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Today's clinical providers and health care systems

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need a strategic partner that is focused on

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the evolution of health care delivery.

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At Surgery Partners, we are redefining the health

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care industry

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as a nation's leading independent operator of surgical

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facilities and ancillary services.

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With an extensive presence spanning over 180

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locations nationwide,

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our commitment extends beyond healthcare.

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It's about fostering successful partnerships

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that enhance the quality of care in the

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communities we serve.

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Surgery Partners is more than an operator or

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service provider. We are your strategic ally committed

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to transforming healthcare delivery.

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Learn more at surgery partners dot com.

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This is Alan Condon with the Becker's ASC

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podcast, and I am delighted to be joined

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today by doctor John Paloza,

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an orthopedic spine surgeon with Midwest Orthopedic and

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Spine Specialists. And, doctor Paloza, a real pleasure

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to have you on, make your debut appearance

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on the Becker's podcast today.

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I'd love to turn the floor over to

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you to tell our listeners a little bit

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more about your role and your background,

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as well as your practice.

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Well, thanks, Alan. I appreciate you having me

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today. I've been in practice for over 30

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years, done fellowships in sports medicine and spine

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surgery.

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And then I've had, quite a bit of

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practice,

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mostly in private practice, but also training residents

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and fellows and then also postgraduate

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surgeons and all the various techniques.

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Started out with a highly complex surgery, deformity

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surgery, tumors, infections and stuff and then did

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more and more degenerative disc disease and that

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led

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to pioneering

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minimally invasive surgery. So, we have patents in

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terms of different implants and

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retractors

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and ways to put it in techniques and

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such.

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So we've been I've been involved in the

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minimally invasive since the late '90s till today.

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Then in the early 2000s, we were involved

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with the FDA on these studies for disc

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replacement

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devices and we've done a lot of FDA

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trials infusion, disc replacement, minimally invasive surgery,

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etcetera. So, we've got a quite a robust

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experience with it.

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So, what happened over the years is that

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we got better with minimally invasive, we found

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that we could do more things with it.

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We could not only do, we'll say, a

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microdiscectomy

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or laminectomy, but actually put metal into the

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spine to little tubes.

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And then,

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the technology advanced to have

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intraoperative

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CT navigation

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and that made everything much more accurate so

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that we could even get

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to smaller and smaller incisions.

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So basically, minimally invasive means that you don't

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damage the normal tissues, you just address

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the problem like the we call that the

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pathology.

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It's akin to,

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I used to describe it,

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open surgeries like a World War II bombing

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run where you just drop bombs everywhere and

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sometimes you hit the target and a lot

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of times you don't versus precision guided bombing

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that you see today,

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decompression,

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our burs,

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the,

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putting in metal were very, very precise.

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And that's made everything quite a bit better.

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So what we eventually did is we start,

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applying minimally invasive to, all kinds of things

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such as deformity. We use minimally invasive techniques

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to fix curves in the spine. We can

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actually do sometimes,

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depending on the case, a tumor and remove

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it. We can,

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put in,

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disc replacements

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through just small incisions.

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And what that has done has expanded our

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ability to take care of spine problems

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with very little

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pain from the exposure.

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So people get better faster and much more

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predictably.

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So then we were able

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to take a lot of these kind of

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cases outside of the

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purview of a hospital

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into a surgery center

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environment.

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So surgery centers, particularly if they're

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geared

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to say spine surgery,

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everybody, the staff,

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doctors, the equipment, everything is geared to just

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do spine surgery and do it at a

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very high level.

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So that means we get

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very predictable results

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with very little trouble for the patient and

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make it very convenient for them.

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And one of the things that struck my

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attention years ago is we had a friend

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that I did a microdiscectomy

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on and his wife drove him up to

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our surgery center, came up, we had a

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report to cashier where he got out of

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the car, went into the center,

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signed in,

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went to the back, got his gown on,

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an ID, talked to anesthesia, talked to me,

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talked to our nurses,

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went back to surgery, had the microdiscecting

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minimally invasive techniques, took about 30 minutes,

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woke up, walked around feeling great and then

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left about an hour later.

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And his wife described the whole experience for

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them as like

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going to meetings to the makeup counter and

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getting your shirt cosmetics,

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dropping her car out at the the concert

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at the valet, getting her cosmetics, and then

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leaving. It was that simple.

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Not scary at all.

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Not very painful, his leg pain went away

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and he had a very good result. So

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that's the kind of thing you can do

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with the minimally invasive techniques with the high

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end technology in a center

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that is geared for

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without all the baggage of a big hospital.

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Yes, it's fascinating

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to hear and I guess just your own

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experience particularly within this realm, like you said,

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I've

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been in the field in a minimally invasive

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in these. Fascinating to see how some of

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that surgical technology has evolved over the last

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couple decades

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and what potentially lies ahead for the future

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as well. Kind of just following up on

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your story there. You know, it wasn't too

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long ago where

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patients who undergone spine surgery would usually be

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2, 3, 4 days in a hospital.

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Now, like you said, it's possible to do

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a lot of these complex spine cases with

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patients up, ambulated, out the door in an

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outpatient setting in just a matter of a

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couple of hours. I guess, with that said,

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when what are the key

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kind of surgical technologies that you see reshaping

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the future of minimally invasive spine care, Doctor.

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Palossa?

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Well, generally we make

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incremental improvements. It's not like we have a

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eureka moment, but every now and then

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the accumulation of

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incremental improvements

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comes to something big.

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I think one of the big things

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was to be able to do

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surgery through small tubes and now even endoscopic

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tubes.

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Then the other thing was the ability to

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navigate the spine in real time in the

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operating room and that was the CT navigation.

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To go further on that, now there are

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robots.

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The robots are dependent on the CT Navigation,

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but the robot itself can fire in

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can place the metal. And now, you know,

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the ultimate goal is have the robot be

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able to do the decompression part 2 controlled

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by the surgeon

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as an adjunct to the surgery, basically a

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tool that the surgeon would use.

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In addition to that, a whole lot of

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improvements have been made in

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the biologics

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of how we get tissue to heal.

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Also the metallurgy in our implants

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that they can actually interact with say the

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bone in a fusion to create,

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to turn on the bone cells to make

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bone.

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So then we don't have to take a

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bone graft

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and because of the surface treatments or the

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internal architecture of the implant,

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the chance that we're going to, you know,

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get a good solid fusion are now approaching,

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you know, almost a 100%.

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So that creates

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really good certainty for a good result.

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The other thing has been the improvements in

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disc replacements.

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The first disc replacement was, designed in Germany

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in the eighties,

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and so that eventually was brought to

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different iterations of that design was brought to

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America in the late 1990s, early 2000s

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and then there's been improvements since then over

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the years

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to where the implants we're using now.

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We also have done these level 1 studies,

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randomized controlled trials

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for the FDA.

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So we have lots of data,

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not just,

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you know, a couple weeks data. We have

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up

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to 10 year data comparing disc replacements, fusions,

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and even, you know, in our European colony,

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colleagues, we have, like, 20 year outcome data.

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So when people

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talk to us us about what's likely to

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happen,

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we really do have a robust literature to

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draw on.

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The spine literature

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is probably the best literature

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in orthopedics and neurosurgery in terms of level

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1 studies

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to answer the different questions.

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So it's an exciting place to be as

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a doctor,

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because we have all these tools, plus we

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have outcome data, and if you use the

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tools the way they were indicated, to get

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a good outcome.

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So as a doctor then,

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you can take all that, improve your skills

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and say minimally invasive surgery and then do

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the surgery

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in a,

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a venue

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that is actually

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conducive to a very good patient experience.

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So what we're trying to do is take

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the fear out of spine surgery because of

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the uncertainty

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to where it's very certain that we'll get

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a good result and not very painful

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and very convenient too.

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It's fascinating to hear just

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all the technology that you mentioned there. Kinda

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touched on the the evolution of endoscopic spine,

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robotic spine surgery. Touched on biologics there.

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The 10, 15, 20 year data that now

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we have before disc replacements.

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I'm curious to hear, doctor Fallows, when you

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think about the future of the field, whether

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from a technological standpoint or just the spine

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field more broadly,

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what what are you most excited about?

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Well, I think we're in a transition from

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most of the,

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the tools were fusions for a long time,

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and now it's kinda turning over to disc

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replacement. And the thing that's important about disc

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replacement for patients

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is that it maintains the motion of your

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spine, so you don't have the stiffness problem,

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but biomechanically

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it helps prevent

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the level next to the surgery from becoming

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diseased or adjacent level disease. So, infusions, everybody

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worries about what happens to the next level

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because forces are transferred. That's much less of

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a problem,

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although not totally eliminate, but much less of

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a problem

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with this replacement.

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So, the chances of having another operation at

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the next level is, you know, either

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1 5th to 1 third that of a

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fusion.

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So, that's a big step. So, that we're

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in that transition and I think the next

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transition probably in

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5, 10 years from now will be actually

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regenerative medicine where we're actually

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able to help heal the tissue

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with cellular

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techniques.

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There's a study we're involved now that actually

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uses

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disc cells that are expanded

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in culture

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and then mixed with a carrier that is

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injected into the disc.

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That has been presented at meetings, so I

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can talk about it, but it's part of

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a FDA trial, it's just finished Phase 1.

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So Phase 1 basically,

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is small numbers of patients. This is going

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on to Phase 2, Phase 3. This may

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be, if everything goes well, available for patients

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in 4, 5 years from now, but there's

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another study using proteins that block the inflammatory

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cytokines in the disc to help preserve the

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disc too. So there's a lot of different,

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strategies and studies going on that I think

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in the future, we may be also able

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to offer

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a regenerative

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option

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as well as fusion or disc replacement or

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just make more room for the nerves, which

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00:12:23,129 --> 00:12:24,190
is called the decompression,

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all done through little tiny incisions.

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Now

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this applies to mainly degenerative disc disease, things

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like tumors and scoliosis and other, they may

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have a different solution set. But the main

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thing is by keeping abreast of all these

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things, we are able to understand

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the spine and predict what's going to happen

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with

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the intervention at the moment and help predict

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what's going to happen in the future too,

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so that we can give the best solution

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to the patient

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for their individual

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problem.

345
00:12:57,495 --> 00:13:00,054
Yeah. Absolutely. It's so fascinating to hear. So

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many studies that you've mentioned as well from

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the regenerative medicine side in terms of what

348
00:13:04,615 --> 00:13:06,570
disc cells might even stem cells might be

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00:13:06,570 --> 00:13:08,009
able to do in the future for spine

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surgery or or nonsurgical, excuse me, in the

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future as well. I wanted

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to finish out our conversation today by just

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getting a little bit of an insight into,

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00:13:18,134 --> 00:13:20,934
your own practice, doctor Palossa. I guess, when

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you think about the next year, the next

356
00:13:22,855 --> 00:13:23,514
2 years,

357
00:13:23,894 --> 00:13:25,335
where are the key areas? How are you

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00:13:25,335 --> 00:13:26,394
thinking about growth?

359
00:13:27,415 --> 00:13:27,915
Well,

360
00:13:28,695 --> 00:13:29,835
complicated question.

361
00:13:30,909 --> 00:13:34,350
The bigger problems in medicine is insurance and

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00:13:34,350 --> 00:13:34,850
reimbursement

363
00:13:35,149 --> 00:13:37,629
and those things. And that, although we tend

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not to think about that as doctors so

365
00:13:39,470 --> 00:13:42,269
much, it's having an effect that, if you

366
00:13:42,269 --> 00:13:43,570
can even do an operation

367
00:13:44,165 --> 00:13:46,165
And and not from the technical part of

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00:13:46,165 --> 00:13:48,644
it, but if you're allowed to, how do

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you afford all these wonderful things? Because somebody's

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00:13:51,125 --> 00:13:52,184
gotta pay for it.

371
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So

372
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the idea is to

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make it

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by putting in a venue, a less expensive

375
00:13:59,950 --> 00:14:01,409
venue where you can negotiate

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00:14:02,110 --> 00:14:05,089
with, patients and vendors and insurance companies

377
00:14:05,549 --> 00:14:07,089
to get the cost down

378
00:14:08,029 --> 00:14:09,230
so that you can offer

379
00:14:10,110 --> 00:14:12,044
pass those savings on to patients. So

380
00:14:12,684 --> 00:14:14,225
there are a couple of things afoot

381
00:14:15,084 --> 00:14:17,325
to do that. It's usually, you know, the

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00:14:17,325 --> 00:14:19,004
business guys are very good at that, how

383
00:14:19,004 --> 00:14:20,065
to manage costs,

384
00:14:21,004 --> 00:14:22,144
but that's the biggest

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00:14:22,684 --> 00:14:23,184
issue.

386
00:14:23,565 --> 00:14:26,044
One thing we're doing is we're also getting

387
00:14:26,044 --> 00:14:27,024
involved with

388
00:14:27,459 --> 00:14:31,059
a more of a concierge or cash pay

389
00:14:31,059 --> 00:14:31,959
business where

390
00:14:32,500 --> 00:14:35,320
we can actually present to the patient exactly

391
00:14:36,259 --> 00:14:38,659
what's wrong, how we would deal with it,

392
00:14:38,659 --> 00:14:40,379
how to pay for it, put in a

393
00:14:40,379 --> 00:14:40,486
less expensive venue so that those cost savings

394
00:14:40,486 --> 00:14:40,659
are passed on to the patient that they

395
00:14:40,659 --> 00:14:41,159
can

396
00:14:42,075 --> 00:14:43,995
patient that they can actually afford it afford

397
00:14:43,995 --> 00:14:44,656
it. So if they get denied by Medicare

398
00:14:44,656 --> 00:14:45,105
or government or or insurance company that we

399
00:14:45,105 --> 00:14:46,105
can do something

400
00:14:54,509 --> 00:14:56,049
that we think works best

401
00:14:56,429 --> 00:14:57,889
at an affordable price.

402
00:14:59,309 --> 00:15:00,830
Yeah. I think that's one thing that I've

403
00:15:00,830 --> 00:15:03,230
heard at a recent ASV event as well.

404
00:15:03,230 --> 00:15:03,870
A few,

405
00:15:04,350 --> 00:15:07,870
independent spine practice or orthopedic practices like yourself

406
00:15:07,870 --> 00:15:10,384
are also go going down that pathway, that

407
00:15:10,384 --> 00:15:12,165
concierge or cash pay business.

408
00:15:12,945 --> 00:15:15,024
Certainly interesting way to kinda combat some of

409
00:15:15,024 --> 00:15:17,105
these challenges and no doubt with the insurance,

410
00:15:17,504 --> 00:15:18,644
sector as well.

411
00:15:19,184 --> 00:15:21,504
Doctor Peroza, it's been a a real pleasure

412
00:15:21,504 --> 00:15:22,786
to have you on the podcast first and

413
00:15:22,786 --> 00:15:23,340
foremost. It's fascinating.

414
00:15:24,120 --> 00:15:26,200
Can I get your perspective on the spine

415
00:15:26,200 --> 00:15:28,200
technology that you're watching, that you're excited for

416
00:15:28,200 --> 00:15:30,460
the future, also how you're looking at practice

417
00:15:30,679 --> 00:15:31,659
growth as well?

418
00:15:32,279 --> 00:15:34,840
Really, really enjoyed the conversation. I certainly learned

419
00:15:34,840 --> 00:15:36,779
a a lot, and no doubt our listeners

420
00:15:36,840 --> 00:15:39,054
did too. I really, really enjoyed it, and

421
00:15:39,054 --> 00:15:40,254
I look forward to connect with you again

422
00:15:40,254 --> 00:15:41,075
down the line.

423
00:15:41,535 --> 00:15:43,154
That'd be great. It was a pleasure.

424
00:15:43,774 --> 00:15:44,995
Thank you very much.