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Welcome to Live Well with UCI Health.

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My name is Gina Grad with Alt 98.7

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and iHeart Radio.

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And today I am here with someone

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very, very special.

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Doctor Ann Ly, board certified

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UCI Health Neurologist

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who specializes in the diagnosis

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and treatment of movement disorders

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such as Parkinson's disease,

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ataxia, tremor syndromes and dystonia.

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Doctor Ly, welcome.

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Thank you so much for being here.

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Thank you so much for having me.

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You know, this is

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this is a big deal for us

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because I am the layperson.

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You are the expert, and I'm here

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to just be filled with your knowledge.

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Oh my gosh.

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Thank you. No Pressure. That is so kind.

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So let's just start at the very,

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very beginning.

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What is an essential tremor?

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How would you how and how common is it?

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Like, just explain that to us.

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Well,

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thank you for throwing an easy question at me.

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Yeah, sure.

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So let me kind of

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put my professor hat on. Please.

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And tell you a little bit

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about essential tremor.

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So it's actually one of the most common

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movement disorders that we see in clinic.

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So I would say in the general population,

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you see it about 1 to 2% of the time.

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And if you look at patients

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above the age of 65, it goes up to about 6%.

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So it's quite prevalent.

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Really?

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It's its own primary neurologic disorder.

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So we actually don't commonly see

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it being associated

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with any other neurologic conditions.

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So it's its own standalone.

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So the basis of diagnosing it

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is that the patient is usually

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you know, complaining

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of brachial onset of tremor saying

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meaning both arms are affected.

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Usually, within the first three years of each other.

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And they say that it's very disabling,

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especially with

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sustained postures or different actions.

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So would you say this is more like

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when people notice their hands are shaking?

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Or how does it manifest it

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when people are like,

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oh, I should go see somebody?

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Yeah.

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So the most common complaint is,

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hey, I'm trying to eat something

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and my hands are shaking. Okay.

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or my handwriting is not the same anymore.

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And this is kind of the most common

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first complaint that we hear.

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But essential tremor goes beyond the arms.

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We have seen

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it affect people in the legs

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as well as their voice

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and their neck as well.

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And then in a good portion of the patients,

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it runs in the family.

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Really, so this is this is not a fluke.

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This is usually a genetic

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has a genetic component.

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It has some sort of hereditary

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component to it.

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That's sort of the basis

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of what you cover.

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And I'm sure the treatments are

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I would imagine vast because this is a

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there's there's just a lot going on

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and it

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affects a lot of

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different parts of the body.

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But what kind of treatments do you

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do you typically see,

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do you typically recommend

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or is there a typical

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when it comes to something like this.

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Yeah.

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So it's quite a wide

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array of treatment modalities.

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Yes, that’s what I figured.

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The first line is pills, right?

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Sure.

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Easy easy to give to patients.

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There's a

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quite a few that are FDA

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approved for essential tremors.

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One is called propranolol

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and the other one is called primodone,

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which are usually our first go to,

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which could be

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a little confusing for patients

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because they sound kind of similar. Right.

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They're both started with PR,

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but they do

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require a slow up

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titration of the medication.

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So the patients,

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you know,

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have to stick with it

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and they may not feel benefit

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in the very first couple doses.

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So they have to slowly,

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gradually increase the dosage

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until they get therapeutic benefit.

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And usually how long does that take?

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Usually within a couple of weeks.

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But I would say most of the clinical trials

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have shown that they have

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about a 50% reduction in tremors.

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Oh wow.

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So it's not usually complete.

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Okay.

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And then on top of that, you know,

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they come with their own side

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effect profile.

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So some patients

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may complain of some nausea, some dizziness,

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and some patients are just not candidates

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because they have liver issues

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or cardiac issues or even asthma.

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That would kind of exclude them

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from the treatment.

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Well, and I would also imagine

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if because, you know, guilty

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when it comes to some things,

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it's like, look, I have side effects.

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It's been a couple of weeks.

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I'm not seeing any improvement.

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I'm just not going to do it anymore.

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Yes.

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They don't know how close they are

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to getting the results

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that they're hoping for.

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Yes.

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And, you know,

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sometimes the side effects

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are more debilitating

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than the tremors themselves.

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So I completely understand

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when our patients don't feel

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like they can continue

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with these modalities.

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Right.

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But there are other modalities

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that have been explored.

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So patients have worked

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with occupational therapy,

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to help

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with different compensatory mechanisms

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or different weighted tools

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that can help suppress the tremors.

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Oh.

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Yeah

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Interesting. Okay.

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So this is where I start asking you

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questions like I'm a kindergartner.

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So when you talk about

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this is a neurological issue.

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But then you can work

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with an occupational therapist

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and say let's say it's in our hands.

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So what benefit

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would I really get from that,

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if it's coming from my brain.

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Yeah.

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So you know the basis

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let me kind of backtrack a little bit.

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Please.

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The basis of essential tremor

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is that there are these

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abnormal pulsatile circuits

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that are coming from our balance center

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Pulsatile circuits. Yeah.

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Yeah. So they're coming from the cerebellum.

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They're kind of going straight

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to this area of our brain

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called the thalamus,

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which is responsible for fine

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motor movement control.

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And so due to these abnormal circuits

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that are being pulsed,

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we get these oscillatory movements

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as a result.

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So although it is from a central generator

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sometimes having something periphery

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in the periphery

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suppressing it, that can just help calm

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calm, calm it down to some extent.

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So for example,

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would that be like me

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having a stress ball in my hand

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or something to do with my hand

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while this is happening?

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Or this is something that really does

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cut down on the tremors themselves?

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I think it's more of

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if you think of earthquake technology.

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Sure.

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So that, so as the earthquake

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happens, it kind of oscillates.

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And then the buildings are equipped

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with basically anti-oscillatory

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gyroscopic technology.

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Right.

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So sometimes the weighted material

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or certain tools can help with that.

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Oh...

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That’s actually another segue to

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other treatment modalities

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as there are biotech companies

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who have worked on different gloves,

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who have that kind of gyroscopic technology

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Wow.

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or some sort of nerve stimulator

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in the wrist to just calm down the tremor.

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We are living in the future.

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Yeah.

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I mean, it's so funny

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whenever I see movies of, like,

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old hospitals, like,

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you know, The Godfather, I'm just like,

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thank the Lord that we live now when I do.

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And we have all of this

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incredible technology.

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And that makes me curious

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about the MRI guided stuff.

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Now, when I think of an MRI,

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I think of like,

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just, you know, in layman's like,

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you know, oh,

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I'll put all the... they’ll slide me in

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and they'll figure out what's wrong.

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And they slide me out and I go home.

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But it does so much more. Right.

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Can you tell me about that?

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Yeah. So now we're going into the realm

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of what we call advanced therapies.

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So what I just told

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you were all kind of first-line.

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Right. The pills...

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the adjunctive therapies

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Right.

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And so then now we move to the realm

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of advanced therapies. 

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Okay.

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There are two.

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So the first one is deep brain stimulation.

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And that has been around

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for for longer than this

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MRI guided focused ultrasound.

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So giving you a little bit about that one first.

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Please.

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DBS.

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Yes.

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You know, starts

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with a battery in the chest.

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Okay.

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So, it's

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kind of like a pacemaker for your brain.

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Wow.

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It delivers electrical currents

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to this deep part of the brain

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called the thalamus that we talked

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about where the circuits are affected.

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And by doing so

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these currents can help control

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this abnormal circuitry.

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But that requires implantable hardware.

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And so now we move on

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to another advanced therapy

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that has been around for a while,

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but not as long as DBS, called

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MRI guided focused ultrasound.

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I'm going to give you

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a little bit of history.

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I'm ready I want it give it to me.

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So for a while

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they had studied open brain surgery

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using radiofrequency ablation.

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So they would actually do

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open brain surgery and use radiofrequency

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waves to cause a lesion

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in the brain in the circuit.

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But then scientists are thinking,

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why do we need to open up the brain?

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There has to be a better way.

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Right. We're talking about radio waves.

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We should be able to

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just leave the skull intact.

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Yeah, yeah.

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So,

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they found out that they could use

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ultrasonic waves instead.

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And then with in conjunction

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with an MRI machine,

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they're able to really localize and converge

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very specific

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ultrasonic waves

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to a specific part of the brain.

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And that causes a lesioning effect

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and it ablates that part

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that could be causing

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the abnormal circuitry.

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Can I ask a question? What's an ablation?

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An ablation, okay. So...

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Told ya.

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It's basically

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when you cause a permanent lesion.

00:08:09:00 - 00:08:09:16
Okay.

00:08:09:16 - 00:08:10:05
Somewhere.

00:08:10:05 - 00:08:12:21
So I think a really good parallel

00:08:12:21 - 00:08:14:19
would be in the cardiology world.

00:08:14:19 - 00:08:15:22
Okay.

00:08:15:22 - 00:08:17:01
It's different technology,

00:08:17:01 - 00:08:18:08
but a lot of patients

00:08:18:08 - 00:08:19:10
in the cardiology world,

00:08:19:10 - 00:08:20:12
they have arrhythmias.

00:08:20:12 - 00:08:21:09
So our specialists

00:08:21:09 - 00:08:23:17
who focus on electrophysiology

00:08:23:17 - 00:08:26:01
and they ablate the abnormal circuitry

00:08:26:01 - 00:08:27:19
in somebody who has an arrhythmia.

00:08:27:19 - 00:08:28:07
Okay.

00:08:28:07 - 00:08:29:14
So similarly we're

00:08:29:14 - 00:08:30:23
using a different technology,

00:08:30:23 - 00:08:32:16
but to also cause an ablation

00:08:32:16 - 00:08:35:05
or a lesioning effect in that area.

00:08:35:05 - 00:08:36:17
So walk me through it

00:08:36:17 - 00:08:38:15
because this is so much harder

00:08:38:15 - 00:08:39:17
for me to wrap my head around.

00:08:39:17 - 00:08:40:14
When you're

00:08:40:14 - 00:08:41:15
there is like you said,

00:08:41:15 - 00:08:43:00
there's hardware, hardware, hardware.

00:08:43:00 - 00:08:45:06
And now we're just like, send the waves.

00:08:45:06 - 00:08:46:23
So how do we do that?

00:08:46:23 - 00:08:48:06
And how do we know it's working?

00:08:48:06 - 00:08:48:21
I mean, it's

00:08:48:21 - 00:08:50:12
I feel like this is like witchcraft.

00:08:50:12 - 00:08:52:19
Like, how do we know it's working?

00:08:52:19 - 00:08:53:09
Yeah. So.

00:08:53:09 - 00:08:53:23
Well, of course,

00:08:53:23 - 00:08:54:03
you know,

00:08:54:03 - 00:08:55:05
before we even start

00:08:55:05 - 00:08:56:11
to even talk about that,

00:08:56:11 - 00:08:58:15
we usually have a very intense

00:08:58:15 - 00:08:59:14
screening process.

00:08:59:14 - 00:09:00:01
Okay.

00:09:00:01 - 00:09:01:12
We walk our patients through,

00:09:01:12 - 00:09:04:01
you know, their different co-morbidities,

00:09:04:01 - 00:09:05:21
you know, things that have been affected

00:09:05:21 - 00:09:07:23
from the tremors, what their goals are,

00:09:07:23 - 00:09:10:14
what their lifestyle looks like. Right?

00:09:10:14 - 00:09:11:15
Because certain lifestyles

00:09:11:15 - 00:09:12:17
may not be fitting for one

00:09:12:17 - 00:09:14:11
treatment modality versus the other.

00:09:14:11 - 00:09:15:11
Oh yeah.

00:09:15:11 - 00:09:17:06
So if they are a good candidate

00:09:17:06 - 00:09:20:06
for a focus ultrasound ablation, then they

00:09:20:12 - 00:09:22:16
it is a same day procedure.

00:09:22:16 - 00:09:23:14
Unbelievable.

00:09:23:14 - 00:09:24:19
Our surgical team

00:09:24:19 - 00:09:26:13
walks you through the whole thing

00:09:26:13 - 00:09:29:19
and you lie down with this really nice, cool

00:09:29:19 - 00:09:32:19
looking helmet to keep your head in place.

00:09:33:04 - 00:09:35:22
And the patient lies down in an MRI machine.

00:09:35:22 - 00:09:38:06
And the MRI basically helps

00:09:38:06 - 00:09:39:04
us localize

00:09:39:04 - 00:09:42:03
where to pulse these ultrasonic waves.

00:09:42:03 - 00:09:43:08
And then the neurosurgeon

00:09:43:08 - 00:09:45:06
slowly raises the temperature

00:09:45:06 - 00:09:46:19
to that exact spot.

00:09:46:19 - 00:09:49:01
Wow. And is the patient awake?

00:09:49:01 - 00:09:50:11
They're awake throughout the whole thing.

00:09:50:11 - 00:09:51:21
There's no anesthesia.

00:09:51:21 - 00:09:53:19
And I would say the most rewarding part

00:09:53:19 - 00:09:54:11
for the patient

00:09:54:11 - 00:09:55:10
is that we slowly

00:09:55:10 - 00:09:57:03
raise the temperature, and in real time,

00:09:57:03 - 00:09:59:14
the patient will have to draw a spiral,

00:09:59:14 - 00:10:00:17
and they can compare it to what

00:10:00:17 - 00:10:02:06
the spirals look like before.

00:10:02:06 - 00:10:03:05
Wow.

00:10:03:05 - 00:10:04:12
And in real time

00:10:04:12 - 00:10:07:22
they'll see certain tremors kind of improve.

00:10:08:00 - 00:10:08:21
That's incredible.

00:10:08:21 - 00:10:10:21
And once only once we see

00:10:10:21 - 00:10:11:23
therapeutic benefit

00:10:11:23 - 00:10:13:19
do we cause a permanent lesion.

00:10:13:19 - 00:10:14:09
Okay.

00:10:14:09 - 00:10:15:21
So it's a very stepwise approach.

00:10:15:21 - 00:10:18:14
And how long does this whole process take usually?

00:10:18:14 - 00:10:19:22
I would say the process

00:10:19:22 - 00:10:21:07
of you being... lying down.

00:10:21:07 - 00:10:21:19
Yes.

00:10:21:19 - 00:10:22:17
You know, with the helmet...

00:10:22:17 - 00:10:24:03
The uncomfortable stuff.

00:10:24:03 - 00:10:26:06
It's about two hours okay.

00:10:26:06 - 00:10:27:08
Sometimes up to three.

00:10:27:08 - 00:10:29:10
Because if we are not at a good location,

00:10:29:10 - 00:10:30:23
we always readjust.

00:10:30:23 - 00:10:31:14
Got it.

00:10:31:14 - 00:10:33:10
So that could take a couple tries.

00:10:33:10 - 00:10:34:17
But after that, the patient's

00:10:34:17 - 00:10:35:21
monitored for a couple hours

00:10:35:21 - 00:10:37:03
and they usually go home the same day.

00:10:37:03 - 00:10:38:03
And I would imagine

00:10:38:03 - 00:10:39:10
you've seen tears

00:10:39:10 - 00:10:42:02
and seen shock on people's faces.

00:10:42:02 - 00:10:43:09
Yes, I would say my

00:10:43:09 - 00:10:44:23
I when this first came out,

00:10:44:23 - 00:10:46:05
I think this was a while ago

00:10:46:05 - 00:10:47:08
and I was still in training,

00:10:47:08 - 00:10:48:07
and I remember seeing one

00:10:48:07 - 00:10:49:22
of my patients afterwards,

00:10:49:22 - 00:10:51:14
and he was so excited to show me

00:10:51:14 - 00:10:52:23
that he could sign his name.

00:10:52:23 - 00:10:53:18
Oh.

00:10:54:13 - 00:10:55:23
my favorite part is that he told me

00:10:55:23 - 00:10:58:00
he went out and bought a checkbook

00:10:58:00 - 00:10:59:19
So that he could sign more checks.

00:10:59:19 - 00:11:01:22
Lots of reasons to sign his name.

00:11:01:22 - 00:11:02:19
Yes, and I was just thinking,

00:11:02:19 - 00:11:04:06
did I fix one problem?

00:11:04:06 - 00:11:06:15
And create another one?

00:11:06:15 - 00:11:08:02
Luckily, he does not have a shopping addiction.

00:11:08:02 - 00:11:08:19
I was going to say,

00:11:08:19 - 00:11:10:10
he didn't go on a spending spree.

00:11:10:10 - 00:11:12:14
We're all good. That's incredible.

00:11:12:14 - 00:11:14:22
So what else is it approved for?

00:11:14:22 - 00:11:16:16
What else can we use this for?

00:11:16:16 - 00:11:17:04
As you know,

00:11:17:04 - 00:11:20:02
this is very a very innovative technology.

00:11:20:02 - 00:11:20:12
Sure.

00:11:20:12 - 00:11:21:08
So around this,

00:11:21:08 - 00:11:23:01
a couple years after this was approved,

00:11:23:01 - 00:11:24:14
for essential tremor,

00:11:24:14 - 00:11:25:23
it was also approved

00:11:25:23 - 00:11:27:06
for tremor predominant

00:11:27:06 - 00:11:28:15
Parkinson's disease.

00:11:28:15 - 00:11:29:20
Okay.

00:11:29:20 - 00:11:30:22
And then more recently

00:11:30:22 - 00:11:32:15
they have started to approve

00:11:32:15 - 00:11:34:09
for its use for other motor

00:11:34:09 - 00:11:36:04
symptoms in Parkinson's,

00:11:36:04 - 00:11:37:06
including rigidity

00:11:37:06 - 00:11:39:12
and what we call bradykinesia

00:11:39:12 - 00:11:40:20
slowness and movement.

00:11:40:20 - 00:11:41:20
Unbelievable.

00:11:41:20 - 00:11:43:04
Beyond that I would say that

00:11:44:05 - 00:11:45:16
the possibilities are endless.

00:11:45:16 - 00:11:46:13
Right.

00:11:46:13 - 00:11:48:06
There has been clinical trials

00:11:48:06 - 00:11:50:15
that had looked at focused ultrasound

00:11:50:15 - 00:11:52:00
in focal limb dystonia

00:11:52:00 - 00:11:52:12
in patients

00:11:52:12 - 00:11:54:11
who are musicians or...

00:11:54:11 - 00:11:56:11
Sorry, focal limb dystonia.

00:11:56:11 - 00:11:57:23
Is that like,

00:11:57:23 - 00:12:00:05
like a paralysis of the hand or what is that?

00:12:00:05 - 00:12:02:05
It's an abnormal posturing of the hand.

00:12:02:05 - 00:12:02:19
Okay.

00:12:02:19 - 00:12:04:09
Usually, if it's task

00:12:04:09 - 00:12:06:10
specific, it's a it's associated

00:12:06:10 - 00:12:07:05
with patients

00:12:07:05 - 00:12:08:12
who have had some sort

00:12:08:12 - 00:12:10:08
of occupational overuse in that limb.

00:12:10:08 - 00:12:11:06
So this could be somebody

00:12:11:06 - 00:12:12:08
with a writer's cramp.

00:12:12:08 - 00:12:13:03
Oh my goodness.

00:12:13:03 - 00:12:14:20
I don't think we write as much nowadays.

00:12:14:20 - 00:12:17:03
No, but I've been known to wear one of those

00:12:17:03 - 00:12:18:15
super cool braces with,

00:12:18:15 - 00:12:20:04
you know, when I've done the mouse

00:12:20:04 - 00:12:21:06
and I'm working too much.

00:12:21:06 - 00:12:22:18
I mean, this this really, like you said,

00:12:22:18 - 00:12:23:10
it could be endless.

00:12:23:10 - 00:12:23:16
But,

00:12:23:16 - 00:12:24:00
Yes.

00:12:24:00 - 00:12:25:10
focusing on the stuff that's, like,

00:12:25:10 - 00:12:27:02
really critical.

00:12:27:02 - 00:12:28:05
You know, the Parkinson's

00:12:28:05 - 00:12:29:18
work, the essential tremor work.

00:12:29:18 - 00:12:31:15
I don't know how this ties

00:12:31:15 - 00:12:32:08
in, so hopefully

00:12:32:08 - 00:12:35:08
you can tell me or guide me, but,

00:12:35:08 - 00:12:37:19
when I was growing up, my mom, her

00:12:37:19 - 00:12:39:06
best friend had dystonia,

00:12:39:06 - 00:12:41:02
which I had never heard of.

00:12:41:02 - 00:12:42:08
I didn't know what it was.

00:12:42:08 - 00:12:45:06
But as I got older and found it,

00:12:45:06 - 00:12:46:23
that it was more debilitating every

00:12:46:23 - 00:12:49:03
day for her between walking,

00:12:50:03 - 00:12:52:06
very one sidedly almost dragging her

00:12:52:06 - 00:12:55:05
leg, her her hands, like you said,

00:12:55:05 - 00:12:56:10
with the fancy word...

00:12:56:10 - 00:12:57:08
Oh, posturing.

00:12:57:08 - 00:12:58:17
Thank you. Yeah.

00:12:58:17 - 00:13:01:07
Her hands just unable to sort of unclench,

00:13:01:07 - 00:13:04:06
and her speech incredibly impacted.

00:13:04:12 - 00:13:06:09
And it's so incredible

00:13:06:09 - 00:13:08:00
to know that we have things like that

00:13:08:00 - 00:13:08:17
that we can do today.

00:13:08:17 - 00:13:09:16
It makes me choked up a little

00:13:09:16 - 00:13:09:22
to think

00:13:09:22 - 00:13:11:09
that she didn't have a chance

00:13:11:09 - 00:13:13:09
to to experience something like this.

00:13:13:09 - 00:13:14:07
So is this something

00:13:14:07 - 00:13:16:05
that also helps with dystonia?

00:13:16:05 - 00:13:17:03
You are hoping so

00:13:17:03 - 00:13:18:22
I would say the University of Maryland

00:13:18:22 - 00:13:20:05
had been studying it for a while

00:13:20:05 - 00:13:21:03
when I was in training,

00:13:21:03 - 00:13:21:19
and it had shown

00:13:21:19 - 00:13:22:17
some promising results.

00:13:22:17 - 00:13:23:10
Oh wow.

00:13:23:10 - 00:13:25:15
Especially in focal limb dystonia.

00:13:25:15 - 00:13:27:04
I have seen some clinical trials

00:13:27:04 - 00:13:28:07
that are ongoing

00:13:28:07 - 00:13:31:00
looking at it for dyskinetic cerebral palsy.

00:13:31:00 - 00:13:32:13
So all these unwanted movements

00:13:32:13 - 00:13:34:19
in patients with cerebral palsy,

00:13:34:19 - 00:13:35:20
we have also seen it

00:13:35:20 - 00:13:37:22
trying to be used in clinical trials

00:13:37:22 - 00:13:39:15
to investigate its utility

00:13:39:15 - 00:13:40:19
in what we call

00:13:40:19 - 00:13:42:10
refractory movement disorders.

00:13:42:10 - 00:13:43:05
What is that?

00:13:43:05 - 00:13:44:05
So any movement

00:13:44:05 - 00:13:46:15
disorders, any movements that are unwanted

00:13:46:15 - 00:13:48:01
and do not respond to treatment.

00:13:48:01 - 00:13:49:03
So would this be.

00:13:49:03 - 00:13:49:18
And again

00:13:49:18 - 00:13:51:13
talking completely out of my depth,

00:13:51:13 - 00:13:52:07
would this be something

00:13:52:07 - 00:13:54:07
that, could treat Tourette's?

00:13:54:07 - 00:13:54:16
Yes.

00:13:54:16 - 00:13:55:20
It is actually

00:13:55:20 - 00:13:58:10
Yes, what a win! Okay.

00:13:58:10 - 00:13:59:09
It is being studied.

00:13:59:09 - 00:14:00:11
It is one of the,

00:14:00:11 - 00:14:02:01
refractory movement disorders

00:14:02:01 - 00:14:03:18
that are kind of in the clinical trial

00:14:03:18 - 00:14:06:02
bundle of hoping to be investigated.

00:14:06:02 - 00:14:09:05
Interesting. So when you say any unwanted movement

00:14:09:05 - 00:14:10:19
that that's exactly what you mean.

00:14:10:19 - 00:14:13:13
Involuntary hyperkinetic movements.

00:14:13:13 - 00:14:14:10
Wow.

00:14:14:10 - 00:14:16:23
So where are we like personally,

00:14:16:23 - 00:14:18:00
how many times

00:14:18:00 - 00:14:19:04
have you seen someone

00:14:19:04 - 00:14:21:01
or how many times have you,

00:14:21:01 - 00:14:24:08
been sort of in charge of the MRI experience

00:14:24:08 - 00:14:25:04
for a patient?

00:14:25:04 - 00:14:25:13
Well,

00:14:25:13 - 00:14:26:19
you know, I'm proud to announce

00:14:26:19 - 00:14:28:12
that we just launched

00:14:28:12 - 00:14:30:20
our focused ultrasound program.

00:14:30:20 - 00:14:31:08
Yeah.

00:14:31:08 - 00:14:31:22
Recently.

00:14:32:06 - 00:14:32:20
So really,

00:14:32:20 - 00:14:34:19
we've only had one patient so far.

00:14:34:19 - 00:14:35:13
Oh, yay.

00:14:35:13 - 00:14:36:08
At UCI.

00:14:36:08 - 00:14:37:07
The gold standard.

00:14:37:07 - 00:14:38:12
Yes, with the one patient

00:14:38:12 - 00:14:40:13
has done incredibly well.

00:14:40:13 - 00:14:41:18
And we're so excited

00:14:41:18 - 00:14:42:22
to see them in the clinic

00:14:42:22 - 00:14:44:07
in the upcoming weeks.

00:14:44:07 - 00:14:45:21
What I think is really funny

00:14:45:21 - 00:14:47:04
is that we see these patients

00:14:47:04 - 00:14:48:20
so often before their surgery...

00:14:48:20 - 00:14:49:06
Yeah.

00:14:49:06 - 00:14:51:04
And then after the procedure,

00:14:51:04 - 00:14:51:21
it's bittersweet

00:14:51:21 - 00:14:53:10
because we actually might not see them

00:14:53:10 - 00:14:54:08
as often anymore.

00:14:54:08 - 00:14:55:10
But no news is good news

00:14:55:10 - 00:14:56:06
because they’re not coming back.

00:14:56:06 - 00:14:58:01
Exactly. They may they may not need us as much

00:14:58:01 - 00:14:58:10
Yeah.

00:14:58:10 - 00:14:59:01
for quite a while.

00:14:59:01 - 00:15:01:01
There are studies that have shown that

00:15:01:01 - 00:15:02:13
there are this durability

00:15:02:13 - 00:15:04:04
to this treatment for up to five years.

00:15:04:04 - 00:15:05:10
Okay, that was my next question.

00:15:05:10 - 00:15:07:00
So yeah, that's

00:15:07:00 - 00:15:07:21
what would you say

00:15:07:21 - 00:15:09:15
is a typical amount of time.

00:15:09:15 - 00:15:10:16
You said up to five years.

00:15:10:16 - 00:15:12:08
So do we split that in half.

00:15:12:08 - 00:15:14:07
Do we say we come back every couple years?

00:15:14:07 - 00:15:15:02
We don't know.

00:15:15:02 - 00:15:16:03
I think it's ongoing.

00:15:16:03 - 00:15:18:16
So the study said as of five years

00:15:18:16 - 00:15:19:15
that at the five year

00:15:19:15 - 00:15:23:11
mark, there are a very big chunk of patients

00:15:23:11 - 00:15:24:14
who have sustained benefit.

00:15:24:14 - 00:15:26:05
Unbelievable.

00:15:26:05 - 00:15:27:09
And when you talk about

00:15:27:09 - 00:15:30:09
like coming back to see you, what is...

00:15:30:15 - 00:15:31:19
I mean I know that there's, there's

00:15:31:19 - 00:15:32:21
a little bit of sort of,

00:15:32:21 - 00:15:34:13
you know, you're sitting still for two hours

00:15:34:13 - 00:15:35:18
and that's hard for any of us.

00:15:35:18 - 00:15:38:03
But in terms of a recovery time

00:15:38:03 - 00:15:39:00
from a process

00:15:39:00 - 00:15:39:22
like this, as opposed

00:15:39:22 - 00:15:42:17
to implanting something in your head

00:15:42:17 - 00:15:44:22
or taking pills that have side effects,

00:15:44:22 - 00:15:45:20
what would you consider

00:15:45:20 - 00:15:48:09
the recovery time for this to be?

00:15:48:09 - 00:15:50:12
So the procedure itself, you go

00:15:50:12 - 00:15:51:16
you go home the same day.

00:15:51:16 - 00:15:52:15
That is incredible.

00:15:52:15 - 00:15:55:03
Yeah. If you do have some transient side effects,

00:15:55:03 - 00:15:57:04
you know, this includes paresthesia.

00:15:57:04 - 00:15:58:03
So numbness, tingling

00:15:58:03 - 00:15:58:13
Right.

00:15:58:13 - 00:16:00:00
Any imbalance

00:16:00:00 - 00:16:01:22
those are usually those usually resolve

00:16:01:22 - 00:16:03:04
within the first couple of weeks.

00:16:03:04 - 00:16:04:06
Oh so is that

00:16:04:06 - 00:16:05:06
just kind of like your

00:16:05:06 - 00:16:06:05
your neurons

00:16:06:05 - 00:16:08:04
coming back online in a different way?

00:16:08:04 - 00:16:08:23
It's just everybody's

00:16:08:23 - 00:16:10:16
sort of finding their new path

00:16:10:16 - 00:16:12:08
now that they've been like sound waved.

00:16:12:08 - 00:16:14:11
It’s just the tissue activation? Okay.

00:16:14:11 - 00:16:15:19
There are local structures.

00:16:15:19 - 00:16:18:03
So they could transiently be affected

00:16:18:03 - 00:16:19:10
by the ultrasonic waves,

00:16:19:10 - 00:16:20:14
but they are not permanent.

00:16:20:14 - 00:16:22:13
Now, here's another kindergarten question.

00:16:22:13 - 00:16:24:14
How do you know that

00:16:24:14 - 00:16:26:01
you're in the right spot

00:16:26:01 - 00:16:27:06
when you're doing this?

00:16:27:06 - 00:16:30:13
So we have we know that this

00:16:30:13 - 00:16:32:17
where the spot is technically located

00:16:32:17 - 00:16:33:03
Okay.

00:16:33:03 - 00:16:34:13
based on that abnormal circuitry

00:16:34:13 - 00:16:35:17
that we talked about.

00:16:35:17 - 00:16:36:20
It's kind of the same for everyone.

00:16:36:20 - 00:16:37:20
It's it's usually the same.

00:16:37:20 - 00:16:38:14
...spot. Okay.

00:16:38:14 - 00:16:41:09
And then we activate very small amounts

00:16:41:09 - 00:16:43:18
with that increased temperature that we talked about.

00:16:43:18 - 00:16:45:03
Just when you start to see the results.

00:16:45:03 - 00:16:46:21
And then we keep making it.

00:16:46:21 - 00:16:48:15
We make the circumference a little larger

00:16:48:15 - 00:16:50:14
and a little larger until we see benefit

00:16:50:14 - 00:16:53:02
and then we stop. So it's a very step wise.

00:16:53:02 - 00:16:54:07
And that's so interesting too

00:16:54:07 - 00:16:57:12
because it's like so like sci fi.

00:16:57:12 - 00:16:58:02
Amazing.

00:16:58:02 - 00:16:59:13
And then part of it is like, I don't know,

00:16:59:13 - 00:17:01:04
we go until we stop.

00:17:01:04 - 00:17:01:18
In a way...

00:17:01:18 - 00:17:02:21
It's like a trial and error.

00:17:02:21 - 00:17:03:19
But you know what you're doing.

00:17:03:19 - 00:17:04:20
We know exactly where we're going.

00:17:04:20 - 00:17:06:13
And that's what the MRI portion is for

00:17:06:13 - 00:17:07:12
That’s incredible.

00:17:07:12 - 00:17:08:15
is to guide us directly to that spot.

00:17:08:15 - 00:17:10:14
That is so unbelievable.

00:17:10:14 - 00:17:13:13
And and you said it's in the thalamus.

00:17:13:22 - 00:17:14:15
I'm guessing that's

00:17:14:15 - 00:17:16:08
a pretty hard spot to get to

00:17:16:08 - 00:17:17:16
if you're actually doing

00:17:17:16 - 00:17:19:08
like surgery on somebody.

00:17:19:08 - 00:17:20:22
You said it's like pretty deep.

00:17:20:22 - 00:17:22:13
Yes. The thalamus is quite deep.

00:17:22:13 - 00:17:23:18
It's part of this deep

00:17:23:18 - 00:17:25:19
part of the brain called the basal ganglia.

00:17:25:19 - 00:17:26:05
Okay.

00:17:26:05 - 00:17:27:16
And that whole part of your brain

00:17:27:16 - 00:17:28:22
is really responsible

00:17:28:22 - 00:17:30:18
for coordinating movements.

00:17:30:18 - 00:17:31:13
Okay.

00:17:31:13 - 00:17:33:15
So any abnormalities along this region

00:17:33:15 - 00:17:35:21
can cause unwanted movements. This...

00:17:35:21 - 00:17:37:22
Who performs this procedure?

00:17:37:22 - 00:17:39:13
Is this like, is this a neurologist?

00:17:39:13 - 00:17:41:13
Is this a neurosurgeon who's in charge

00:17:41:13 - 00:17:43:08
On the day of the procedure?

00:17:43:08 - 00:17:46:09
The person who does the procedure itself

00:17:46:11 - 00:17:47:17
is our neurosurgeon

00:17:47:17 - 00:17:50:04
who is very highly skilled.

00:17:50:04 - 00:17:51:10
And then afterwards

00:17:51:10 - 00:17:54:10
the patients follow up with us long term.

00:17:54:12 - 00:17:55:04
Interesting.

00:17:55:04 - 00:17:56:03
And like you said,

00:17:56:03 - 00:17:56:23
because this is like,

00:17:56:23 - 00:17:58:10
you know, just that day

00:17:58:10 - 00:17:59:01
and you're not staying

00:17:59:01 - 00:18:00:08
overnight in the hospital

00:18:00:08 - 00:18:01:09
and everybody's awake.

00:18:01:09 - 00:18:04:03
There's no, anesthesiologist, I assume.

00:18:04:03 - 00:18:04:17
No.

00:18:04:17 - 00:18:05:11
Oh, wow.

00:18:05:11 - 00:18:07:21
Because it doesn't hurt.

00:18:07:21 - 00:18:08:13
It should not.

00:18:10:00 - 00:18:11:21
Do they feel do you do you feel anything?

00:18:11:21 - 00:18:12:22
Does the patient feel anything?

00:18:12:22 - 00:18:13:09
I would say

00:18:13:09 - 00:18:14:16
the only complaint really

00:18:14:16 - 00:18:16:11
is a little bit of lightheadedness

00:18:16:11 - 00:18:18:06
and that kind of tingling sensation

00:18:18:06 - 00:18:19:10
that patients may feel.

00:18:19:10 - 00:18:20:15
And then after the procedure,

00:18:20:15 - 00:18:22:01
they may feel a little imbalanced.

00:18:22:01 - 00:18:22:13
Okay.

00:18:22:13 - 00:18:23:19
Doesn't happen to everyone.

00:18:23:19 - 00:18:24:16
It is a side effect

00:18:24:16 - 00:18:27:07
that we coach our patients on beforehand.

00:18:27:07 - 00:18:27:20
Interesting.

00:18:27:20 - 00:18:29:03
And they hear it a lot.

00:18:29:03 - 00:18:29:23
They hear it from us,

00:18:29:23 - 00:18:31:14
and then they hear from the neurosurgeon.

00:18:31:14 - 00:18:32:13
And then even during

00:18:32:13 - 00:18:34:01
the procedure we’ll say, hey,

00:18:34:01 - 00:18:35:08
are you feeling these symptoms?

00:18:35:08 - 00:18:37:11
So they're really closely watched.

00:18:37:11 - 00:18:38:09
And then when they say

00:18:38:09 - 00:18:39:07
yes, you're like, don't worry about it.

00:18:39:07 - 00:18:42:02
You're laying down, you’re fine.

00:18:42:02 - 00:18:42:12
Well, you know.

00:18:42:12 - 00:18:43:18
Unfortunately, some of our patients

00:18:43:18 - 00:18:44:17
with the essential tremor

00:18:44:17 - 00:18:46:02
do complain of balance issues.

00:18:46:02 - 00:18:46:13
Oh sure.

00:18:46:13 - 00:18:48:09
So it's usually nothing

00:18:48:09 - 00:18:49:10
beyond what they haven't

00:18:49:10 - 00:18:50:07
already experienced.

00:18:50:07 - 00:18:51:01
Understood.

00:18:52:01 - 00:18:52:17
So I've

00:18:52:17 - 00:18:54:03
heard that this procedure can be done

00:18:54:03 - 00:18:55:20
on both sides of the brain.

00:18:55:20 - 00:18:57:12
So is that one procedure.

00:18:57:12 - 00:18:59:12
Is that two procedures. What is that?

00:18:59:12 - 00:19:00:07
Walk us through that.

00:19:00:07 - 00:19:03:07
Yes. So this procedure is done

00:19:03:07 - 00:19:04:13
in two separate stages.

00:19:04:13 - 00:19:05:05
Okay.

00:19:05:05 - 00:19:06:20
If you want to address both sides

00:19:06:20 - 00:19:08:08
and for the majority of our patients

00:19:08:08 - 00:19:10:16
because it does affect both arms,

00:19:10:16 - 00:19:11:23
they do do both sides,

00:19:11:23 - 00:19:13:04
but they have to be at least

00:19:13:04 - 00:19:14:05
a few months apart.

00:19:14:05 - 00:19:15:12
Oh why is that?

00:19:15:12 - 00:19:16:18
For recovery. Yes.

00:19:16:18 - 00:19:18:22
And we usually start with the dominant hand.

00:19:18:22 - 00:19:19:20
Oh that makes sense.

00:19:19:20 - 00:19:21:21
That is where the screening really is important.

00:19:21:21 - 00:19:22:20
You know, one of my patients,

00:19:22:20 - 00:19:23:22
I think one of the first patients

00:19:23:22 - 00:19:25:06
I had encountered,

00:19:25:06 - 00:19:27:20
he said although he was very debilitated

00:19:27:20 - 00:19:29:06
in many ways,

00:19:29:06 - 00:19:31:07
he said his goal was to be able

00:19:31:07 - 00:19:32:23
to eat his favorite chips again,

00:19:32:23 - 00:19:34:18
which were Pringles.

00:19:34:18 - 00:19:37:03
So he really wanted his right arm

00:19:37:03 - 00:19:39:12
to go first, you know, priorities.

00:19:39:12 - 00:19:41:01
And he was able to get his hand in there.

00:19:41:01 - 00:19:43:08
And that was very meaningful to me.

00:19:43:08 - 00:19:44:08
That’s really funny.

00:19:44:08 - 00:19:45:16
And then he went back for the left side later.

00:19:45:16 - 00:19:47:07
So is it the right side

00:19:47:07 - 00:19:49:08
that controls the left side and vice versa,

00:19:49:08 - 00:19:50:17
or how how does that work?

00:19:50:17 - 00:19:52:05
For the most part, in the superior

00:19:52:05 - 00:19:53:15
aspects of our brain,

00:19:53:15 - 00:19:54:22
the left side does

00:19:54:22 - 00:19:56:12
control the right side of the body.

00:19:56:12 - 00:20:00:05
Okay, so you do one side at a time, months apart,

00:20:00:05 - 00:20:01:18
and you start with the dominant side,

00:20:01:18 - 00:20:03:02
which makes sense.

00:20:03:02 - 00:20:03:19
Whichever. Yeah.

00:20:03:19 - 00:20:05:21
Whichever side is dominant to the patient.

00:20:05:21 - 00:20:07:04
We don't always start on the right side.

00:20:07:04 - 00:20:08:20
There are many lefties out there for you

00:20:08:20 - 00:20:10:07
Leftie right here. Thank you.

00:20:10:07 - 00:20:10:21
Yes.

00:20:10:21 - 00:20:12:11
And does that... is that...

00:20:12:11 - 00:20:14:07
Could you just cut down the entire body

00:20:14:07 - 00:20:16:01
and say that one side is dominant?

00:20:16:01 - 00:20:18:03
Or would it be different for

00:20:18:03 - 00:20:19:13
if it just affected

00:20:19:13 - 00:20:21:17
somebody's left leg and right arm?

00:20:21:17 - 00:20:22:18
I think that's as a neurologist.

00:20:22:18 - 00:20:23:22
This question's very difficult

00:20:23:22 - 00:20:24:17
for me to answer

00:20:24:17 - 00:20:25:06
Okay.

00:20:25:06 - 00:20:26:22
Because the brain is so complex,

00:20:26:22 - 00:20:28:04
and it's not as easy

00:20:28:04 - 00:20:29:22
as splitting things down the middle.

00:20:29:22 - 00:20:31:18
But for the sake of focused

00:20:31:18 - 00:20:33:08
ultrasound ablation,

00:20:33:08 - 00:20:35:05
you can simplify it and say yes.

00:20:35:05 - 00:20:37:11
If you are trying to target the left side,

00:20:37:11 - 00:20:38:05
the tremors,

00:20:38:05 - 00:20:38:21
you would

00:20:38:21 - 00:20:41:02
focus on the right hemisphere of the brain.

00:20:41:02 - 00:20:41:13
Okay.

00:20:41:13 - 00:20:42:23
And you were talking about

00:20:42:23 - 00:20:45:03
how the patient will make a spiral

00:20:45:03 - 00:20:46:15
and we'll see how that improves.

00:20:46:15 - 00:20:48:05
What if you're focusing

00:20:48:05 - 00:20:49:23
specifically on lower body?

00:20:51:08 - 00:20:52:15
What would you ask them to do?

00:20:52:15 - 00:20:52:21
Yeah.

00:20:52:21 - 00:20:53:21
So you know, we have a

00:20:53:21 - 00:20:55:12
tremor, tremor rating scale,

00:20:55:12 - 00:20:57:04
that we do before the patients

00:20:57:04 - 00:20:58:14
go for the procedure.

00:20:58:14 - 00:20:58:22
Okay.

00:20:58:22 - 00:20:59:17
So the rating scale

00:20:59:17 - 00:21:00:15
also includes

00:21:00:15 - 00:21:03:02
certain tasks in the lower limb as well.

00:21:03:02 - 00:21:04:18
And so if that is the case,

00:21:04:18 - 00:21:06:23
then we would have them raise their leg

00:21:06:23 - 00:21:07:19
and kind of sustain

00:21:07:19 - 00:21:09:07
that posture during that time.

00:21:09:07 - 00:21:09:18
I see.

00:21:09:18 - 00:21:10:14
Or do certain tasks

00:21:10:14 - 00:21:11:06
with the leg.

00:21:11:06 - 00:21:11:23
That makes sense.

00:21:11:23 - 00:21:13:05
But that doesn't happen as often.

00:21:13:05 - 00:21:15:09
Okay.

00:21:15:09 - 00:21:18:09
So what sets UCI Health apart

00:21:18:09 - 00:21:19:05
in this treatment

00:21:19:05 - 00:21:20:07
with these movement disorders?

00:21:20:07 - 00:21:21:08
Because like you said there's

00:21:21:08 - 00:21:23:01
you just had the patient.

00:21:23:01 - 00:21:23:15
It's awesome.

00:21:23:15 - 00:21:25:05
There are other places working on this.

00:21:25:05 - 00:21:26:02
Like what makes

00:21:26:02 - 00:21:28:04
UCI Health something that's

00:21:28:04 - 00:21:30:13
that's more specialized in this.

00:21:30:13 - 00:21:32:12
I think this is a question

00:21:32:12 - 00:21:34:09
I can ramble on for a while.

00:21:34:09 - 00:21:37:00
Please. We’ve got nothing but time.

00:21:37:00 - 00:21:38:06
I cannot speak on behalf

00:21:38:06 - 00:21:39:04
of other institutions.

00:21:39:04 - 00:21:41:09
I'm sure everyone is doing fantastic,

00:21:41:09 - 00:21:43:15
but I'm very proud of our team.

00:21:43:15 - 00:21:44:04
Yeah.

00:21:44:04 - 00:21:44:18
Our team,

00:21:44:18 - 00:21:46:16
you know, we are consisting of movement

00:21:46:16 - 00:21:47:21
disorders, neurologists.

00:21:47:21 - 00:21:49:08
We have our neurosurgery team.

00:21:49:08 - 00:21:51:14
We even work closely with neuropsychology...

00:21:51:14 - 00:21:52:06
Wow.

00:21:52:06 - 00:21:53:19
to just balance out risk factors.

00:21:53:19 - 00:21:54:15
So each patient

00:21:54:15 - 00:21:56:13
gets a very tailored approach.

00:21:56:13 - 00:21:57:10
It's incredible.

00:21:57:10 - 00:21:59:07
They may get a little annoyed by us

00:21:59:07 - 00:22:00:01
because they come.

00:22:00:01 - 00:22:01:17
And I ask them so many questions

00:22:01:17 - 00:22:03:00
because to decide

00:22:03:00 - 00:22:04:19
what is the best treatment for a patient,

00:22:04:19 - 00:22:07:13
it goes beyond just are your tremors bad?

00:22:07:13 - 00:22:09:16
Right? It's what medications have you tried?

00:22:09:16 - 00:22:11:02
What kind of side effects do you have?

00:22:11:02 - 00:22:13:13
What lifestyle are you hoping to regain?

00:22:13:13 - 00:22:13:20
Right.

00:22:13:20 - 00:22:16:00
What is the most disabling symptom?

00:22:16:00 - 00:22:18:02
Do you have support at home to help you?

00:22:18:02 - 00:22:19:02
Post-surgically.

00:22:19:02 - 00:22:20:14
These are all things that we weigh in.

00:22:20:14 - 00:22:21:08
That's interesting

00:22:21:08 - 00:22:22:23
because I was thinking to myself, well,

00:22:22:23 - 00:22:24:00
who wouldn't be a candidate,

00:22:24:00 - 00:22:25:07
just be a candidate.

00:22:25:07 - 00:22:27:08
But apparently it's not that simple.

00:22:27:08 - 00:22:28:20
Yes, for all advanced therapies,

00:22:28:20 - 00:22:31:12
we we do try our best to sit down

00:22:31:12 - 00:22:33:09
and have this talk with all of our patients.

00:22:33:09 - 00:22:35:14
I'm actually so proud to announce

00:22:35:14 - 00:22:37:07
that at UCI Health,

00:22:37:07 - 00:22:40:01
we are launching an advanced intervention

00:22:40:01 - 00:22:40:14
in movement

00:22:40:14 - 00:22:41:18
Disorders program,

00:22:41:18 - 00:22:43:07
and it's a clinic that yours

00:22:43:07 - 00:22:44:18
truly is spearheading.

00:22:44:18 - 00:22:46:20
This is awesome, Doctor Ly.

00:22:46:20 - 00:22:48:14
So what is that going to be like?

00:22:48:14 - 00:22:50:06
It's kind of like a hub,

00:22:50:06 - 00:22:51:15
a lot of our patients with movement

00:22:51:15 - 00:22:52:16
disorders are being seen

00:22:52:16 - 00:22:54:01
by community neurologists

00:22:54:01 - 00:22:55:07
because unfortunately,

00:22:55:07 - 00:22:56:06
there are not many movement

00:22:56:06 - 00:22:58:03
disorder specialists out there.

00:22:58:03 - 00:22:59:07
So it's a nice hub

00:22:59:07 - 00:23:00:18
to let our patients

00:23:00:18 - 00:23:02:07
have a safe space

00:23:02:07 - 00:23:03:16
to talk about their options

00:23:03:16 - 00:23:05:13
or even learn about their options.

00:23:05:13 - 00:23:07:16
And that way we can

00:23:07:16 - 00:23:08:03
get them

00:23:08:03 - 00:23:09:13
an expedited track

00:23:09:13 - 00:23:10:19
to get the advanced therapy

00:23:10:19 - 00:23:11:23
that they may need.

00:23:11:23 - 00:23:12:16
It’s incredible.

00:23:12:16 - 00:23:14:02
And once things are working well.

00:23:14:02 - 00:23:14:21
They can still go back

00:23:14:21 - 00:23:16:06
to their community neurologist.

00:23:16:06 - 00:23:18:17
So we're not stealing patients from anybody.

00:23:18:17 - 00:23:21:08
We just hope to be a centralized location

00:23:21:08 - 00:23:22:07
to give access

00:23:22:07 - 00:23:23:21
to our patients in the community.

00:23:23:21 - 00:23:24:21
This is unbelievable.

00:23:24:21 - 00:23:27:09
You go from, you know, a generation ago

00:23:27:09 - 00:23:28:17
and beyond where it's like,

00:23:28:17 - 00:23:30:10
well, sorry, this is your diagnosis.

00:23:30:10 - 00:23:32:08
And, you know, we hope for the best for you

00:23:32:08 - 00:23:34:04
and we hope you live a comfortable life.

00:23:34:04 - 00:23:37:06
Now to having a centralized hub, a team

00:23:37:12 - 00:23:38:08
that can

00:23:38:08 - 00:23:39:12
that can get you over

00:23:39:12 - 00:23:41:02
so many of these obstacles.

00:23:41:02 - 00:23:42:06
It's incredible.

00:23:42:06 - 00:23:43:00
Yes. And our team,

00:23:43:00 - 00:23:44:19
yeah, it's very multidisciplinary.

00:23:44:19 - 00:23:46:12
Even at UCI once a month,

00:23:46:12 - 00:23:48:15
we have very in-depth discussion

00:23:48:15 - 00:23:52:05
about each patient's case to kind of decide,

00:23:52:09 - 00:23:54:15
are they the best candidate for this therapy

00:23:54:15 - 00:23:55:12
or are there alternatives

00:23:55:12 - 00:23:57:06
that we have not considered yet?

00:23:57:06 - 00:23:59:06
So it's a very team based approach.

00:23:59:06 - 00:24:02:06
So if you thought you were cared for in your

00:24:02:06 - 00:24:03:02
regular life,

00:24:04:02 - 00:24:06:04
there is a team of experts

00:24:06:04 - 00:24:07:04
who want to care for you,

00:24:07:04 - 00:24:09:15
who are literally just debating you like,

00:24:09:15 - 00:24:11:08
yeah, narcissist dream.

00:24:11:08 - 00:24:13:01
Yeah, that does sound like it.

00:24:13:01 - 00:24:15:03
That does sound like a pretty thoughtful,

00:24:15:03 - 00:24:16:10
incredible experience.

00:24:16:10 - 00:24:17:12
Yes, I agree,

00:24:17:12 - 00:24:18:20
and you know, as neurologists,

00:24:18:20 - 00:24:19:15
we're notorious

00:24:19:15 - 00:24:22:11
for debating the most miniscule things

00:24:22:11 - 00:24:23:18
for a very long time.

00:24:23:18 - 00:24:25:10
So I would say that our patients

00:24:25:10 - 00:24:26:11
get a lot of attention.

00:24:26:11 - 00:24:27:23
Doctor Ly, thank you so much.

00:24:27:23 - 00:24:30:07
This is so informative and so inspiring.

00:24:30:07 - 00:24:30:21
Thank you.

00:24:30:21 - 00:24:32:18
And we're just we're just so grateful to you

00:24:32:18 - 00:24:33:15
for doing this work.

00:24:33:15 - 00:24:34:14
Oh thank you.

00:24:34:14 - 00:24:36:10
It's been something that I've been inspired

00:24:36:10 - 00:24:37:17
by for a very long time.

00:24:37:17 - 00:24:39:09
Well, we are lucky to have you.

00:24:39:09 - 00:24:40:05
Thank you again.

00:24:40:05 - 00:24:41:12
Thank you so much for having me.