Pediatrician and sports medicine specialist Celina De Borja, MD, paints the big picture of why strong bones are essential to overall wellness and explains how providers can efficiently assess and address their patients’ risk factors. Her tips cover how to ask questions about sensitive topics (such as menstrual cycles and disordered eating), when to run labs, who needs supplemental vitamin D, how to interpret pediatric Z-scores, and the level of physical activity needed for bone growth.
You know, um issues um I, you know, do phone, phone a friend. Um And so we, we can talk about, you know, different strategies as well. So, um our two main objectives are to recognize conditions that may interfere with adequate bone health and also review strategies to help optimize them and our Children and adolescents. And so, um uh I am on zoom and so I only see a few thumbnails on the screen. So if I don't realize that you're raising your hand or, you know, have a question, so just feel free to unmute, please. OK. Uh so um before we begin, you know, what is bone health? So, you know, bone health is, you know, a public health issue um that with an emphasis on, you know, prevention, um an early intervention to promote strong bones and prevent fractures um and their consequences. And that was a definition provided by the office of the surgeon general. And so why do we want to talk about it, you know, aren't both just for mobility and the, the, the answer is not, not really, you know, bones are very important, they're not just for movement or mobility um they help protect our vital organs or brain in our spinal cord, you know, our heart and our lungs and, and other vital structures. Um and they're also involved in producing important cells or essential cells um in, in day to day functioning. So RB CS, you know, our immune cells also help, you know, regulate calcium and and other electrolytes. So, you know, bones are very important and we, we want to keep them healthy. And so, you know, when do we even talk about these, you know, issues on bone health. And you know, the answer is, you know, as soon as you possibly can, you know, as soon as you have the opportunity. Um and you know, this is why I love talking to primary care providers about these things is because you usually have, you know, first your first point of contact, you know, with the medical system, especially those who are seeing them. Um you know, in infancy, um our kids have a unique um risk for fractures, you know, just by being skeletally mature. So, you know, their bones are built differently from, from, from us adults. And so, you know, they have their own risk for fractures, but also their activity levels, you know, they're just really brave and, and, you know, um adventurous and so they, you know, we, we get to see them, you know, here in the clinic for a lot of, you know, different musculoskeletal injuries. Um but more importantly, you know, 90% of our peak bone mass is obtained during childhood and adolescence. And so, you know, I usually tell the kids, you know, you're able to collect calcium for your bone bank, you know, during the first three decades, as you can see on the photo over here, this is that, you know, upward slope of, of, you know, calcium, um you know, collection into your bone bank. Um you know, after 30 you see that processes become slower and in fact, by your forties, you know, you, you start to lose more calcium uh um or start to lose more bone that your body it can't create. And so, you know, thereby leading to, you know, osteoporosis, you know, when, when we're elderly. And so, you know, where do we even start? Um and who remembers this diagram from medical school or medical training? Um Yeah, no, this is not my favorite diagram. I'm, I'm, I'm also so intimidated by this diagram myself. Um It's calcium homeostasis. Um And you know, when I was, you know, trying to, to, to study it, you know, better and you know, help explain it to, you know, our residents or, or fellows and, and also other colleagues and I was able to, you know, bring it down to kind of, you know, three simple things. So three organ systems are influenced by three hormones. Um and they all, you know, regulate calcium. So, you know, the three organ systems include the bones where, you know, 90% of our calcium is stored. Um and then, you know, it also involves our G I tract um and our kidneys and the three hormones that influence, you know, the direction at which, you know, calcium moves our pth or parathyroid hormone. So, parathyroid hormone, um you know, aims to, you know, keep calcium in the bloodstream or in the serum by, you know, taking away from bones, you know, increasing re absorption from the kidneys, but also increasing absorption from, from the gut or the G I tract. And for that to happen, you need vitamin D, which is our second hormone. Um vitamin D um improves absorption of calcium from the diet and without adequate vitamin D, all that calcium rich nutrients from the diet just gets flushed away. And so vitamin D is very essential in, in conversations about bone health. Um and then lastly, calcitonin cain likes to keep calcium within the bones. And so it acts through reverse mechanisms um to keep calcium away from the stream, but you know, towards the bones. So that's kind of how I I think about it. And you know, ultimately, if we're trying to keep calcium in the bones and absorb all the calcium on diet, I really emphasize imports of vitamin D, you know, through this mechanism. Now, who needs to have this conversation about, you know, bone health. Um and the answer is, is everyone really you know, you could be working in primary care. Uh you can be working in, you know, Scotty clinic like myself, I'm in orthopedics. You can be in the urgent care. Um you know, you can be an MD Dopanp, you can be a nurse. Um I even encourage our life trainers who are on the field with these athletes to, to really talk about bone health because um you know, some risk factors are more obvious in certain clinical settings. And that, you know, brings us to our um first objective for today, which is recognizing conditions that may interfere with adequate and bone health. Um you know, there's intrinsic factors, right, or nonmodifiable factors um that we, we, you know, consider when we're talking about conditions with our patients. So intrinsic factors in uh terms of bone health include age, um we see higher risk for, you know, muscle skeletal injuries in the adolescent group. Um because there's just, you know, a high, you know, bone turnover, you know, they're growing, they're active, they're, they're um you know, they have this significant risk for injuries and then also with our elderly, like I mentioned earlier with the whole osteoporosis um situation. Um And then there's gender as well, you know, we see more bone health issues in women, you know, compared to men. Um and then genetics, uh while we see, you know, bone health impairments in, you know, diverse facial populations, uh they seem to be most common in our white and Asian women, especially um those that have um family history of osteoporosis. Um medical facts um are very important in screening, you know, patients for inadequate bone health. And so this is why, you know, I encourage, you know, having these conversations in primary care. Um because um you know, these patients more than, you know, we do, we see them in, in little snapshots during their childhood, you know, during these injuries or whatnot, but you, you get to meet them, you know, throughout their, their lifetime. And so anyone with G I issues, you know, specifically those that may um increase risk for fat mal absorption, say I bt celiac, you know, CF um you know, I would think about their bone health. Um then, you know, anyone with chronic uh medical issues such as the liver or kidney disease, like we said, you know, vitamin D um is monopolized through those organ systems. And so you wanna make sure um that you're thinking about their bone health, if they have any of those pre-existing, uh childhood cancers, inflammatory conditions, rheumatological conditions or endocrine conditions, you know, think about their bone health. Um anyone with uh medication exposure. So, you know, those uh that were exposed to any steroids, especially, you know, um you know, high dose or prolonged courses. Um a lot of times you think about standard exposure um and the kids with rheumatologic conditions or maybe, you know, childhood cancers but don't forget about, you know, those who have been exposed for respiratory exacerbation. So, when I was, um, you know, uh, training in the east coast and primary care pediatrics, um, you know, we, we had harsh winters and, you know, with, with every season, you know, a kid may get, you know, an, um, like a standard burst, right, for their asthma exacerbation and, um, you know, having known them for the past three years of, of, of medical training, you know, you realize that they've gotten at least one or two of those first, you know, throughout the past three years. And so just being mindful of that and, and thinking about how that may affect um their bone health is, is really important. Um any patients who have seizures, you know, anti convulsant, um you know, think about their bone health, um antifungals, antiretrovirals and antidepressants have also been implicated in impaired BMV. So uh just be mindful of that. Um And, and then last, but not the least, you know, mental health or behavioral conditions um uh are also linked to poor bone health. So this isn't the setting of eating disorders or disordered eating um or, you know, female athlete triad um where we'll get to a little bit um and few slides. So, um orthopedic factors um are usually when we kind of capture these patients with bone health questions. Let me just see. There's something in the chat steroids. Oh, great question. So someone asking the chat for medication, is it just the stomach steroids are inhaled as well? So, um traditionally the T shirt was systemic steroids, right? Be on the lookout for those for um any, you know, endocrine um disturbances or, or bone health disturbances. However, um I did meet a patient I was seeing her for, for fractures who was on inhaled steroids um that had some form of, of growth disturbance. And so I know that, you know, the the classical teaching um is that, you know, inhales steroids for control for asthma um is is less um of an issue for complications, right? Um You know, still, still think about it um in, in terms of their bone health. But yeah, good, good question. And yeah, I was, I was actually pretty surprised to tap a conversation with that patient because, you know, in pediatric primary care, I was just taught to like, you know, put them on controller so that they don't get their flare ups and their, their bursts. But apparently they, these um inhaled ones aren't, aren't as safe as we, we originally thought. So um just, yeah, be be, think about it as well. Um And so um moving on to, to orthopedic uh factors. Um so recurrent fractures, um you know, especially here in, in, in our clinic, this is, you know, an opportunity for us to talk about own health. So usually two or more um fractures in childhood. Uh we start, you know, having a deeper conversation about it. Um stress fractures in those athletes or even the non athletes especially. Um we start talking about bone health. Um I've seen bone health issues and stress fractures in the non athlete population. One was just prolonged walking um because he had been very inactive because he was sick, you know, for um you see to feel like suit, he was always, you know, not, not active, but now that he's feeling better, he started walking, you know, in their neighborhood and they got a stress fracture. So you gotta think about, you know, why they, they injured so easily. And then another one, was just running, you know, laps and pe and, you know, you would, you would think that, oh, you know, every other kid's running laps and pe, right? And so why did this kid get like a tibia stress fracture? But, you know, we, when we kind of, you know, work them up, they, you know, had vitamin D deficiency. Um And so that, that was kind of one of the, um the triggers for us to have a conversation. Um, vertebrae compression fracture is also in a risk factor, risk factor, especially if it's a low impact um mechanism. Um And then for other factors that seem routine, but they're just not healing um, with our expected timelines or delayed union, we also think about any issues about bone health. Um And for those who see um kids who, you know, are mobilized, say they have any neuromuscular condition or cerebral palsy. Um you know, kids who lack that impact right in their bones, uh they may have impaired B MD um because of, of that. And then um there have been other Ortho associations with low vitamin D or for bone health um specifically in Skiffy or scoliosis. And so, uh we don't routinely um treat those patients for, you know, bone health issues. But um especially if we're gonna be treating them, um surgically, we, we do um check their overall, you know, bone health status just to make sure that we, we kind of um anticipate any issues when it comes to, you know, postoperative outcomes. And so, um, you know, other factors um that, you know, I, I put under modifiable factors include their diet. So, um I asked very specific about diets, um because, you know, with, with kids, it's, it's pretty broad, you know, do you avoid any, you know, food groups, do you have any special diets? You know, is it for, you know, specific reasons, you know, is it, you know, social, is it cultural religious? Um is it for medical reasons? So, you know, say, you know, some kids are lactose intolerant so they'll avoid dairy in their diet. Um And, you know, some kids are on the spectrum and are very, very picky eaters. So, you know, just making sure they're having, you know, balanced diet and not missing out on important nutrients is important. Um uh studies show that kids who have high protein or high sodium in their diet, they're um associated with reduced calcium retention. Um And then, you know, a lot of studies from the A P also show that those kids who um consume soda, um when they're younger, they're associated with lower um intake of, of milk and calcium in their diet. So that's why we're trying to, you know, keep them away from these, um these drinks and, and you know, to make sure that they're, you're taking the right nutrients and then lastly, obesity. Um so vitamin D right is very important in bone health. Um And, you know, vitamin D is a fat Sobule vitamin. Um And so the, the, the theory behind obesity and, and poor bone health is that vitamin D is getting sequestered into the fat cells and not into their bloodstream. Um And so a lot of times they're vitamin D deficient and that's why they have impaired B MD. Um So, uh moving on to modifiable factors, there's um you know, lifestyle, um and you know, and just habits, good habits. So, you know, sedentary lifestyle and a inactivity um is, you know, risk factor for poor bone health. You know, like I mentioned earlier, Impact Act on the bone helps it become stronger. And so our, um you know, kids and adolescents nowadays who don't engage in sports as much or don't have pe as often as we did when we were younger, you know, definitely may have different um status in terms in terms of their B MD. Um And then sleep, sleep is apparently also very important for bone health. So, um this article over here on the right side, you know, was published out of a study that was performed in uh University of Buffalo. Um And um at their institution, they perform a lot of DXA scans um for, for women. And they looked at 11,000 women who've had Dexa scans um in their institution and they asked them about their sleep patterns. Um and what they found was that, you know, those who slept, you know, seven hours or more had better B MD compared to those who slept less than five hours um each night. And so what they're suspecting or their theory behind this is that, but, um you know, bone remodeling or healthy bone processes happen when we're sleeping and if you're not sleeping enough, then it's just not happening properly. So, you know, always um emphasize the importance of, of adequate sleep for our Children and adolescents. All right. And then lastly, um you know, since, you know, sports medicine is, is my special area of interest, you know, I always want to talk about athlete specific factors. So the female athlete triad um was a phenomenon that was described back in um 1997 by the American College of Sports Medicine and it described this phenomenon where in female athletes um who had eating disorders. So this red triangle over here had eating disorders also had stress fractures or osteoporosis um were also missing their periods. Um Over time, they realized that, you know, it wasn't just exclusive to this triangle over here that the, the triad is more of a spectrum. So, um in certain seasons or times of the year, these women can have optimal energy availability or not have an actual eating disorder, they can have regular periods um and they can have optimal bone health, but they can travel through the continuum. Um you know, over time or in, in various uh seasons and it is important to recognize them everyone as a whole. Um Before they get to the, this red triangle over here, it's important to intervene so that we keep them on the green triangle over here. Um about a decade after the female athlete triad was described um the A CS M and also the International Olympic Committee um introduced the concept of relative energy deficiency in sport. And so um two things were different from the triad phenomenon. One, the triangle was only a slice of a bigger pie. And so, you know, low E A or, you know, um inadequate nutrition didn't only cause mental dysfunction and you know, poor bone health or osteoporosis or stress fractures. It's also associated with uh you know, a few different uh complications in different organ systems. Um More importantly, the second thing that's um with the red S compared to the is that this is something that's also seen in our male athletes. Um and it does not only cause zoological um complications, it also affects their performance. And so now our athletes are paying attention to low E A or an A or get nutrition because it doesn't only cause cause, you know, physiologic issues, it actually affects their ability to, to play their sport or optimize their athleticism. And so, um now that we, you know, kind of reviewed um risk factors for um impaired bone health, I'd like to move on to our second, um you know, objective which is, you know, reviewing the strategies that can help optimize bone health in, in Children and adolescents. And so, you know, it really starts with, you know, very, you know, thorough conversation about their overall health. And so, you know, sometimes they come in to see me for like a 15 minute fracture visit, but then we end up, you know, talking for about 45 minutes or so because we really need to do an extensive review of their um their history. So again, um foreign points to, to highlight, you know, any dietary practices or restrictions. Um I asked about, you know, very specifically, um you know, what kind of physical activities do they engage in? Uh if they're not in organized sports, I asked, do you still have pe how many minutes a day? How many days a week? Um, if they don't have pe, which I'm finding a lot of our older high schoolers don't have anymore. Um, I ask about, you know, certain lifestyle, um, activities that may count as physical activities such as, you know, walking to and from school, you know, take, taking public transportation, having after school activities that may be on the club or recreational level or any activities that they do with the family during the weekends. Um, I also ask about, um, uh, meal dysfunction specifically. Um, and, and with these, um, young girls, I, I don't just ask if they're regular or irregular, I ask how many cycles they're getting in a year. Um, because I've already had, you know, one kid tell me she was regular and when I asked her how many cycles she had, she said she had six each year, which, you know, I said, no, no, no, that's not regular. Um, you have to have at least nine each year for us to, to, to say that's, you know, kind of a, a healthy, um, you know, number and, you know, although, you know, we think that, you know, when they're younger, maybe they're irregular in the beginning, um, you know, things have usually, you know, follow a more regular pattern after about, you know, 12 to 24 months. Um And then also, you know, I asked how these um periods um are affected by exercise, you know, if they're saying that, you know, when I'm in season, when I'm exercising more, you know, things start to, to space out. Um And then when I'm not in season, you know, things are happening more on a regular basis then that I, I advocate that, that, that might be, you know, an, an indicator of low E A or an advocate nutrition. Um and then fracture history. So, you know, how many fractures in the past, you know, what are the mechanisms? Um Is it really, you know, high impact, like, like, you know, trampoline or monkey bars or is it something that, you know, seems very subtle? Um And then also asked about, you know, how they were treated, were these, you know, injuries that, you know, heal in about four weeks in a cat or a splint maybe or are these injuries that, you know, required prolonged immobilization? Um And then, um lastly, you know, family health again, you know, any um history of osteoporosis or poor B MD, we, we'd like to ask um any inflammatory conditions or chronic medical illness in the family that may be, you know, diagnosed early on, you know, during their child adolescence, I asked about that. Um And then, you know, looking, just looking at their overall growth chart um could be helpful as well. Um All right. So, um the A AP doesn't necessarily um require us all to you know, check for bone health labs but they do recommend, you know, being proactive if you find any significant risk factors. Um But, you know, a good place to start would be, you know, your vitamin D level. So it's the 25 0, vitamin D. Um and um, you know, although the definition for deficiency is below 20 the what's optimal, you know, for our Children and adolescents is 30 above. Um and that's because, you know, 30 seems to be the magic number where and it's preventative of fractures. And so now this table um is kind of how we, um, you know, treat our kids who were, you know, treating for any vitamin D um issues. Um, 30 above no need to supplement them. Really, you can just get it from their diet or, you know, sun exposure. Um, at 20 to 29 we treat, um, and this is usually the over the counter um dosing and then less than 20 is deficiency. And so we definitely would treat that with prescription dosing. Um There's a few different methods, there's the, you know, 2000 daily and then there's the bowls dosing of 50,000 weekly for 6 to 8 weeks. Um There have been some studies that say that the weekly bowls dosing works better because of the compliance aspect. So a lot of, you know, families may forget to take their vitamin every day. But if you, you know, prescribe them just six or eight pills that they need to take, you know, say every Sunday, um, that seems to, you know, work well, um, with a lot of our patients and then after that, you can reject their levels in like 6 to 8 weeks. See where they're at. If they're still less than 20 you actually can repeat the cycle. Um, but if they're bumped up, say 20 to 29 or 30 above, then you can treat them accordingly. Um Usually we'll, you know, do maintenance after that, you know, after, um, you know, they got the bullets for deficiency because, you know, just because, you know, if, if they're really that low, they're probably not getting enough um through their regular diet. Um And so, you know, uh other labs, you can also check depending on the clinical picture and this is, you know, where if you like, you know, primary care is, is better than us by, you know, by doing these things. So, you know, with the CBC, you can look for any clues, you know, say any Meron disease, any pancytopenia, the electrolytes are good way to screen for any G I um liver kidney issue, um, inflammatory markers, ESRCRP are a good way to screen for um rheumato conditions and then, you know, pth for any endocrine concerns. Yeah. So, um you know, um Dexa scans, um we don't routinely get them for all patients that were doing, you know, B MD um Evals, it is a formal way to assess B MD but we not everyone necessarily needs it. Um Usually it's for those with primary bone disease or secondary bone disease, we're in um, you know, like medical intervention, you know, would be um indicated for prevention of lectures. So a lot of times even if I initiate, you know, getting the scan, I usually um you know, attach it with a referral to um our pediatric metabolic bone clinic, you know, to make sure that, you know, should anything come out, um you know, out of the ordinary that, you know, there is an endocrinologist who's um able to not just interpret, you know, these results, but also, you know, discuss medical management of these patients. And so I just wanted to mention a few different um uh details about the pediatric excess scan. Um just so you're aware, you know, for when you're ordering it or if you know someone's transferring care and, you know, has a report with them. Um and to, to better interpret these things. So, um pediatric and adult scans are different. The pediatric protocol um includes the P A of the spine um with a TB LH or total body loss head. Um because some body parts that are used in adults aren't as reliable um when we're looking at, you know, skele, I mature individuals, um the report has to have these scores when you're looking at Children and adolescents. Um and not T scores, T scores are for adults. Um These scores are standard deviations that are um sex, age and race or ethnicity matched reference ranges. Um and anything above negative two should be fine and anything, you know, equal to or less than negative two is considered low bone density. Um The term osteoporosis is uh according to the guidelines for, for pediatric dexa osteoporosis is not used in a pediatric Dexa report because it has to be um at negative two or less with a clinically significant fracture history. So, um these score report plus, you know, either reti compression fracture from low energy trauma um or more than two frac long bone fractures. Um you know, in in childhood and adolescence. Um so um more strategies to optimize bone health. Um you know, we we focus a lot on, on modifiable, you know, factors. So maintaining healthy weight is very important, you know, you mentioned earlier, too low of weight, right? You know, relative energy deficiency in sport, you know, disordered eating is, you know, is is associated with poor B MD, but also obesity, right, um is associated with obesity. So just, you know, managing healthy weight is in a balanced diet, is recommended. Um This um diagram over here um is, is called the athletes plate. Um It's something that I learned from our registered dieticians while I was training in sports. Um the the bottom line is that all macro nutrients are important So if you can see the plates, everyone has their, you know, carbs or pro protein, their, their fat, um, and, and fiber. Um, and, you know, the, the proportions change, you know, depending on their level of training. And as you see down here, you know, when they're training harder, when the intensity of their sports are, they're getting higher, you're gonna need more carbs, um, in your diet because carbs are the main fuel um for, for us who are exercising. So it's important to, you know, um you know, express that to, to the kids uh to make sure that they're eating enough, you know, depending on what season they're in. Um for sports. Uh yeah, I can share the links uh to these plates. Um uh and um I, I think uh at the top of my head, um if you type on Google the, the athletes plate, um it, it will show up. Um But yeah, I'm happy to, to share these resources as well. Right. And so I'm going back to calcium and vitamin D. Um, you know, these are the RDAs or recommended dietary allowance for calcium and vitamin D, you know, for our pediatric patients. Um, what I wanted to highlight in this um uh table is that the 9 to 18 age group needs at least 1300 mg per day. Um And, and I, I, and I highlight that a lot to, you know, the families because when you look at and the dietary sources of, of calcium, you know, a glass of milk, you know, barely makes 300 mg. And so it would take, you know, about 3 to 4 glasses of milk each day. Um, obviously there's non milk, you know, dairy products and there's also non dairy products, um, or fortified foods that are good sources of calcium. But um, while I usually push for dietary sources, you know, I talk to the family and, you know, be realistic with them and say, hey, if you feel like, um, these items aren't part of your kids' usual diet, then it may not be, you know, a bad idea to, to supplement. Um, the A P says, you know, kids in general don't need, you know, vitamin supplementation. But if they are to need anything, it's us, usually Callum D um, or iron. So that's why I, I try to um encourage, you know, dietary sources, but also, you know, kind of have a low threshold of supplementation if, if the kids really, um, picky and then, um, moving on to vitamin D, you know, the, the RD A for vitamin D isn't that high? It's 400 to 600 IU per day. Um, however, if you look at these dietary sources, um, of, of, uh, vitamin D, you know, they're salmon, sardines, mackerel, tuna, talking mushrooms. Um, and, you know, when was the last time you've seen these items in a kid's lunch box? Right? So, you know, a lot of times these, these, um, these items aren't part of a child's usual diet. And so, um, you know, although I, again, I, I push for, um, dietary sources, especially the, the fortified, you know, foods, um, breakfast cereal and, and whatnot. Um, if, uh, you know, I get a sense from the family that, you know, it's not really, you know, part of their diet, then I would also encourage supplementing in that case. Oh, thanks for, um, finding the athlete's place. Appreciate it. That was quick. All righty. All right. And then, um, lastly, you know, again, physical activity, um, that we talked about this a little bit, um, in the chat earlier, you know, the A P recommends about 60 minutes per day of moderate vig exercise for our kids, Children, adolescents. Um, but I do understand that, you know, there are a lot of sedentary kids, um, you know, who come to see us and, you know, it's, it's hard to encourage them if they're not already, you know, involved in these activities. Um, you know, sometimes it's, it's low hanging fruit. You know, what studies show is that significant bone growth has been seen and with those who do 20 minutes, you know, three times a week, um, and so if we can get at least that, you know, um, with the recreational activities or even ad L si think, you know, we're, we're, we're making, um, big difference in their B MD, uh type of exercise, you know, also is, is important. And so, you know, sometimes I see athletes who, you know, exercise a lot. Um, but they're not necessarily high impact athletes. So the swim swimmers and the cyclists, um, and, and usually, uh, they hate their high impact exercises. Usually they're not a fan of their dryline exercises, you know, they're just not in their element so they hate running. And so in these athletes, um you know, I encourage other activities such as, you know, Plyometrics or resistance training um that are also associated with improving your, your B MD. And then for those who are high impact athletes, um you know, say endurance runners or um or triathletes, um you know, making sure that they have, you know, a gradual increase in their load when they're exercising or entering their season. Um and also having adequate rest is important for a avoid avoiding stress injuries or stress fractures. And so, yes, Amy, we're almost there. Um That was actually my last slide. Um So, yeah, if, if any questions um or consoles, you know, please feel free to, you know, reach out to us. I'm available on email and also, um I'm on, I'm on in basket, a lot of, of um you know, community primary care providers do message me about, you know, mutual ca patients or even patients. They are kind of, you know, on the fence between like sending over here or not. Um, usually responsive to these um, avenues. So yeah, please, um, don't hesitate to, to reach out um, for anything.
