Dr Ben Newton Facebook Live Q&A | Treating Knee Issues
Regenexx Cayman visiting physician, Dr. Ben Newton from Stem Cell Arts recently participated in a Facebook Live. During the Q&A, Dr. Newton discussed the use of stem cells and blood platelets for treating knee issues and answered some of our patients’ frequently asked questions.
As a triathlete himself, and Regenexx Physician, Dr. Newton understands the impact training and competition can have on an the body, and has extensive experience treating sports injuries.
These are just some of the questions that Dr. Newton answers in the video:
Regenexx Cayman: Hi everyone, I’m Jacqueline Ebanks and I’m one of the directors here at Regenexx Cayman, and we’re gonna be live today with Dr. Newton. He’s one of 13 visiting physicians here at Regenexx Cayman and today we’re gonna have a little chat, Dr. Newton and I, and we hope you’ll enjoy it. So just a few things first, a little bit of housekeeping. Regenexx Cayman was founded in 2011 and we provide orthopedic treatments with stem cells, using your bodies own stem cells. So we will be live today having a little chat we’re gonna probably be live for about 20 or 30 minutes. If anything goes wrong, technical difficulties, we will come back – so you can just watch for it popping up, hopefully, there will be no tech runs today but just in case.
We will be answering questions that we have received already and if you have any questions now you can go ahead and pop them in the comments, and we’ll be monitoring those as well. If by chance we don’t get your question while we’re live then, we will go ahead and respond to that either in the written comments, or we will spawn to you privately. So I’ll also give you details later on in the broadcast about how you can contact us and stay in touch. If you’re getting ready for pirates week festivities today and you can’t stay live for the whole time and you want to come back and watch it later, an easy way to do that is hit the share button, and some of your friends that might need this information will have it as well, but it will also show up in your timeline so you can come back easily and find it. So first things first we’re gonna go ahead and get started and Dr. Newton thank you for being here with us today.
Dr. Ben Newton: Pleasure.
RC: And why don’t you tell us a little bit about yourself. Give us a little bit of your background and how you came to be involved in regenerative medicine.
Dr. Newton: Okay, so I started out in primary care and initially had a very strong interest in musculoskeletal kind of pathology and issues and that led me to do a fellowship in sports medicine. While doing that fellowship I was exposed to professional teams that I worked with the Cincinnati Reds and was able to help with a lot of the local high schools and colleges in the Cincinnati area. And that just ingrained even more a desire to help those active folks not just professional athletes, but those that are active across all boards, to stay active and then I started noticing this trend that we’re all kind of falling apart at a certain level or degree, and we want to do the best for ourselves that we can, but sometimes we’re not looking for that surgical fix.
I was looking for you know what are the alternatives and by the time I had finished my sports medicine fellowship, I’d been exposed to other ways to get a tissue better; whether that be sprains, and different types of degenerative conditions, better in a shorter period of time and avoid surgery, and that led me to do another fellowship in Colorado with Centeno-Schultz. They have a one year fellowship, I was able to go out and do that, and when we’re exposed to a wide variety of the regenerative therapies that are out there right now; that’s your prolo-therapies, your PRP’s, stem cells and that gave me the opportunity to even come down here to Grand Cayman and do some of the fun stuff that involves the culture experience – and we’ll talk a little bit more in detail about that later. But I’m fascinated by the body, fascinated with how it can even work all of these different pieces together and it’s no question that we do put a hard and heavy load on our bodies every day, and if I can help people get back to doing the things they want to do, that’s what we’re all about here.
RC: Perfect, yes well we’re so glad that you’re here and a part of our team. And today we’re going to focus mainly on the knee. I understand that’s a particular interest of yours. So we’re going to be talking a little bit about the knee, and we have received some questions so I hope you guys will indulge me, I’m going to get my little note cards here because I don’t want to miss any questions that we have. But like I said if you have other questions or even if you’re tuning in on the replay, and you haven’t had a chance to ask questions live – you can go ahead and pop your questions in the comments and we’ll be sure to get back to you. So let’s just go ahead and have a little chat together and we’re going to start with, you know I’m not a health care provider and we run the business admin side of things (when I’m not channeling my inner Oprah on Facebook Live), but one of the things that’s fascinating to me is how many things can actually go wrong with our bodies and with our knees.
On our website for example we have a page that talks about the conditions we treat, and just for the knees alone there are 15 conditions listed there, and I’m pretty sure that’s not all of them, but we’re not going to talk about 15 conditions today because I’m sure that would take quite a long time, but would you go ahead and share maybe some of the top three or five that you see in your practice?
Dr. Newton: Sure. So yeah the knee it seems like a pretty straightforward joint I brought a model – everybody has seen a model like this and you’ve got knees yourself you know how they work. It’s thought of as a hinge joint, but it’s a little more complex than that. There is some rotation here and there with the knee as you’re doing your activities of daily living and so a lot can go wrong there’s not only tendons and muscles attached here but there’s also cartilage surfaces. If I peel the kneecap back there are some cartilage surfaces that can get worn down. And you can start to develop problems there and these problems can be a pain. Pain such as arthritis is one of the big reasons that people come and see us. Other things are more traumatic, or maybe just worn out over time which would be your meniscus tears, maybe you’ve got an ACL or a PCL strain or spring. And when you start having mechanical problems with the joint that’s usually when you start seeing folks come in – they want to know “hey I can’t straighten my knees anymore, or when I go running it swells up real big. What do I do about that?” So I’d say that top three is osteoarthritis, meniscus injuries, ACL or ligament injuries, and from there they may split off into the smaller groups.
RC: But we have options to treat all of those things right?
Dr. Newton: Yeah
RC: One of the questions that we get is how do you know which options to use for which things?
Dr. Newton: That’s a great question. And really it’s not as simple as just saying my knee hurts you know my knee hurts well I’m wearing black so you can’t see that, but my knee hurts right here and knowing what to treat it with it – we like to have people come into the office, let us evaluate you, we can do an exam when we’re kind of twisting the knee pushing it and pulling on it in different ways to try to make the real problem area jump out at us, and we also get some advanced imaging, that that would include potentially x-rays or MRIs and we even have ultrasound right here in the office that we can take and look at your meniscus or we can look at some of the cartilage surfaces and say “hey you know you have pain here but that’s that the problem is specific to the tendon for example and that then lets us say treatments from conservative to aggressive are XY and Z”, and a lot of folks I would say come to our office in the States and say “okay I want you to fix me” and when we go through all the options that they have, here’s our conservative to our aggressive treatment options, they look back at me and say “well which one should I do?” Well, it depends on what you want to do and what your goals are and so part of helping you helping us treat you is knowing what you want to be doing what. What are the things that you enjoy, what are the things that you can’t live without and we’ll try to get you to those points based on the treatments that we have.
RC: Alright so we have blood platelet procedures. We have stem cell procedures. Those are the two sort of main categories of treatment options that we have. So when would you use for example blood platelet type treatment?
Dr. Newton: Sure. So if I’ve got a tendon issue – so let’s say my quadriceps tendon is a little bit irritated, so again I’ll pull up the model because I’m a visual guy so you’ll see me pull this out a lot. But if we’re looking at the knee, the quadriceps tendon comes from you your groin or your hip area, down to the front. There’s a kneecap here and some people get some irritation along the top of that tendon as it then inserts into the kneecap. So this is one of those cases where PRP would probably be sufficient. That’s where we rotate your blood, we process the blood, and they were able to visualize it with an ultrasound and inject exactly where things are not looking right. So whether the tissue is disorganized or there’s a big bone spur hanging off, we’re going to address that problem very specifically and under direct visualization, which is just to say we’ll see the problem and be able to treat it without just sticking a nail in the joint and hoping the cells go where they’re supposed to go or that the platelets signal the way they’re supposed to do.
So the tendons are one thing that we use with platelets. Certain meniscus tears we may treat with just platelets. But if you’re starting to have cartilage involvement is where you know the blue area on the screen is the cartilage surfaces on the bones, there’s divots and/or loss of cartilage somewhere that’s when we’re going to lean more towards the stem cells. Meniscus tears, certain meniscus tears also we’re going to say “hey let’s maybe try some PRP first, and if that’s not sufficient we may shift gears and go to the stem cells”.
RC: Perfect thank you so much for that explanation. Let’s talk a little bit more about the stem cells, so we have the Same Day procedure (Regenexx-SD), and then we have Regenexx-C, the cultured procedure which is what we offer exclusively here at Regenexx Cayman. When would you recommend Regenexx-C for example versus Regenexx-SD?
Dr. Newton: Very good question. I think that it’s a pleasure to be able to come down here and offer this to patients. The Regenexx-C allows us to take bone marrow, just like we would up in the states, but we have the ability to process the cells here in such a way that we can multiply the number of cells we have to work with. And this is very helpful if you’ve got more than one joint, or a very large joint. It’s not infrequent for us to see people come down and say “you know my knees hurt and I got a shoulder that’s also been bugging me for a while. Can you treat all of these?” And for a Regenexx-C procedure, this is perfect. Because we will get several times over the number of cells here in Cayman than we would up in the states, and we just don’t have the same processing and the same ability to analyze the cells as well.
So what’s great about coming down here, is once they do take your cells and they put them through the culturing process there’s also some testing that goes on those cells to make sure that once they’ve gone through their expansion cycles that they’re still you know mesenchymal stem cells that they don’t have any weird abnormalities as far as their genetics, and their karyotyping is done. And so this is above and beyond what we can do, or we’re allowed to do even in the United States.
RC: Alright and that’s one thing I want to emphasize is that we do take patient safety very seriously, so all of our cells are tested for sterility and safety prior to re-injection. One thing that you said, you were talking about treating multiple joint, but one thing that I have learned that I found absolutely fascinating is sometimes people, you know come in and say “you know my knees hurt”, and then it turns out that it’s not just their knee though. So when is it that a knee issue is not really a knee issue?
Dr. Newton: That’s a question that’s hard to know off the top of our head. I can’t tell you how many times people come in and they complain of their knee and yeah they may have some problems with their knee, but when you solve that knee problem, you find out well that the knee was a result of something else whether downstream at the ankle or upstream at the hip or back. And so when we have people come in, and this is why you can’t just send an image and expect that the physician to know all the things that are wrong – because if you send us an image of your knee and it looks bad we’ll tell you what the knee looks like. But when you come down here, what we’re going to do is do an exam. And not just an exam on your knee, but we’re going to examine your hip, and your back, and your ankle. And the reason that we want to do that is we want to make sure that the other parts aren’t playing a contributing role to the knee.
I mean oftentimes you have a low back, someone’s got smoldering low back pain, it’s been going on for years and years, you take care of that and all of a sudden the knee pain is much reduced. So I think to answer your question, “how do you know when it’s when the knee pain is not coming from the knee?” It’s when you do an appropriate evaluation, and you look at all of the components that come into it. And we take a full hour with our new patients. We’re not trying to see 30, or 40, or 50 patients in a day so that we can, you know, meet whatever quota. We are trying to see what is your problem, what’s connected to the complaint, and how can we help the whole chain, everything that is connected, improve itself. That way you’re getting longevity out of what we’re trying to do here.
RC: Exactly. So oftentimes I think people come to us and one of the reasons they find us is because they’ve been recommended for surgery, either some sort of a surgical repair or even joint replacements for example. And they want to explore all of their options you know prior to committing. Surgery is a big commitment. Can you talk a little bit about the advice that you might give to someone, just generally? What sort of general advice might you give to someone who has been recommended to have a surgical procedure?
Dr. Newton: I mean most of the patients I see, have either had their surgical evaluation or I send them for one after I’ve seen them because I think it’s nice to have all the cards on the table when you’re trying to make a decision about what to do with your body. So when trying to tell somebody you know you should consider surgery or not, we can’t go back to what’s the problem – is it pain, or is it function? And if it’s functional, where the knee is not bending or straightening the way it should even get appropriate gait walking, then we’ll say you probably need to have a surgical evaluation. I mean that’s when your range of motion is so decreased that that joint is no longer probably going to be helped much by … injections, by cortisone, by anything other than probably replacement.
But there are a lot of folks who have, you know they’re very functional, still, they’ve just got pain or they’ve got some mechanical problem that’s impeding their range of motion and their function, and it’s what’s causing them pain. So if we can look at that and give a complete evaluation to that joint, that’s where we can say “hey there’s options”, and these injection options are using your own body stuff is, I think it’s miraculous. You know I get excited about it and I could go on talking about this forever, but I get excited because we’re using your own body to fix you. That that just seems to inherently make sense to a lot of people, and I think we just we want to give people knowledge and then help them know what their options are, instead of just you’ve got arthritis, or you’ve done cortisone, now it’s surgery, that’s becoming an antiquated solution.
RC: Yeah and like I shared before on our last Facebook live with Dr. Fenton, we’re involved in this practice but we’re also patients of this practice. I think you know, my mom has had treatment, my daughter has had treatment, Phillip (Regenexx Cayman Director) has had treatment, and even me – so we’re very grateful and we believe in this. And I think another important thing that I find fascinating is how many health care providers actually choose Regenexx as well, or choose the non-surgical option first. They want to explore that. Doctors and other health care providers, I think at one point we were having sort of 25-30% of our patients were other health care providers. So you know when people who work in this field are also choosing this option and you know it brings a level of sort of comfort to other people as well because it is a big decision.
Dr. Newton: It is. I mean it’s when you’re faced with the option of saying “hey we’re going to just lock that joint out and put a new one in, and then you’re going to be fine.” versus “hey let’s try a couple of other things first and see if we can’t make that joint better”. I mean that that makes people do a double-take. A lot of times they’re like “wait a minute I didn’t even know that was a possibility” and so when we feed them this information, well you can try you know platelets or stem cells and then there’s the cultured procedure, it opens a whole window of hope and opportunity that they’ve been looking for and maybe, I mean some people drag their feet for months before they even want to commit to a surgery, because they just don’t like the idea of something else being in them and they want to go with what the good Lord gave them, or mom and dad gave them. And so if we can help them understand that these are options.
RC: It is really a great feeling to be a part of that and giving people that opportunity you know to recover faster and heal naturally without surgery. But let’s help our viewers understand a little bit more about the differences between surgery and our procedures, so I spoke a little bit about the timeline for recovery from like various surgical procedures. And then we will talk a little bit about what our approach procedure process is like.
Dr. Newton: So a typical procedure, one of the most common is a meniscus repair so that involves going in and again apologize for reaching over you there, but you’ve got a meniscus tear, so if we’re looking down here we’ve got this kind of this white tissue here, if I look from the side it’s the bumper or the cushion between the bone here, and the bone down here. As you’re walking sometimes that will get torn and irritated and when it does get torn there’s a zone that’s got a good blood supply in a zone that doesn’t have a very good blood supply, and oftentimes historically the surgeon will go out and trim the stuff that doesn’t have a good blood supply because their thought process is it’s not going to get better. When you do that you’re losing a bit of your shock absorption. And though it may feel better for a time it’s gonna speed up the progressions towards arthritis, and pain will come back, and then it comes back with a vengeance.
So when you go through a procedure where they’re fixing that meniscus, they’re putting you on crutches for several weeks and usually you’re gradually getting back into activities, but by six to eight weeks most people are back doing what they were doing before. So for someone who’s very active and they want to get back active, this seems like a very attractive idea and for of couple years maybe it is reasonable. But the long-term effects of the having done that are well known and well documented. There’s an article just came out in one of the major magazines, a peer-reviewed journal, comparing physical therapy to meniscus repair an acute injury and they found that there was no difference in the first six months three years, something like that. So it was interesting that the body wants to repair itself it wants to fix itself but we need to give it the tools to do so, and oftentimes that’s where we get a lot of patients wanting to know what can we do to help them, help that happen.
RC: Right. So it sounds like time is sort of an essential component. And sometimes we do need to give our bodies a little bit more time, so investing a little bit more time on the front end might save us in the long term, and have a better outcome.
Dr. Newton: Absolutely if something’s injured you can prime that injury, give it the appropriate nutrition, put things where they need to go to kind of help the body have extra growth factors for example and you’re likely going to get better healing. Like a knee replacement, for example, you’re gonna be out for six to nine months. Most people say they don’t feel normal for the first year. That’s a long time to go.
RC: That is a long time to go.
Dr. Newton: Trying to deal with that depending on the age of the patient, if you’ve got someone who’s a little bit elderly or more elderly and they’ve got a year of rehab – that’s a lot. That’s a pretty onerous process to go and get back, and they should if you get a knee replacement you should be committed to doing that kind of rehab, and we find that with the regenerative processes. You don’t have that length of recovery, which is great. You get back sooner, you’re less invasive, the chance of infection, I mean the list goes on and on, but you are not in a hospital setting for … you’re not exposed to tourniquets and things like that that can set you for a higher risk for blood clots and infection and things like that. So if you’re thinking of risk versus benefit, stem cells by far outweigh the risks to benefit ratio compared to surgical procedures in my opinion and in what we’ve seen.
RC: And another thing too is if you’re a younger person who’s been recommended for a joint replacement, those things have sort of a lifespan of their own right, so you might end up actually having to have another procedure afterward. So sometimes, our procedures, it’s not that you might never end up having surgery, but you could maintain your ability to enjoy doing what you love for longer without having that.
Dr. Newton: Well yeah, can you imagine that at 40 years old, getting a replacement, whether it be a hip, a knee, or a shoulder, at 40 years old with the lifespan of that replacement being, you know at beat 20 years, now you’re looking at 60 years old and you’ve got to get that thing re-replaced, and re-replacing you know it’s not that it can’t be done, it’s done pretty regularly, but every time they do that there are those risk factors come back, and they’ve got to take a little bit more of you out when they’re replacing things. It’s just that whole recovery cycle and risk of adverse events that we’re trying to help people – if we can cure you 100% fantastic. If we can get you functional, to doing all the things you want to do, great. If we can get you so you can push off replacement so that you have only one of them in your lifetime in that joint, great.
RC: So we have just a few more questions here if that’s okay with you for us to keep going a little bit longer. This is great, this is fascinating. I think people will actually really learn a lot from it, so thank you for taking the time. Earlier you mentioned sometimes people have steroid injections and I know that can be that sort of immediate relief and when you’re in pain there is nothing like immediate relief. But what are some of the things that we have learned about steroid injections on how can we help people determine whether that sort of you know the best choice for them, and maybe let them know about another option?
Dr. Newton: Yeah, well I think its cortisone has run rampant in the last 10 years or so. Everybody has had one or is going to get one and we shouldn’t just accept that as gospel as the best thing for our joints. We know there have been multiple studies showing that cortisone itself is not good for the tissues, it’s not good for the joint, it doesn’t help things heal, it’s great at turning off inflammation but when we talk to people about inflammation…
When you turn off the inflammation, it feels awesome. Your joints are not swollen anymore, you’re not feeling pain, so you can get out and continue running or doing the activity you want to do. But when we do that we’re stopping the natural process of the body trying to heal itself. I mean it needs that step of inflammation to signal the body’s immune system to bring over the helpful cells, the stem cells, and the growth factors, the natural anti-inflammatories that are very helpful in healing an injury, and if we don’t have it if we stop that by taking steroids, we’re just asking for problems. And certainly if you know if I put something in a joint, cortisone in a joint and the body has gotten injury there, the flags of help are being disregarded. And I’ve seen people go out and continue doing their sport and what was a moderate injury becomes something significant, and now the option for doing something like a regenerative procedure now becomes a non-option. It becomes, surgery is needed because they did so much damage. And that’s unfortunate.
RC: That is unfortunate so we hope that this information helps you to learn a little bit more about how to think about your body and what’s going on with you and then give you some ideas for how, if a problem arises or how you might go about best treating that for you.
So we’re going to shift gears a little bit just in the last few minutes of the segment because we’ve talked a lot about what to do when something happens. But some of the questions that we get is “how do we keep things from happening?” This is one of the things that I’m really interested in because we all want a sort of Fountain of Youth and a lot of things go into that – diet, exercise, how we treat minor things, so what are some general tips that you might offer and maybe think about different sets of people. I know for example you’re an athlete yourself, a triathlete. And we have the marathon coming up in just a few weeks here, so maybe you can give a few tips for athletes and maybe just a few general lifestyle tips for people who just want to be able to stay active and healthy as they grow older.
Dr. Newton: Sure. I think the athletic population has a special interest for me. I think it’s just because I’m in the midst of that right now myself, and I think there’s a couple of things I think about. Number 1 is the training that you’re doing if you are an athlete and your training is allowing for no breaks, no rest, that’s one thing you should correct. Give yourself some time to recuperate. Number 2 is don’t always train the same way. If you’re always working the legs, the quads, or like the calf muscles you need to give time for the other imbalance to the other muscles. So have a good rotation where you’re working the front side, so think of it as front compartment stuff and back compartment. Your quads, your hamstrings, your calf muscles, everything needs its attention. And having balance and symmetries is important. So for those athletes obviously having a good regiment where you’re also warming up before you go into a competition, a marathon is no small feat it’s a long distance of…
RC: I’m not running a marathon…
Dr. Newton: I’m not running either… 26.2 miles is no joke, and most people do hit the wall in that 13-17 mile range because they haven’t trained appropriately or maybe the conditions aren’t right. And so helping yourself by making sure you’re well, you know stretched out that, you’ve got plenty of fluids in your body, electrolytes, and specific to the knees if you’re on balance if your quads are stronger than your hamstrings you’re gonna have knee problems most likely. Those quads, when they contract they’re pulling that kneecap right back into the femur, and you will have, if there’s an imbalance there, you’ll start to have potentially patellofemoral issues, you may have some meniscus issues.
Having good shoes if you’re a running athlete or anything you’re doing on your feet, you should have appropriate Footwear because this there’s no excuse, with technologies now and I’ve got all these great shoes you should be able to get shoes that have a good arch support that can support you through whether you’re a runner, a cyclist, or a weightlifter, you should have some good shoes because it comes from the bottom of your feet, your knees, your hips, if something’s wrong and one of those three areas or even your back if something is wrong there it will pull from another area until there’s dysfunction.
For young folks, I wouldn’t stick in one sport. I would alternate sports. So if you’re a rugby player one part of the year try to do something else – whether it’s swimming, or whether it’s something that doesn’t do the same type of impact, that’s helped a lot of folks. And also keeps your interest, you don’t fatigue and burnout. We talked a little bit about nutrition with some of the runners and then I think if you can get a personal trainer or someone who’s into the physical therapy, having someone work on just watching you walk and run and making sure that you’re not asymmetric. That your muscles in your butt are firing compared to, you know, most people have that funny waddle when they’re running. Sometimes their butt muscles are not firing right or maybe the quads are too strong on the outside versus the inside. And so investing in yourself isn’t just going out and exercising, it’s investing in those around you as well to help you be your best athlete or your best person.
RC: And that’s going to help throughout…
Dr. Newton: Oh so I mean for the older folks, I think the flexibility is probably the biggest thing. Flexibility gets, as we get older I hate to say it, we start to dry out a little bit. You know when we talk about folks feeling like they’re getting shorter and they’re not bouncing back as quickly, we’re just not as hydrated in our discs and in our muscles and our tendons and ligaments when we’re not as hydrated, we’re not as flexible. So working on flexibility for the older folks is super important.
Working on strength and balance are second to that. If you don’t have a balance and going out and taking a run or even walk can be quite dangerous especially with some of the sidewalks and debris that can be out. So I think for older folks definitely having that, plus again a good a nutrition plan should help them out a bit.
RC: Perfect so but what I’m hearing is that exercise is important to your general health and then also like even if you’ve had a procedure, it’s important to sort of increase that or work back up to including exercises a regular part of your routine.
Dr. Newton: Absolutely, I think some people feel like they have a procedure and maybe they don’t feel perfect, so they just kind of wait and wait and pretty soon so much times gone by that they’ve lost whatever gains they had prior to the procedure so it’s important for folks to have a rehab protocol and follow that, and if you feel like you’re getting stuck somewhere talk to your physical therapist, your trainer, and then find out where you’re missing and get yourself back on track. But being active it’s kind of one of those use-it-or-lose-it things. If you don’t, if you’re not active, you can’t expect your body to perform when you want or need it to. And lots of things, you know mental health, we know that mental health is better when your folks are physically active.
We know that the metabolic rate is increased somewhat from physical activity. We know that people are generally less stressed and things like that when they’ve got a little bit of exercise in them. Whether to walk down the driveway or around the block or a vigorous run for 20-30 minutes. It all plays to your benefit, but we just want you to do it safely and we’re here to help make sure that your parts are staying together and that if you need surgery we’ll send you that way, but a lot of times, when I was a fellow they said 98% of any of the sports injuries can be treated non-surgically. And I’ve always kept that in my head you know, there are some injuries where a surgeon should see that person. But for the most part let us have a look at you. We love sports medicine and musculoskeletal stuff, and we look forward to seeing you here in our clinic.
RC: Dr. Newton, thank you for your time. If you’re catching the replay and you have any questions, feel free to drop them in the video comments or you can send us an email [email protected] and once again Dr. Newton, thank you so much for your time and I hope you get a little bit of time to enjoy some of our island pirate festivities tonight.
Dr. Newton: Pirate weekend!
RC: Have a great Friday everyone, thanks for tuning in, bye.
Dr. Newton: Thank you.