the disease and who doesn't.

Dr. Sneha Mantri 00:10:10
Exactly. It's a very complex sort of interaction.

Dr. Ray Dorsey 00:10:14
But we try to simplify it in The Parkinson's Plan. We give you 25 things you can do in your individual life. Sneha's laughing because she's going to get to it, that you can do to lower your risk, even if you carry a genetic cause or genetic risk factor of the disease.

Dr. Sneha Mantri 00:10:28
Right. We will get to the 25 things in a moment, but before that, one of the things that really struck me about your book, and that I really appreciated as a movement disorders specialist caring for people with Parkinson's disease, is that each chapter contains so many personal stories of people living with Parkinson's disease who are so incredibly generous in sharing their stories with you and then allowing those stories to be shared really with everybody in this publication.

Can you tell us a little bit about why it was important to you to include those individual stories in addition to all of the numbers and the data that you've shared with us so far? Why stories of people?

Dr. Ray Dorsey 00:11:17
Because stories matter, and that's how we communicate. When you tell your grandchild a story, reading at night, you don't read about the changes in the GDP. You talk to them about stories, and stories are the best way to communicate information. In addition, the book has 60 pages of references, so if you'd like to geek out a little bit, you can read the references. We want to really thank the people who contributed their stories. These stories came from a listening tour that Michael and I have been doing. I did one in New York State, one in the Midwest, and we're doing one nationally.

If you haven't been to our website, PDPlan.org, you can click on Tour and you can see us coming to your community. This is how we learn. I learned a lot about these toxic sites because I visited these toxic sites and I met people who had Parkinson's. I met a man in Nassau, New York, whose daughter developed back pain at age 16, was diagnosed with a rare tumor linked to trichloroethylene, and then died before graduating high school. Those stories stick with you, and you hear these stories enough and you start connecting the dots. That's what Michael and I have been spending the last eight years doing, connecting the dots.

You see a clear pattern emerges in that this disease is principally fueled by chemicals, and it's unnecessary and avoidable.

Dr. Michael Okun 00:12:41
I'll just add, Ray and I are in our third decade now practicing medicine, and we're tired of talking at people. We want to talk with people. We want this to be a community disease, and you just can't go anywhere where it doesn't affect somebody that you know, usually a family member, if not a very close friend. It's getting more and more common. The story is in the people.

Dr. Sneha Mantri 00:13:12
Absolutely. To that point, in the book you talk about something you call the Parkinson's universe. Can you say a little bit about what that means, what that type of care model could look like?

Dr. Michael Okun 00:13:26
Sure. The broken record for me over many years has been, I've always said the person with disease, or the patient, is the sun, and we should all orbit around them. I think it's a very important concept. However, as we begin to build a model for everybody, I think the model needs to go beyond that. The Parkinson's universe is a construct where we look at the entire solar system, and we're looking at Mercury as the closest planet to the sun, right?

That gets hot. That's the caregiver, right? The care partner. Sometimes it gets hot on both sides, and then they also have the communication. Mercury, god of communication, right? Back and forth. That's the caregiver, care partner. The planets represent all those team members. We're lucky to get parking, much less see one person, and we actually need to see a lot of people to be successful with Parkinson's and know how to coordinate those things.

Pluto, the almost planet, is always out there, always circling us, and represents stigma. Twenty-five percent of people hide their Parkinson's diagnosis. That's unnecessary. We should call for an end to that. The satellites that are up there are all these new technologies, like wearables and sensors, things Dr. Dorsey has done a lot of research on with his Parkinson's Disease Udall grant, and how we can use that connectivity and even use AI into the future to help get care into people's homes in many cases.

We have also the stars. The stars are your support groups, your support system, shining up there to help guide you, your guiding North Stars that can help you navigate out of situations. You shouldn't be by yourself. Then, of course, the asteroid fields are the insurance companies, the payers and all those barriers that folks have.

The quote in the book that everybody seems to love is the one on Star Wars where Chewbacca and Han Solo are flying the Millennium Falcon through the asteroid field, and they're like, it's almost 1 in 4,000 odds they're going to survive. It's the same odds if you're in Parkinson's trying to go through this complex healthcare system. So we need to collapse it some. We need to make it more real. We need to move those chess pieces differently.

Now that we've got almost 12 million people with Parkinson's, while we're creating a plan for prevention, learning why and amplifying our voices, which is the care part, and navigating new treatments, I think a quarter of our effort and our investment should still be in better models for people. They do it better in HIV. They can get HIV drugs to everyone. They can get care. They can get monitoring. We do better in cancer. It's time to do it better in Parkinson's. So we boldly call for a new movement in that direction.

Dr. Sneha Mantri 00:16:07
Yeah, for sure. In the book, you have referenced already in our talk, but you go into a lot of detail about the 25 actions or action steps that people can take to lower their risk of Parkinson's disease. From each of you, what are the top five things that you would say people tuning in should be aware of?

Dr. Ray Dorsey 00:16:33
I'll start with a little background and then I'll give Michael a chance to do his five. One, the Parkinson's 25 is not just for people who don't have the disease, it's for people with the disease. There are 1.2 million Americans, and most people listening have the disease. We're giving you 25 recommendations that might slow the rate of progress of the disease. We know that some people with Parkinson's have a faster rate of course, and some have a slower rate of course. Why is that? One of the factors could be that some people could still be being exposed to the toxics, to the chemicals, that are fueling their Parkinson's in the first place, and some might not be. Just like if you're a smoker and you get diagnosed with lung cancer, what's the first thing the doctor's going to tell you to do? Stop smoking.

But if you live near a golf course, or if you're a farmer, or you're a dry cleaner, are we telling patients to stop being exposed to dry-cleaning chemicals, stop being exposed to pesticides? In the book, we give 25 recommendations that can possibly slow the rate of progression of disease, and there's some evidence that this actually can happen. Then we give you 25 recommendations for your children, for your grandchildren, for your spouses, for your brothers, for your sisters and your friends. If you aren't exposed to these chemicals, and your food, water and air are clean, it is very, very, very unlikely you're going to ever develop the disease. If you are not exposed to these toxins, it is very unlikely you will ever develop the disease.

We give you 25 recommendations to prevent Parkinson's from ever happening in the first place. Michael.

Dr. Michael Okun 00:17:59
Yeah, I have some favorite ones. Of course, one of my favorites is sleep. We talk about sleep now in the modern era, and I think about it as, at night, all these dump trucks kind of driving by your brain and taking away all of these things that need to be recycled and taken out of your brain. We're actually learning now with the glymphatic system and Parkinson's and everything that sleep is really important. Getting a sensor and making sure that you're getting six or more hours a night of sleep. We need to work harder on sleep and help people and pay attention. It can make your cognitive, your thinking symptoms, your motor and mood symptoms better.

Of course, exercise is like a drug, but not everybody should be dosed for Olympic-level exercise. We need to do a better job of how we implement that. The best exercise is the exercise that you'll do. If you can get people to 7,500 steps or step equivalents, and know that some people can't step, using things like portable steppers, things that can go under your desk or in front of a couch, try not to trip over them, of course, and be doing that for 20-minute intervals maybe three or four times a day, or walking 20 minutes three or four times a day to make 7,500 steps. That's great.

Watching to make sure you've got a water filter on your house, particularly if you haven't had your water tested. You may be drinking out of your aquifer, especially if you're close to a golf course or something like that. Making sure your water is clean, and you can ask the city to check your water as well for TCE and things like that, is important. Washing your fruit, one that Ray Dorsey loves, certainly washing for more than 15 seconds, which is the rule for the USDA, I think is super important. At least with water, Ray uses washes that you can get, safe washes that you can put your fruit into. Getting the pesticides off of your fruit and vegetables, I think, is super important.

Then, of course, wine. There are pesticides in wine too. We don't know how harmful or toxic they are, but almost every bottle of wine that was tested in one study in France had some level of pesticides in it. Going organic with your wines or going Italian, where it's supposed to be illegal to have pesticides in them, and thinking about these things, I think, is going to be important. I don't want to give away all 25, Ray, so I think I'm going to stop there.

Dr. Ray Dorsey 00:20:18
We'll just say, we also make it very user-friendly thanks to our wonderful Monica Perino. These are very easy to read. They're short. There are pictures. They're at the back of the book, and they're also described in more detail in the book. Michael and I are devoting all of our future proceeds from sales of this book to efforts to prevent and treat Parkinson's disease. If you haven't had a chance to get a copy of the book, please do so. You can get it at any local bookstore, your favorite bookstore. If you have a support group, you can buy it at a discount at BookPal and others, at discounts up to 40% or more. If you go to PDPlan.org, you can find additional details.

Dr. Sneha Mantri 00:20:59
Along those lines of actions that people can take, one of the things that I think makes it challenging sometimes in this space around pesticides and other exposures is there's often a very long lag between when somebody's exposed, maybe in childhood or early in adulthood, and then they develop Parkinson's disease decades later. What are some things that individuals can do, or that we can do as a society, to help mitigate some of those risks if somebody's exposed when they're 10 years old and then we need to know what happens to them when they're in their 50s, 60s and 70s?

Dr. Ray Dorsey 00:21:48
Yes, an outstanding question. The seeds of Parkinson's are planted early. The seeds of Parkinson's disease are planted early. You don't likely get exposed, just like you don't smoke a cigarette in your 50s and get lung cancer in your 60s. You get lung cancer in your 60s because you were exposed to cigarette smoke in your teenage years, 20s and 30s. We have good evidence of this. This Camp Lejeune study looked at Marines who served at a base contaminated with a chemical called trichloroethylene, widely used in degreasing, widely used in dry cleaning. Caroline Tanner and Sam Goldman looked at Marines who served there versus Marines who served at a less contaminated base in California, and Marines who served at Camp Lejeune had a 70% increased risk of developing Parkinson's disease.

Now, three important notes. One, Marines are generally healthy, so these are generally healthy individuals. Two, the Marines were young. Average age was only 20, right? So getting exposed at 20. And three, the duration was short. On average, they were only there for 25 months. Members of the military switch bases frequently. Yet 34 years later, Marines had a 70% increased risk.

Brian Grant, the former NBA basketball player, was a three-year-old boy when his father was stationed there, and he was exposed to trichloroethylene. Thirty-three years later, when he's 36, he is diagnosed with Parkinson's disease. So the seeds are planted early. What can you do? In your communities, we can stop spraying pesticides on kids' playgrounds and schoolyards. Stop spraying pesticides on kids' playgrounds and schoolyards. Some of these pesticides are nerve toxins. I have not met a kid who's bothered by weeds. Kids like to pick at the weeds.

Stop spraying pesticides, especially pesticides that are most toxic and those linked to Parkinson's disease, on playgrounds. If you live near a golf course, call your golf course up and ask them if they can spray less frequently. Can they use less toxic pesticides? Can they use less pesticides? Then, on a societal level, we need to pass the Healthy Brains Act, which funds additional research into the environmental causes of not just Parkinson's, but other brain diseases. Congressman Gus Bilirakis and Congresswoman Jennifer Wexton, who wrote the foreword to our book, were the sponsors, the creators of this act, along with the Parkinson's community. We need to ban paraquat. Paraquat has been banned by over 50 countries, including China. The EPA's own website says one sip can kill. It's time that we ban paraquat.

Dr. Sneha Mantri 00:24:27
Thank you. Turning now toward the future of Parkinson's and Parkinson's research, what is there in the research pipeline that gives you the most hope?

Dr. Michael Okun 00:24:39
Yeah, so we talk a lot about this in the last part of the book. Each of the PLAN letters stands for different pieces of it: prevent, learn why, going upstream with therapies and research and the basic research, amplifying voices, changing that care system like we talked about, and navigating toward new therapies. We divide it into the things that we need to do now because we've got 12 million people now with Parkinson's. That's a lot of people, right? So things we need to do now, near term, midterm and long term. Some of the things that we're particularly interested in and watching are the gene therapies. They're starting to get hot, and we're seeing it in other diseases as well, and starting to get more and more successful. Could we target some of the things that we're learning through PD GENEration and through other studies, right?

Gene editing is starting to get closer to prime time, and we're actually seeing some real humans getting gene edited now. We're actually watching that technology pretty intensely and seeing if there's potential uses. Of course, remember these things can be used in combination.

We've been a little disappointed over the years. I think I speak for a lot of people in the Parkinson's community who have spoken with me about the hope of stem cells. Stem cells are going to do all of these great things, but here we are a couple of decades plus later, and we're not there. We're really good at making the stem cells. We're not really good at putting them in and making them do what we want them to do, especially with all the symptoms beyond the motor symptoms. But there's a rebirth now, a talk about using regenerative therapies on specific circuits, particularly the cognitive and thinking circuits. I think that's something that's going to be really interesting to watch, how we might be able to use the stem cells in a more targeted way, instead of saying, 'Well, let's put the stem cell in and it's going to cure everything, it's going to help everything.' Why not think about it? Could it help something that's really important, that is an unaddressed area? So, regenerative medicine and those unaddressed areas.

Dr. Michael Okun 00:26:45
Then nanomedicine, going nano, going smaller, surface area to volume ratios. We're getting very good at delivering drugs. We need to work on those delivery systems and develop the right tools, but getting these smaller things into the brain. Of course, remember, Parkinson's, Sneha, you know this and everybody knows this, it isn't just dopamine. It isn't just brain. It's in the skin. It's in organs. It's all over. So using nano-delivery systems and nanoparticles is going to be an important future.

Then linking things on them. I love this word: uncage, right? You can link stuff on and then uncage it, open the cage up and then let it do its thing. There are a number of things we're super excited about. Then, on the short term, lots of new pumps, lots of new devices, some new drugs and new approaches that are happening right now in real time. I think there's a lot of hope in the community.

Dr. Sneha Mantri 00:27:37
Wonderful. I think it's a very exciting time to be in our field and to see all these new things coming ahead. In our last couple of minutes, what do you tell your patients about living well with Parkinson's disease right now and in 2025?

Dr. Michael Okun 00:27:56
Yeah, so I tell folks, one, Parkinson's is not Alzheimer's. We need to do so much better at the time of diagnosis. We need to teach as many people as we can. Most people walk out thinking they just got diagnosed with Alzheimer's. Again, no ill intent toward the Alzheimer's field. Parkinson's is a completely different disease, and we have so much on the horizon and so many treatments, okay? Starting there, making sure the diagnosis is correct, knowing that when people get connected together with the right teams, with the right approaches, they're going to be able to do really well.

I talk to them about being proactive with their health, making sure they have a good doctor that can help to coordinate and be the captain of their team, making sure that they know depression, anxiety, sleep dysfunction and apathy could all be the Parkinson's talking. It might not just be that they're sad because they have Parkinson's disease. We treat those things. Those are usually more disabling than the other motor symptoms. Making sure we have the right people on the bus to take care of them and making sure that they have access to those people and we have a plan. Just like we talk about The Parkinson's Plan, we talk about, do we have a plan for society? But then, do each of you have a plan for your disease going forward? Making sure that there's a plan and knowing that we're going to have to adapt over time because it's a dynamic disease.

Got to be on a vitamin if you're on dopamine. Here are a few tips to end our podcast. Got to be on a vitamin if you're on dopamine, just one multivitamin. You don't need 100,000 vitamins, but one multivitamin for those cofactors so they don't get depleted. Twice the risk of skin cancer, twice the risk of osteoporosis, even if you're a man, okay? Checking for that is really important because you want those bones nice and strong. Then making sure that they know that the data suggests exercise and sleep are really important. We focus on those things and try to be as tailored as possible to each person. Make sure they have a plan.

Dr. Ray Dorsey 00:29:52
I'll give just three to cap Michael's suggestions. One, stop getting exposed to toxicants. Look at the Parkinson's 25 so that we can slow the rate of progression for you. Two, exercise. Three, protect your children and your grandchildren from this disease by having them look at the Parkinson's 25. Let our generation be the last that bears the burden of this terrible disease.

Dr. Sneha Mantri 00:30:18
I think that's a wonderful line to end on. Thank you so much again, Dr. Dorsey and Dr. Okun, for being here with us today. For those tuning in, I do encourage you to read this book. It's really compelling. It's really powerful. Go to PDPlan.org. Dr. Okun and Dr. Dorsey are doing a book tour around the country, and the dates and locations for all of that are on their website, and there's a lot of additional information. You can also go to Parkinson.org for the Parkinson's Foundation and get more information about living well with Parkinson's disease, how you can participate in research around Parkinson's, and help everybody with Parkinson's live as well as possible for as long as possible.

Dr. Ray Dorsey 00:31:08
One last plug. Wednesday, we're in Washington, DC, at Politics and Prose Bookstore, 7 p.m. It's free. It's open to the public. No registration required. If you're in DC or in the DC area, please attend. We have a former editor of Politico moderating the session. Congressman Gus Bilirakis, the chair of the Parkinson's Congressional Caucus, who is the chief sponsor of the National Plan to End Parkinson's Act and the Healthy Brains Act, will be there, and C-SPAN will be televising. When C-SPAN looks around the room, I want them to see a full house. I want the message to be loud and clear that people with Parkinson's are tired of the disease, and they want actions to be taken to prevent future generations from ever bearing this burden of this debilitating disease.

Dr. Sneha Mantri 00:31:56
Wonderful. All right. Thank you all so much.

Dr. Michael Okun 00:32:01
Thank you. We really appreciate it.

Dr. Ray Dorsey 00:32:03
Thank you.