The Neurologist Is In, Episode 5: Determinants of Cognitive Functioning in Aging Populations With Alyssa Gamaldo, PhD

In this episode, Rachel Salas, MD, MEd, interviews Alyssa Gamaldo, PhD, on her research into determinants of cognitive functioning, risk factors for cognitive impairment, and health disparities in cognitive aging among older adult populations.

Can't get enough of The Neurologist Is In? Make sure you're caught up on all the episodes--find the full catalogue here.

About the Speakers:

Rachel Marie E. Salas, MD, Med, FAAN, FANA, is a professor in the Department of Neurology at Johns Hopkins Medicine with a joint appointment in the School of Nursing. She is board certified in Sleep Medicine and Neurology. Dr. Salas is the Director of Ambulatory Sleep Services at the Johns Hopkins Center for Sleep and Wellness. Dr. Salas has been the Director of the Neurology Clerkship for over a decade. She is the Chair of the Undergraduate Education Subcommittee for the American Academy of Neurology and is an appointed member of the Alliance for Clinical Education. She is the director of the Interprofessional Education and Collaborative Practice for the School of Medicine and a Co-Director for Interprofessional Teaming for the High Value Practice Academic Alliance. Dr. Salas is also the founder and Co-Director of the Johns Hopkins Osler Apprenticeship Program (in Neurology), a medical education research program for senior medical students and the Johns Hopkins PreDoc Program, a pipeline premedical college program. Dr. Salas is a certified strengths coach and uses a strength-based approach and coaching to connect to, support, and develop those involved with her educational mission and clinical practice. Dr. Salas is a 2019-21 Josiah Macy Scholar,  a 2019-20 AMA Health Systems Science Scholar and a 2021 AΩA Leadership Fellow.

Alyssa Gamaldo, PhD, is an associate professor of human development and family studies and affiliate faculty member of the Center for Healthy Aging at Penn State.  Her research focuses on identifying biological, social, and psychological influences of health and well-being in older adult populations.  Her work has been particularly focused on determining mechanisms and consequences of cognitive and functional impairment risk within older adults that identify with a racial/ethnic minority group. 

Read the Transcript:

Dr Rachel Salas:  Hello, everyone. This is Rachel Salas. I'm back. We were out for a couple of months but I'm back. I am a sleep neurologist. I'm at Johns Hopkins Medicine.

Today, we have a special guest. We have Dr Alyssa Gamaldo, who is an associate professor in human development and family studies at Penn State. She's a researcher and educator. She's doing some interesting research on cognition, aging, and health disparities.

I thought that she will be great to do an interview with and learn a little bit more about the research she's doing, what's coming next, and what are some issues currently that need to be looked at and just to know her a little bit more and learn more about her work.

Dr Gamaldo, it's great to have you here.

Dr Alyssa Gamaldo:  Thank you. I'm happy to be here. Thanks for inviting me.

Dr Salas:  Let's get started on some of the research that you are doing. I know that I worked with you in the past in terms of sleep and cognition and sleep in older adults. Can you tell us a little bit about that?

Dr Gamaldo:  Absolutely. I started out really focusing on life course development, and not knowing what aspect of life course development because that includes from womb to death. I originally started off thinking, "I'm going to focus on childhood and early adolescent or young adulthood."

Fortunately, I had the opportunity to work for the Alzheimer Disease Research Center at Johns Hopkins University. This was in my early 20s. That's when I got exposed to the adult and aging population, particularly those who are about 65 and older.

When I had engaged with the participants of the Alzheimer Disease Research Center, as well as their family members, I definitely was recognizing some key issues that needed to be addressed.

Particularly as it pertains to older adults' cognitive functioning, which I was observing in the community, that many older adults were very much concerned about changes in their cognition and how that may impact their functioning, particularly when they were on the course for cognitive impairment like Alzheimer disease and related dementia.

That's what really stuck with me and that's what really got me into the research that I am into right now, which is really trying to identify determinants of successful cognitive functioning as well as risk for cognitive decline and impairment.

Dr Salas:  Tell us a little bit more about that.

Dr Gamaldo:  As I mentioned, I was observing it when I was actually going out into the field and testing older adults, and engaging with family members and hearing the personal narratives. I was actually able to see the course of the disease, because I've worked with the project for almost about five years where I was testing older adults.

I was asking them about subjective reports regarding changes in cognition and changes in their physical health as well. I was also engaging with family members, who were able to also describe what they were observing with loved ones. It was interesting to see how the disease unfold.

At the early stages, the older adults would actually recognize that, "Yes, things are changing." We're quite scared and afraid of those changes. Later on, during the course of disease, where it got more severe, that's when you actually saw that it was having an impact on several of the family members. That they knew that their loved one wasn't remembering who they were anymore.

To see the disease unfold, from the individual's perspective, the older adult who's going through it. Then also the family members are really wanted to be a part of the effort to better understand what are these factors that are related to the disease.

The other thing that I was also picking up on, working in the setting I was in, was that there wasn't really a lot of representation of individuals coming from different racial and ethnic backgrounds. I was curious, is this disease strictly affecting one particular racial or ethnic or socioeconomic group? Is it having a bigger impact on these other groups?

Dr Salas:  When you said this disease, which disease are you talking about the most?

Dr Gamaldo:  In terms of Alzheimer disease, as well as vascular dementia. I actually started working with some colleagues. I decided to go back and do my PhD at North Carolina State University. Fortunately, I started working with two researchers, who were really getting into understanding patterns of cognitive aging, particularly in African Americans and Black adults.

Those researchers were Dr Jason Allaire and Dr Keith Whitfield. With their research, I was able to get a better understanding that there was this lack of representation of the experiences of Black and African American older adults as well as their family members, who are also going through this process and who are at risk for being diagnosed with Alzheimer disease and related dementia.

In fact, statistics actually have said and have uphold for quite some time that Black adults are about one to two times more likely to be diagnosed with Alzheimer disease and other related dementias. More so than other racial and ethnic groups.

Dr Salas:  That's interesting. Do we know why that is?

Dr Gamaldo:  That is the key question. That's what prompted me to go into the research. Much of what people have examined has focused on individual factors like behaviors, beliefs, educational levels. There's been quite a bit of research focusing on those factors and actually seeing that those are potential risk factors.

That doesn't necessarily explain all of the risk. There's still all of these other factors that we haven't truly identified that could be related to why we're seeing such a greater risk in Black Americans in terms of the disease. There also is some evidence talking about Black Americans are more at risk for cardiometabolic disease.

That's been linked to risk for Alzheimer disease and vascular dementia. That's been another factor that people have identified are related to the disease. Again, that doesn't fully explain this disparity we're seeing in terms of cognitive impairment risk between Blacks and other racial and ethnic groups.

One of the reasons I got started with sleep, and I started connecting with you, is, I thought that was an underlying mechanism that may be a connection for further explaining cognitive aging within Black Americans. Indeed, I started working with sleep as a potential pertinent factor in grad school.

Looking at the time, didn't have the objective equipment like PSG and the EEG and all of that. I did self‑reported data and asked our older sample of Black adults about their sleep quality, including their duration.

At the time, when we looked at their reports on sleep, as it relates to their performance on cognitive tests of memory, reasoning, and processing speed, we indeed found that those older Black adults that had reported worse sleep quality were more inclined to perform worse on these tests.

That was the first bit of evidence that made me say, "Oh, there's something to this mechanism. Let's further explore this."

Dr Salas:  Great. Tell us a little bit about some of the research you're doing now?

Dr Gamaldo:  I've definitely been still looking at the sleep and cognition functioning, particularly in Black older adults. Also expanding out to lower socioeconomic households of older adults. That can include not just Black adults, but that can include also other racial and ethnic groups.

One of the projects that I'm working on that I'm hoping to get off the ground, is now incorporating more objective measurements of sleep by use of actigraphy to see again, this can potential connection between sleep patterns, as it might relate to everyday cognitive functioning.

The idea is to look on those nights where people are showing on these objective measurement tools like actigraphy, poor sleep. The next day, what do we see in terms of their cognitive functioning. Their ability to do task in their environment that require some cognitive processing.

Dr Salas:  A lot of our listeners are practicing clinicians, actually seeing patients. I'll bring my perspective as a sleep neurologist in that. Obviously, there's been a ton of research looking at the links between sleep, the importance of sleep with cognition.

In fact, the Memory Center at Hopkins, they often refer their patients that are getting evaluated for cognitive decline to the Sleep Center because it's such an important factor.

Sometimes patients may have other sleep disorders that are undiagnosed and therefore untreated. For example, obstructive sleep apnea that's identified and treated, and the cognitive issues can improve.

I'm wondering from your perspective is there any advice or any tips, things that we should be thinking about, things we should be asking, especially, you mentioned at the beginning, talking to the family members. Are there key questions or any tips that we could at least ask about when we're seeing our patients?

Dr Gamaldo:  Yeah, I think and you already know this, because we've talked about this before, but there definitely should be an effort to ask people about sleep as much as possible.

I know that typically you as a sleep specialist, that's your specialty, you're going to ask those questions, but taking your approach and seeing if it could be transformed into other practices within medicine. A general practitioner, that should be part of some of the questions that they ask.

Ask people about their sleep. I know that some practices ask people about, especially older adults, they'll ask the older adults about their memory or give them a global mental status questionnaire such as the Mini‑Mental State Examination or now the Montreal Cognitive Assessment, the MoCA.

Why can't we also incorporate some sleep measurements in there as well, so that we could get a holistic idea of what's going on with that individual? That could be explaining the reason why they're coming to you to begin with, which is the complaints. They might come in and complain, "My memory is not so good, right?"

It might be because their sleep is impacted and their quality is not so good, but if you're not asking questions about their sleep, you're not going to probably be able to make that connection.

Dr Salas:  You're right. I'm obviously a big advocate about non‑sleep specialists asking about sleep, because sleep is one of those aspects of life that's important across the health domain. It puts people at risk. Definitely the message here is to ask your patients about sleep.

If they are having issues with sleep, certainly thinking about referring them to a sleep specialist, someone that can take a little deeper dive because as I mentioned earlier, they may have an undiagnosed sleep disorder that can be treated and helped any memory or cognitive issues that they may be having.

If that cognition does not improve, they may need to be referred for more extensive testing like at a memory center or whatnot.

Dr Gamaldo:  Absolutely. I totally agree, and to add to not just to sleep question and to add to some additional questionings that could be useful in taking like I said, this holistic approach. Rachel, you were the first to bring me to this terminology called personomics or tailored medicine.

It is trying to think about other factors that are going on in the individual's life that are tapping into social influences, environmental influences that could also contribute to a person's sleep health as well as their cognitive health and their everyday functioning.

I think questions that are tapping into that like what's going on in your environment, like what does your environment look like, not in just your neighborhood environment, but the actual residential environment that you're in?

If there's not a goodness of fit between characteristics in terms of the social, the physical built aspects of those, and that's impacting the person in terms of how well they sleep at night as well as how their mood, how they feel, which could also impact their sleep as well as their cognitive functioning.

Those are also some potential additional questions that maybe we need to start thinking about incorporating into clinical practice. That will give us more of this holistic picture of what's going on with the individual.

It also gives a sign of potential intervention or prevention designs that could tap into those things to adjust them, and those adjustments may be enough to help sustain a person's successful health.

Dr Salas:  Yeah, great. I want to give recognition to Dr Roy Ziegelstein, who's a cardiologist by trade and our vice team for education at Hopkins, who coined the term personomics, which fits into the overall scheme of precision medicine that personalize road map for taking care of the patient in front of us.

We still use evidence‑based medicine and now are able to get biological data on the individual in front of us, but at the end of the day, we do need to remember that this is a person with beliefs, past experiences, different levels of support, the environment as you mentioned, and all that factors in.

We can recommend xyz treatment or managements, but at the end of the day, if the patient has heard something from their friend or had a bad experience in the past, they may not do it.

Dr Gamaldo:  Yeah.

Dr Salas:  I love this idea of treating the person in front of us and meeting the patient where they are. Before we started the recording here, you were saying some very interesting things that I think are important in the setting of the pandemic and talking about a little bit about loneliness, especially in older adults.

On the sleep clinic side, not only has insomnia and issues with just poor sleep quality because of circadian rhythms, now with people working more from home and not getting out and getting sunlight exposure, and things like that, all of that can negatively affect their circadian rhythm and therefore your sleep‑wake schedule.

You mentioned this point about loneliness in older adults that has worsened during the pandemic. Can you talk a little bit more about that?

Dr Gamaldo:  Yeah, this is empirical data that was increasing before the pandemic, emphasizing the need to address potential social isolation and loneliness that's being observed in our older adult populations. Particularly as it pertains, there might be some disparities in terms of risk for isolation and loneliness.

I remember coming across a study, escapes from mind the name of the study, but a study that was identifying that particularly for Black adults and men that there could be this risk of social isolation and loneliness, particularly in urban areas or metropolitan areas.

There was this literature out there before the pandemic, but since the pandemic that has amplified, so there is more recent literature talking about us being mindful of the consequences of the isolation that many of our older adult population was exposed to during the pandemic.

You're seeing evidence of the consequences of that. If you're not familiar, I think last week or the week before that Alzheimer Disease Research Center, actually reported that the proportion of Alzheimer disease has gone up since the pandemic.

Some have speculated, is this a consequence of some of that social isolation that occurred during the pandemic, and lack of social engagement that occurred. It's just something that we need to be mindful of, that our older adult community is definitely in need of resources to help them maintain their social engagement. The ability to use that engagement as an opportunity to help with maintaining their cognitive processing. Which we know there's a connection with social engagement and cognitive functioning, as well as we know the benefits of social engagement when it comes to mood.

Those are definitely something you need to pay attention about. I'll say this, I'll get on my soapbox a little bit here because I typically do this when I talk about older adults. I've been saying this for years, and now I'll say it even more. Now, since this pandemic.

I am at a point now in my career, and I'm trying to do better at this. I'm starting to engage with people who are experts at this, not just thinking about just strictly conducting observations in terms of research but thinking of ways of how can these observations be translated into meaningful practice or solutions?

I don't think we can hold off any more of trying to make a conscientious effort of trying to perform transformative research, which is this idea of taking the research and putting it into practice.

That is something that I think I would like all of us to make a better attempt at doing that, of not just strictly saying, "We're just doing basic science anymore," and not thinking about how is that going to transfer to applied research?

Dr Salas:  Yeah, thanks for that. I think this is an important message. I also think the focus on loneliness. I just finished reading the surgeon general's. Dr Vivek Murthy's book "Together" which talks about human beings.

We're social beings and at the end of the day, who we are is we interact with and who we love, and who we hang out with. The pandemic certainly has taken this to another level.

I almost feel that we should be, in clinical practice, asking our patients "Who are you hanging out with? Are you having fun doing that?" I know many of our colleagues in primary care often do that. I have colleagues that are geriatricians that are really focused on that. I think that it's so important. Definitely for the older adult population, but honestly, I think we should be doing it for everyone.

Dr Gamaldo:  I think so too. I was just about to say that. When you're, in terms of, I don't just see that for older adults. I'm seeing this with my undergraduate young adult students. I'm hearing the same type of need. I'm hearing it also is a sentiment, even for the younger population.

I just think about, yes technology has been beneficial in terms of getting people some of that ability to socially interact and engage, but it's not enough. There is this human need for us to actually be with others, face‑to‑face and engage.

Technology is not going to fill that potential role. I do think that as we are in this tech era, and we are finding these technological solutions, to make it feasible to have a wider social network. The question is, are those quality social relationships? Which is really what we need.

We need that quality, meaningful relationships. How much of those, that we're getting through this wider social network through electronics, is giving us that component? That's pertinent.

Dr Salas:  Yes. I guess we will see. We were just having an important discussion yesterday about our medical students, and this new generation. They've come up having access to smartphones, and tablets. Their interactions with other human beings are different.

Now that we are in this pandemic and there's a lot more telehealth happening, and telemedicine happening. How is that playing out? You know what I mean? It would be different if the pandemic hadn't happened. Even though the generation has been connecting with each other through electronic means, but now everything seems to be revolving around electronics.

Dr Gamaldo:  Absolutely. What's interesting, is I see some people trying to tap into these questions, but I would love to see more people tapping into these pertinent questions. It's that there's pros and cons to this, like everything.

Like I said, the benefits is that we've widen the opportunity for people to connect with others. The disadvantage is, how meaningful are those connections. If they're not meaningful, is that detrimental to people's well‑being and health? Those are definitely some critical questions that I'm hoping some research group is starting to further disentangle.

Dr Salas:  I think that that is going to happen. The pandemic has helped us uncover the need to further investigate this especially in the setting of loneliness, and the need for social interaction and how that can affect a person's health and well‑being, not just patients, but anybody.

Dr Gamaldo:  Exactly. Across the lifespan.

Dr Salas:  It'll be interesting to see where we are in a couple of years with that, and what recommendations we're making. In the meantime, a couple of take‑home messages at this point would be, if your patient is having cognitive memory issues, concentration issues, is obviously to do a cognitive screening or assessment there.

Then, to dig a little deeper. To ask questions about, potentially, their sleep, how's that going? Are they at risk for a potential sleep disorder? Is this someone that you should maybe refer to a sleep specialist for further evaluation?

Trying to get back in and to connect with the person that's in front of you, that patient. What's going on in their lives? Are they connected with others? Are they getting out?

I've had patients in the last few months that are working completely from home, and they're so busy now because you can go one meeting to the next. They're not getting out and walking outside or even getting sunlight exposure.

There are environmental things that you mentioned, and I mentioned as well, which relates to sunlight exposure and impacts on the circadian rhythm, and how that can lead to poor quality sleep and insomnia. Circadian rhythm, sleep‑wake disorders often get overlooked, and they're very prevalent right now especially with people working from home.

Currently, daylight savings times. It's darker, and this and that. All of that can impact a person sleep‑wake cycle. Again, circling back to maybe even contributing to any issues that people may be experiencing related to cognition.

Dr Gamaldo:  Absolutely. I'm not quite sure if it's feasible to ask all these. I'm not a clinician, but I do think if we can make an attempt to hit on some of those topics that you hit on, through questioning, it will at least give a better insight of what may be some contributing factors for why that person is seeing you today.

Also, gives you an idea of like, "What might be some recommendations for this individual that is going to be feasible that they will incorporate it into their everyday life?" as you talked about earlier.

It's one thing to tell someone do it, but if they're going home and they don't have the social support, they don't have the environment that's conducive for them to incorporate that recommendation that's going to be very hard for them to incorporate that. If they do, it's going to be hard for them to maintain that over time.

Dr Salas:  Again, going back to that personomics that we mentioned earlier, meeting the patient where they are, connecting with their social support. In fact, I'm the director for interprofessional collaborative practice at Hopkins.

When we talk about the interprofessional teams, it's not just the doctor, the nurse, the pharmacist, the social worker. Actually, the patient and the patient's family are part of the interprofessional healthcare team.

It's for the point you mentioned, we can make all the recommendations, but at the end of the day, the patient doesn't have the support, especially their cognitive issues. Are they going to be able to take their medication? You rely on the family members or friends or close neighbors to help to provide that care.

Dr Gamaldo:  I'm so glad you brought up that point because that's an extremely important point, especially, when it comes to early no diagnosis for mild cognitive impairment or even if the person is beyond that, is making sure that all the in family is involved in that conversation so that everybody is on the same page of how this is going to progress.

What are some recommended things that they should start incorporating so that they can maintain that person, their loved ones functioning. Far too often, you see that not all the family members are part of that process.

Sometimes you'll see that because of that there's some confusion going on of, "What should we be doing? I don't agree with this. Why are we doing it this way?" That creates unnecessarily family tension.

It is important to have these conversations with the critical family members and friends, that will likely be part of the care process for their loved one.

Dr Salas:  Yeah. Thanks a lot for that. I'm curious, one of the things that I like to do when I have these discussions with experts in the field are, especially in the context of what we're talking about, social beings, well‑being, overall mental health, and overall health.

What do you do personally? What do you do to stay engaged and to balance or not maybe not balance to try to achieve wellness for you. What's that look like?

Dr Gamaldo:  Yeah, so I think it's fluid. I'll be honest with you on that one, it's fluid, and it shifts over time. To maintain wellness, it could be a matter of just trying to get in some physical activity. When I have the time, especially it's been a very hectic three months here in the semester.

During the summer, when I had a little bit more time not having to teach classes, I really tried to get out and do walking just taking a good long walk outside in nature.

Not putting my headphones on, just like letting natural sounds of the environment help to soothe me as I'm walking and getting in those that physical activity. I thought that was extremely relaxing. Now that it's winter, of course, I'm not doing that as much, but actually getting on the treadmill occasionally.

Sometimes I can't keep...I'll be honest, I'm not consistent with that. Other things that I do to achieve that wellness is doing a pamper time.

I wasn't going to this spot because of COVID. But I'll just have my own little mini pan throwing session. I had my face masks, I do my routine, had a foot massager, like anything that to just decompress and de‑stress was what I was doing in terms of my wellness, and then doing creative things.

I was doing paint by numbers one time. I was into this paint by numbers kit. I was doing creative things like creative activities, crafting, cooking if that's something you like, that relaxes you. You do that. Why I say it's fluid because obviously, you're not going to do the same thing over and over. You want to flip it around.

Definitely, I think it is extremely important to be cognizant of when you do need that relaxation time. Think about things that you would enjoy doing to help you decompress. Because we all are going through a lot of stressors right now. I think it's important that you recognize some subtle signs that it's like your stress is becoming more reactive, and trying to bring in strategies to help relax.

I've heard people do mindfulness, I haven't tried that but if it works, do that. Yoga? I've done that. That was helpful. Again, it's not like I'm going to run to a yoga class during the pandemic. I could do it at home, but it's not quite the same. Those are, I would say, an array of things I do to help me with my wellness.

Dr Salas:  Yeah, and I like asking that question because I think that as people in healthcare and healthcare research, the practices that we have, that we know we're more likely to engage with the patient. I feel that the more we share what we do that others who hadn't even think about painting by numbers.

I tried to do the mindfulness and I tried to do it in little bits of time. If you're driving somewhere, you don't want to zone out at all, but just be present. It's that meta cog. Where you're just aware of being present. You talked about taking that long walk, I think the Japanese call it forest bathing where you just get out in nature and soak it all in.

One of the things I heard recently with one of the groups I'm involved with was about bringing nature inside. Because it's going to be too cold, or maybe it's too late. If you have plants or a terrarium, or a goldfish just something that connects us with nature because I think that's the other.

We talked about human beings being social beings but also we're connected to nature. If there are any that could be a nice so maybe you can't take your walk outside, or go to a forest or anything like that. Maybe could have walk inside and see some things that are nature. Some plants or things like I had just mentioned.

It's really a lot we can do and a lot that we can share. I think the more that we talk about it, either as clinicians or researchers, I think kind of reminds people that this is important and that.

Dr Gamaldo:  I'll tell you, during the pandemic, I'm going to put my colleagues out there. They listen to this but my good strong group of colleagues that I had, we had a female scientists Zoom, happy hour every other twice a month, if not every week.

We met on Zoom and we just chatted about our work, about our personal life. It was a great way of us connecting, especially connecting with some people who actually understood what you're going through in your day‑to‑day routine.

I think I have to say that my impressions from what they've said, my own is that that was extremely helpful, particularly during that time. That's another way I think people can also help maintain their wellness is having those meaningful engagement opportunities with colleagues that you feel like you can trust and you could talk to. As well as friends, close friends, and then definitely family.

That's one of the things that I definitely do value is the time I have with my family, and just having a conversation at the dinner table, and it could be on any topic. Having that time to engage and laugh and have over a good meal and play board games, if that's something you are interested in. That's I think could also very pertinent for wellness.

Dr Salas:  Yeah, no, so that it all great tips and ideas and certainly many of those I've even done myself and I just want to encourage those that may be listening to think about. Not only asking your patients about what they're doing for fun, and are they connecting with others?

Then also taking that next step and actually giving some examples. You're going to hear me ask these questions to all of our speakers because I think we need to show that it's important not only for us but for everyone. I want to thank you Dr Gamaldo, for taking the time and coming to share your research, what you've done, where you're going. Bringing up four important points about how sleep is related to cognition, and how we should be asking our patients about their sleep.

Especially, when they're having memory and concentration issues. Then also going beyond that and reminding us all that it's about the person in front of us. Who they are, again, what their experiences are, what their beliefs are? That idea of personomics is truly important, and I'm glad that we're moving. This is not new. I'll talk about physicians but back in the day doctors went into patients' homes, and they really got a sense of who the person was.

They saw the living conditions. They saw the family members. Many times, the doctors were in the same community. They went to the same church, or the kids went to the same school. They had a better connection with the patients. Now, there's more people. We're more connected by technology. It's almost just needing to circle back. Now, we have a term for it, personomics.

I want to thank you. We've discussed some important points, particularly, that are very current with the pandemic. I look forward to hearing more about the work you're doing and getting some tips in the future. Thank you so much.

Dr Gamaldo:  Well, thank you so much. Thank you for having me. I'm glad to be able to speak with you and your listening audience today.