Ep. 28 | Hernan Posas, MD, Neurologist, SGMC Health

Transcript

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- Welcome to another episode of What Brings You in Today.

- I'm Erika Bennett.

- And I'm Taylor Fisher We wanna thank everyone for tuning into the podcast, and we hope if you haven't already, that you will consider subscribing to the podcast so you don't miss episode.

- And if you have any questions you'd like to submit for any of our experts to answer, you can do that at sgmc.org/podcast.

- Alright, today we are here with Hernan Posas, MD neurologist at SGMC Health. So Dr. Posas, what brings you in today?

- Well, I am a sufferer of migraines and I see patients regularly. Some follow up, some, and I still hear that. Well, when the weather changes, I guess sinus headache, unfortunately the patients point to the temple and we don't have sinuses in the temple, so we need to talk about migraines, headaches in general. We're gonna talk about the big guys and the dangers one as opposed to the regular chronic stuff.

- All right. Well let's start out by, tell us a little bit about yourself first. Maybe about your journey, how long you've been practicing, and kind of what intrigued you about neurology.

- Well, I was in medical school and there was a neurologist that came in and drew the image of the brain. The spinal cord facing away from us says, you guys are all dummies, you can't understand this. And unfortunately, I am one of these people, if you tell me it can be done, I'll go for it. And that was number one. Number two is my mother had migraines for years and years. This is before the new stuff is available. And then she developed a bleed from an aneurysm and died from it.

- Wow. - So it's, it's, it's been many years ago. Yeah. I was in my twenties, but that really cemented my passion, determination and so on and so forth. Yeah.

- Mm. Okay. So how long have you've been practicing? You know, you've had a very successful career thus

- Far. You've been I've been in Valdosta since 1993. Before that I did my residence in New Orleans, LSU. I was one of these guys that my father said, you're a professional student because I became a pediatrician and then a neurologist.

- You're a pediatrician too.

- Yeah. And then I went on and neuromuscular disorders at MCG, two years. I just do an emg. So it's one of those I could never be satisfied with. I thought it was, my field was too wide, so I was trying to narrow it down as much as I could.

- Yeah. And that's hard. I mean, to decide, I imagine when you're becoming a medical doctor deciding exactly what field you wanna go into. 'cause it is so many avenues you can

- Take.

- Right. So you're fascinated with the brain. 'cause someone said you can't do it.

- Yeah. Alright. Right. That was the beginning. And then the restless, the clinical stuff that came. I am a migraine neuro, I began having migraines when I was nine.

- And you had nigra migraines?

- I still have 'em,

- Yeah. Oh, wow.

- And had one this morning.

- Wow. Yeah. So did Taylor.

- Yeah. So that, let's talk about it. That is why I wanted to talk about this. It is because I am a migraine sufferer as well. And I think that there's a lot that is not understood about it. Right. And I'm still learning every day how to deal with them.

- So let's start with, you know, headaches first. So You get up the, the big issue is to split him into the dangerous headaches, meaning things that are atypical, things that can kill you. Like it did my mother. And the, the, the pattern is recognizable when a patient with migraine tells you, this is not my regular headaches. Whoever's listening to the patient need to jump because we, people in Montgomery, we know where it is. And we just go, yeah, I just have another one. No biggie. But when it's, when the patient's different, when the patient has fever, when you have loss of consciousness, whenever you have, well we in neurology call focal neurologic deficit, meaning weakness, that doesn't go away. And then paralysis. And then you have to worry about, oh, hold on, this is not part of the migraine. So you need to defer the studies. So you exclude what we call a secondary headaches. You gotta make sure it is done due to trauma, meningitis, encephalitis, infections of the brain and meninges or a malformation of the brain, either on the venous side, what we call the arterial venous malformation, AV mal or an aneurysm. Once you exclude those possibilities and then you're left with a primary headaches, this is what is extremely common in very disabling.

- And what causes a headache? Just a general, in generalized

- Regular headache. So what happens is that you get this, the brain is wrapped, and this piece of tissue is, is a membrane called the meninges. And the meninges have a lot of feedback, nerve endings to it. And that's what hurts. As a matter of fact, people say, my brain hurts. You can, in the Medical College of Georgia and University of Florida big centers, they can disturb you. They put the patient to sleep, to open the skull, open the meninges, and then they wake you up to cut the brain out and there's no pain, there's no sensation.

- Hmm.

- They do that in order to avoid in injury in the speech area, the motor area, and so on and so forth. It's a very sophisticated way of doing that stuff. But that's an example of how that is. So what hurts you is the nerves that end in your meninges, the wrapping of the brain.

- Wow.

- Yeah. That's where the pain comes from.

- Did not know that.

- Yeah,

- That's very interesting. So can you tell us, is that what happens during a migraine? Is what you just described, is the nerve endings or what happens during a

- Migraine? So, so the, the origin of migraines, the, the concept has evolved. It began with, and this was better clinical description from the 18 hundreds. There was a gentleman who described his own migraine and he saw the, they call him the fortification spectras, a high balut term for, he saw this flashing lights and he noticed that it began in the back of his field and he moved on. So he described it, he made drawings. This was then proven in the mid thirties in Harvard and in, in the west coast by a doctor called Al called the spreading depression of liao. And they, and then in Washington state, they did a PET scan, several people with migraine who had AARs. And it showed that that's exactly what happened. So there is, and then they went back and look, okay, why does that happen? Some of us have a genetic susceptibility to have this headache. So it doesn't happen to everybody. You have to have the gene, it's gotta do with electro abnormalities, calcium, magnesium. And as of 2018, well actually they started starting this stuff in 1982, but they finally approved the use medically for a set of peptides or proteins called calcitonin gene related peptide. That is a group of proteins that are expressed in the surface of the brain and the meninges, the blood vessels in the brain. And they're all the common denominator. They're all innervated by one nerve called the trigeminal nerve. When you have too much of that, the way I explain this is having a volume, if you have too much of the CGRP and then you get, tend to have migraines. So if you block those, you block the migraines. That's why you recently, they, as of 2018, so recently in medicine that is recent, they approved medications that are all CGRP blocking agents, a OBI Am, oic, Emgality, those are all injectable subq once a month. And then you have the tablet qta, and then you have IV vy eti. Before that, we used to use medications that were never study prospectively. They were all by the word, someone is using this medicine. Oh by the way, doc, the migraines got better. And then they started doing look looking back. And then that's how medications like Depakote, Topamax in dural, ZLA or Serline were approved because they found out. And then you look at the mechanism of action is, so the, one of the things that happened in migraines is the serotonin receptors. And before 1992, the only thing that would we would treat people with would be either antiinflammatories, goodie powders, for example, is aspirin. That's pure a hundred percent aspirin. It works because of non-inflammatory. There is. And then before that it was Fiori said, which beil mixed with either caffeine Tylenol or all of the above. The problem is that if you use too much of the as needed medication, you end up with overmedication headaches. But let's go back and define what is a migraine? A migraine

- Is. Yeah, that's about to say. 'cause I don't think, I think that's one of the one things. Yeah. I've never had a migraine. Yeah. I don't think, yeah, it's terrible. Yeah. So I don't want one.

- So a migraine is something, so you define it as, and there are clinical criteria, there's no test for you. You do is you do a clinic, you exclude the secondary headaches, The things that are dangerous, that can kill you, meningitis, encephalitis, et cetera. You, once you exclude that, you start looking at, so gimme the pattern. And that's why I emphasize to my patient, you gotta keep a diary. Tell me what happens when and how before, during, and after. So a migraine is a headache that the character can be pounding, throbbing, stab, accompanied by sense of it to light to noise and nausea. And the, the strict definition in adults is five or more headaches. So if you have five or more with any two of those, you can call it a migraine. And then there's another and about 30% of people that develop what we call migraines with aura. So you had to meet the previous criteria, plus you develop either auditory, visual or sensory changes that occurred to you either right before 15, 20 minutes before the headache or during the headache.

- And are they, are migrants common among?

- Yes. The incidence is 43% of the general population. Wow. As a matter of fact, before puberty, males and females are about the same. And then once pub hits, it triples in women compared to to men. It's gotta do with the estrogen. I

- Was,

- Yeah. That's a relationship between estrogen and the CG PS. For some reason, estrogen promotes the development of CDPs, huh?

- Yes.

- Yeah.

- Certain points in my cycle, I have more migraines.

- Yeah.

- So I, I do keep a journal. I do keep a, I have an app, I keep track of it and I, my symptoms in there. So that has helped me try to identify what my triggers are. Like today, as I was saying earlier, the barometric pressure is a little high, so that appears to be a trigger for me. So I'm trying to identify those triggers. I've been trying for years and I still am trying to figure out exactly which the pressure is not something you can avoid, but some you can avoid. Right?

- Yeah. So, so the big issue is how do you treat migraine? So first you have to define, make sure there's nothing dangerous. And then you start, a lot of people say, but how can I have a normal MRI normal CAT scan, normal test, and I have this headache. Because you gotta go back to the, in highfalutin term, pathophys meaning what causes it is the receptors on the meninges, they're very sensitive, et cetera.

- And you can't see that on any of those scans.

- No,

- Nothing. Yeah,

- Nothing. If you see something, you worry.

- Yeah. - So you want to have a negative workup and you

- Go - Check migraines and then you talk about treatments. So if they are less frequent than two per week, then you treated as needed. And this when you started using medications, like again, 19 nine, the reason I mentioned 1992, because 1992 was the year that the FDA approved the tryptans. These are serotonin blockers. The first one is sumatriptan, and then they began risotriptan, sumatriptan, et cetera. There's a whole lot of them. The problem is that they're vasodilators. So if you have basically constrict terms, sorry. If you have someone who has cardiovascular disease, which is common, especially in our side of the country, then they're contraindicators. So you can't use that. So you have blocking, so you still can resort to antiinflammatories because there's an inflammatory component there. There chemicals that are released when the CGRP get activated, it releases chemicals. One of them is inflammation. And that's why goody powders and anti-inflammatories work. The problem is, again, over medication, headaches is danger. And then if you have three or more headaches per week and then you start talking preventive or prophylaxis,

- How often do people typically suffer from migraines before they seek help?

- This is why I mentioned before, and I think it's nice that we're talking about this because I've seen many people who come to me and say, I have sinus headaches. And again, they point to the temple when we don't have sinuses there. As a matter of fact, sinus headache is unlike a migraine, a sinus headache is usually in the, either the forehead, the face, and it usually starts in the morning. And by 10 o'clock, 11 is gone. It's usually positional. Whereas in migraines, usually 2, 3, 4 o'clock in the evening, unless there are other triggers. And then you start looking at the pattern. That's the importance of keeping a diary.

- So knowing the difference between a sinus headache

- Yeah.

- Is important. Is that what they do when they like tap on you?

- They tap on your forehead

- Face when you get,

- So you do the, the, the, the sinuses, you know, you have an area here between, you know, just inside the, the, the forehead. If you press over here, if his sinus is sensitive, same thing down here. And then, I mean, I'm talking, people jump when you

- Do that, right? Hmm. I didn't know that. I mean, I know I've, they've definitely done that.

- Yeah. That's what they do.

- Turn that tapping. That's the purpose of doing that. So, so they, so, so, but how long do they typically wait before they come? I mean, they, they think they have sinus headaches and

- It's not coming in. So they're, well, in our time we have two complicated things. One is people don't want to hear that they have this condition. Two, there's not enough neurologists.

- Right.

- So, so you have a, but in, ideally if you try over the counter medications and things persist, three to six months is a reasonable

- Period. Okay.

- Yeah.

- Yeah. That's, I mean,

- Yes.

- Especially around here. I've, with the allergies being frequent and stuff, I'm sure a lot of people

- Right.

- Chalk it up to, yeah. Do allergies cause migraines in

- Any way? No. No. The the problem is that remember if you have biometric pressure changes, it's gonna be changing humidity pressure. So they're flowering. So you're gonna have flowers that come certain time of the year. Spring is another time that things happen. And that gets confusing.

- Yeah. - And there's the, so you have seasonal migraines, you have the menstrual migraines and you have migraines related to stress. Two, especially in teenagers, you know how teenagers need to sleep more physiologically need 16 to 18 hours of sleep. So the big issue is gonna be so they sleep, they don't get up to eat. So they skip meals, they sleep longer. That triggers a migraine.

- All right, tell me that again because I've got two boys and they are not teenagers out. My oldest will be 13 this month. And how, I mean, so say that again. How much do they need to sleep?

- Like they done about 16 hours of sleep.

- That is a lot of sleep.

- That's a long time. Yeah. That's why teenagers do what they do. They wake up, they're goofy. Yeah. And again, I'm a pediatric neurologist, so.

- Yeah.

- Yeah. And, and you see that it happens and that's why they try to

- Move. But they need to sleep to get that. Yeah. I mean to, because there a lot of things are happening in their body right now,

- In addition to the fact, and this is a, a metaphor, when they turn 13, they know everything. Yeah. They get horns and a tail with a forehead.

- It hasn't happened yet. I'm nervous.

- That is not the doctor talking. That's daddy of five kids.

- Yeah. Yeah. Okay. So sleeping and then, I mean

- Changes in sleep patterns, dietary habits, keeping meals. But also there are things in the food that we consume, for example, tyin from chocolate can trigger it. Oh yeah. Tyin gets converted in sero in, into serotonin. Thus remember what I told you was sumatriptan, it's a serotonin blocker. Mm. And that's what medications that are serotonin uptake inhibitors work for migraines.

- And I thought chocolate was always good for you. Like I thought chocolate was, it always says to make you feel

- Better. But remember is if you give me a bar of chocolate, I can guarantee you 20, 25 minutes later I wanna get a migraine. So I don't, yeah.

- What are some other triggers? 'cause that's a very

- Interesting, the trigger msg, monosodium glutamate. Glutamate is, is a chemical used in Southeast Asia for everyday use over here we use it to preserve. So anything's got, for example, I don't touch hot dogs because they have,

- They - Have to be preservative and they have a lot of,

- Do we, do we even know what a hot dog is? No. Do we know what's in hot

- Dogs? No, I don't. And then there's another one for those of that right age in the United States. Red wine is supposed to be good for you, another one. But they, they put sulfites in it.

- Yeah.

- And if you're sensitive to it, you're gonna get a migraine. Not because of the red wine, not because of the tanning, but because of the sulfites.

- Yeah. I've heard a lot of people say they can't drink wine 'cause it gives 'em a really bad habit. Well, they need to, but maybe it's, well, they

- Just, well they need to just get a wine from Europe. In Europe then use, they use very minimal. Or they tell you they do, but they don't use sulfites. And I have experimented with myself. I went to to Madrid and I tried wines up and down, expensive, middle, very expensive. I never had a migraine. And I had, at that time I had risotriptan, I traveled with a lot of rice, I was ready to experiment it. I never needed

- It. Wow. Well, it's very sweet. Wine gives me a migraine. Yeah. So I can't drink. That used to be what I would drink. I can't drink sweet wine anymore.

- Yeah. It is, it is a process of elimination. If I learning, I mean, I learned this and I, I I I, I share this with my patients because it's easier to share your stuff than imagine telling a teenager who's a teen full of health that he's gonna have to restrict what they do. Good luck with that.

- So drinking enough water is very important. Getting enough

- Sleep, that's

- Another hydration. Yeah. I know if I sleep too much, then I wake up with a migraine because over Christmas break, yeah. I slept in and I woke up almost every day in pain because I slept

- In that. That's the other part. So sleep changes, sleep patterns. So you gotta sleep the right amount for you. Like through my life, I sleep five and a half, six hours if I sleep less than or more than, and again, that's anecdotal medicine, but if you look across the board, changes in sleep patterns is one of the biggest trigger of migraine, especially teenagers. And I do see those in, they give you their look when you tell

- 'em. Well, I bet you see it more now too with children being on electronics.

- Right.

- And

- It's called social insomnia. Yeah, they're they're, they're coming up with a term because they stay up all night on the

- Phone. Yeah.

- It's called social insomnia. So instead of sleep, they're in bed.

- Right. They just can't go to sleep.

- They're just not sleeping. They're,

- My older one says he can't sleep in his own bed because he just can't. But he can sleep in his with because he's got a

- Tablet. No, you need to take it away. I

- Know, I know. Tell me, I

- You can take it away. This is when you put restrictions.

- Yeah. I mean, because he's gotta get all those hours of sleep.

- Exactly.

- He's never gonna get six hours.

- The the, the, the trick is remember how the grandparents, well at least my grandparents used, said, if you don't go to sleep, you're not gonna grow. Well it was thought to be in old wife's tail. Well, it comes to be that didn't study. And what happens, growth hormone is secreted when you go to sleep.

- Yeah.

- So tell you kids,

- Well that's, I do, I I already did on that, Dylan. If you don't go to, you're not gonna grow. That's when you grow. That's when you grow. You've got to sleep.

- No, but there's a physiologic they've done that. The study, the pattern, cortisol, you know, the stress hormone, the beta protein and growth hormone secreted when you go to sleep.

- Okay, well I'm gonna heard it straight from the doctor. So we're gonna be making some changes

- As far as Mike going back to migraines. So in 2018 finally got approved. That stuff that was studied since 1982, the CG R

- Ps, - They are three injectables, A OBM, Obi, Emgality, I'm not gonna tell you the generic name because they're too long and I not gonna do that.

- They're

- Not, they're not

- Generic. We won't remember it. So,

- And then there's the, we won't go to repeat it. There's the calta and then ti and then there are two as needed, NEC and rebi. So you use the first five preventive and then neuro took and rebi as needed. I thought it was gonna be the aunt of migraines. Well,

- I was gonna say, do you still get migraines? Do you They

- Know migraine know the problem is there are people who don't get better with that. And that's why in 2010, so let's go back in time, the sequences in 1992, you started using tryptans and then you gotta prove Depakote, Topamax, enderol, amitriptyline. And then, but that was not a hundred percent, you still have 70% efficacy. In 2010, they did a prospective study and bot toxin Taipei, that is Botox.

- But

- They are, yeah, all the brands, Botox, Dysport, and cine. And they did prospective, it was a very, well, it's the only medication that has ever been studied prospectively to see the efficacy side effects to our ability to treat migraines. And he was 70% effective. And the beauty,

- Where do you put the Botox?

- So the Botox for migraines, you have to stick the patients here,

- There, - There and then three injections in the temple.

- So almost everywhere you would go get it if you were getting actual Botox for cosmetic reasons.

- Well, no, you do the temples and do it back.

- Yeah. I mean, aside from

- This. Yeah. So, so one of the side effects that most women love is, oh my God, my forehead's be

- Yeah, that's what I was

- Gonna say. Yeah, yeah, I know the but, but as far as efficacy, the beauty of Botox is I don't worry about the person being hypertensive diabetic heart disease on any kind of medication because I don't worry about it. What you do is you inject, you make sure there's no bleeding, you stop it. Even people on Eliquis, Prax, Coumadin, et cetera, you just pressing it. It may take you longer to do it, but you do it. But it's extremely effective. And the beauty of it's, I don't worry about any systemic side effects.

- Right. - Whereas the cgrp, a big problem is the G rrp. Those, those proteins polypeptides are suppressant and gastrointestinal tract. So if since you're reducing the volume of those, you end up getting very constipated. That's a side effect.

- Everything has its

- Yeah.

- Pros and cons, right? Yeah.

- I use the, the, the metaphor I use is the triangle of therapy. The top of the triangle is efficacy. You look for tolerability and that's where you have to adjust the dose. You start low and build it up. And then side effects are the ones that you go, you're allergic, you have this and then you stop.

- Oh, for, since we talked about pediatrics a little bit, and I know a lot of our listeners are women that are, have children, they're in that age group. What are other common things that you see in your neurology office amongst children in that

- Pediatric? Oh, so, so you can see what you see in adults. You see epilepsy, you can see ticks. You see behavioral autism is, is more common now than it was when I was growing up. For example, I don't remember having, maybe I had one classmate my whole life and, and since I came here, if I had one diagnosis, maybe once of a six month, it was a miracle. Now one out of every 84 l born in in the state of Georgia may develop autism.

- Yeah. What do you,

- I mean Yeah, but epilepsy is, is very common. Okay. In in talking about different subject epilepsy, the first 20 years of life, the most common cause is family history. And the last 20 years of life that is 60 plus 20 is usually stroke tumors and so on. If you see anyone with epilepsy in between, you have to look for trauma, you have to look for tumor, you have to dig a little harder because that's atypical.

- So would you say that, what's the most common thing you treat in your practice? Is it migraines or is it something else? Or do you just have a

- Well there's things because of subspecialize in neurology, that's just because of what I did. Migraines, but also neuropathies because of my subspecialty. That's what I did in neurology, neuromuscular disorders. And then you have uncommon conditions like lugar's disease. So on nootropic lateral sclerosis, this is sad disease. Or you can see myasthenia gravis. But neuropathy is a very, very common because in our population, us baby boomers we're a hundred million of us. We are typically diabetics. We have autoimmune disorders and that leads to a neuropathy. And then we have here, and I'm not blaming the docs, is there are people who have cancer, they have to be given chemotherapeutic agents. So as a result of that ends up with a neuropathy. And it's not the doctor's fault. This is,

- Yeah, no, we actually just talked about that in our episode that with Dr. Hayes. 'cause we're talking about tingling of the skin and when your leg goes numb, you know, just in general.

- And

- That is a neuropathy. Yeah.

- Now there's another factor that plays role and needs to be spoken to make a difference. So it's a split. So you have neuropathy as someone who has a cause like, and it's about 80% of the time we find a cause. 20%. No matter what you do, you can't. And you can't go as far as doing skin biopsies and so on. And then there's another group of people that everything is negative, but they have the symptoms of numbness, stinging, urge to move your feet, stump your feet at night, go to bed, you rest or you go lower your bed and and you what? My feet come alive. It's a condition called restless leg syndrome. And there are two kinds. One is primary. This is the one that your children come to you when they are 6, 7, 8, 9, 10 years old.

- Yep. - Mama. My legs hurt. They call it, they go pain. I

- Remember that. Pain

- Is not growing. Pains is restless like

- Syndrome. Yeah.

- Those kids who began doing that now have grown and they're in the twenties, thirties. And they tell you the same symptoms I have now as what I had when I was a child.

- Because it wasn't growing pains, it was rest syndrome. No it

- Was not. It ISS restless like

- Syndrome. What is so growing pains, it's

- Not is - But what is growing pains? Is there a growing

- Pain? No, it's just leg syndrome. Okay. It's just a misnomer.

- Okay. So people just called it growing pain. Yeah.

- Parents were tired sleep at three o'clock in the morning. Oh my god. So they get alcohol right here and I me rob you, you have growing pain, go to sleep. Yeah. But, but in retrospect, they've done studies. It's another thing when I first came here and I'm in diagnosis, I had docs call me crazy, et cetera, et cetera. I'm like, no, it's real. It, it relates to the me metabolism of iron. So if you look at that, look at iron deficiency.

- Mm, yeah, no, you're right. No, no, I did have that. And then I did have an iron deficiency, so

- I had to take iron. That's the root of the problem is not growing pains is iron deficiency. And then you look for other deficient, B12 methylmalonic acid itself. There's a lot of chemical interaction. And what happens is the function of the nerves, iron is a cofactor. If you don't have enough of it, you're gonna, the nerves are gonna misfire fire.

- Oh, interesting. It is that, so we've had, we've been talking about a lot of wipes tails and just different things in general, but that there's a source and how and how people, how our parents told us stuff and then we just believed it. Yeah. But the growing pains is interesting to me just be because of that. My son also had, he was having pain in his knees and initially I just assumed, oh, it's growing pains. And then it turns out like with his age, he had a particular condition flourished, his

- SCO slaughter disease. But that's different. That is, that is the growth. You know the, it is called TIA tubercle.

- And

- As it stretches, because you're getting gro, it hurts.

- Yeah.

- And another part of it is the he.

- But it just makes me think how many actual medic medical conditions do we just kind of ride off because we've heard weird things come down generation. So we're here to fact check those for you, for our audience.

- So

- It's fine.

- That's interesting. So we're gonna wrap up, but I just wanted to see if you have any suggestions or recommendations for chronic migraine.

- According migraines, go to see a neurologist to start prevention, but please, please, please. There I said it three times.

- Three pleases.

- Keep a diary.

- Yeah.

- You'd be surprised I can't

- Do that.

- How much things you find about your headaches Once you keep a diary, you find things about yourself, then you go, oh my god. That's how I found out that in my, again, it is anecdotal, but it's, this goes across the board. If you look at the Academy neurology website, as a matter of fact, I recommend for them to, I handed seeds as an acronym for sleep, exercise stress, et cetera. Dietary stuff. And a diary.

- Yeah,

- It's, it's part of that because you find out things that if you can avoid them and then all of a sudden you don't have to worry about the migraine. Now is it always a hundred percent No. But at least you reduce the frequency.

- Yeah. All preventative. Yes.

- And being intentional.

- Yes. I think those are great tips. And this has been a great episode. Thank you Dr. Posas for coming in today.

- You're welcome. My pleasure.

- You did great. It

- Was nice talking with you again. I hadn't seen you since, I think kind of when you joined on with SGMC. Yes. With our physician network. It's been a couple years now and, but

- We, we've been, we've been busy. We're trying to recruit neurologists. They don't want to come here. So if you have a relative, a friend,

- We need all of the

- Neurologists, a law, law, it doesn't matter. This is a good place to practice because it's a family town.

- Yeah,

- Absolutely. Selling point. I came here because at that time I didn't have, well, I had two kids from a previous book, a previous volume. And then since then I've had three more. So I got taller of five. And it's a wonderful town. I, I can't complain.

- Yeah. Well good. Well thank you for everything you do.

- Oh, you're welcome.

- Yes. And thanks for joining us today. And then of course, thank you to everyone listening and tuning in, and we hope you'll continue to watch our future episodes.