A recent study has found that repetitive Transcranial Magnetic Stimulation (rTMS) is effective in treating depression. The results showed that the majority of patients experienced a significant reduction in symptoms, with some even achieving complete remission.

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The combination of TMS (Transcranial Magnetic Stimulation) treatments and Ketamine Infusions is gaining national attention as a powerful way to alleviate Treatment Resistant Depression. For more information or to schedule an assessment call or text us at 330-754-4844.

Rooted Pelvic Wellness

In this conversation, Nick Angeles, a nurse anesthetist, interviews Rachel Russell, an occupational therapist specializing in pelvic floor therapy. They discuss the importance of the mind-body connection in relation to pelvic floor health and overall well-being. Rachel explains that pelvic floor issues can affect both men and women and discusses various conditions she treats, such as pre and postnatal care, interstitial cystitis, and pain management. They emphasize the significance of relaxation techniques, particularly breathwork, in addressing pelvic floor dysfunction. Rachel emphasizes the long-term commitment required for pelvic floor therapy and the need for ongoing self-care. Transcript below.

Nick:
Hello and welcome to the Ascend Health Show. I’m your host, Nick Angeles. I’m a nurse anesthetist and one of the owners of Ascend Health Center. And I’m here with Rachel Russell. Hi.
Rachel:
Thanks for having me.
Nick:
And this is a very rare show because usually I’ve known I know the people on the show, I refer to them. But in your case, like one of our mutual friends was like, you guys should meet. I was like, let’s just meet on the show. We’ll figure it out then That’s fine.
Rachel:
I like impromptu things and conversations. So. So here we are. Perfect.
Nick:
I know very little about you. You don’t know all that much about me. And we’re just going to pick each other’s brain. And other people might watch it too.
Rachel:
Sound good? Well, how about I introduce the fact that what I am Because it sounds great. So I am an occupational therapist. Most times people hear pelvic floor therapy and they think physical therapist. But I’m occupational therapy. So I’ve been an occupational therapist for 12 years now. I’ve done neuro, I’ve done ortho, I’ve done schools and finally landed here in women’s health and pelvic floor therapy. So awesome. Yeah.
Nick:
And the difference between a physical therapist and an occupational therapist. A physical therapist is more of like, let’s get these muscles working. Occupational is like more of let’s get practical things done.
Rachel:
Yeah, that’s a good way of putting it and kind of putting I like to think we think of a triangle mind, body and soul. So while we’re doing those practical things so you know, and what if you’re in pain and that’s affecting your getting dressed or you’re taking care of your family or your work, We look at kind of those things and trying to pick those apart and figure out what the problem is and how can we help that.
Nick:
Right. Well, that makes a lot of sense and a lot of times we don’t even realize we’re in pain because now that I’m an elderly 40 years old, I’m like, no, it’s normal for me to like kind of walk like this a little bit and maybe I shouldn’t bend over when I put in like 30 IVs a day. But yeah, a lot of times I need that reminder of like, no, actually get the right ergonomics. You still might have some pain because there was a study that came out that said like, Oh, you know how we’ve told nurses do things this way and you won’t get injured, you’re still going to get injured, but at least it won’t be as severe. What a.
Rachel:
Good what a good study.
Nick:
Was like. I knew it.
Rachel:
I knew it. I knew it. Yeah.
Nick:
And all this time I thought, well, no, I can lift this very large patient by myself and as long as I have the right posture, I’ll be perfectly fine. Yeah. I won’t be in bed for four days afterwards. Yeah.
Rachel:
I can’t tell you how many times that happened, but I’m glad I’m not doing that now, so.
Nick:
Okay, so what you are doing is working on the pelvic floor. Yes. And the interesting thing and why I also want to talk to you is because there is a mind body connection that you work a lot because now that this might be the 35th, 36th episode on this show. Okay. And more times than it really should have been, we’ve veered off into the topic of the autonomic nervous system and how more and more people every single year it seems like the root cause is like your parasympathetic nervous system which is supposed to relax, rest, let you eliminate waste, which is a lot of the pelvic floor. Right. And the sympathetic nervous system which is for running away from sabertooth tigers, are not working properly. They’re being switched on and off incorrectly. Whether it’s a mental health issue where they’re like, it’s 3:00 AM and I have a panic attack, I’m not scared. I’m not nervous. My body thinks it should be scared at 3 a.m.. And this is ridiculous. Right? Or the opposite where, you know, I know a patient that they can’t drive for more than ten minutes without starting to fall asleep. They need like gum or coffee. It’s like, well, even if this isn’t my specialty, I’m pretty sure that constant caffeine to stay awake is not something that’s going to be good for your adrenal glands.
Rachel:
Yeah, no kidding. And like, so getting to the root of it, right, Which is the whole reason why I named my practice rooted pelvic wellness because let’s figure out where your root cause is, right? And we talk so much about your we always talk about your upper body or your lower body and then this mid section. Right. We don’t talk about it at all.
Nick:
Right.
Rachel:
Nobody wants to talk about it. Oh, no, let’s no, let’s And I’m here to, you know, just tell everything about it because.
Nick:
It’s community TV. You can say whatever you want about the pelvic floor.
Rachel:
Fantastic. Fantastic. So the pelvic floor is so important because there’s it it like you said, about autonomic nervous system. So if you are tense and you are tight, what’s going on with your pelvic floor? Probably tight. Yeah. Yeah. So same with your jaw. So if you have jaw tightness and you’re like driving down the road and you’re clenched, I can probably guarantee that your pelvic floor is also clenched. Oh, crap. Yeah. Well, and pelvic floor. Did you know that? Not just it. Yeah. I focus on women’s health, but it’s not just a women’s health issue. It’s also You have a pelvic floor too. I do have a pelvic floor. You have a pelvic floor? So do you know how to relax your pelvic floor?
Nick:
No, I do not know.
Rachel:
We were kind of talking before about what we need to do and whether it’s strengthening or lengthening.
Nick:
And this relaxation isn’t going to, like, relax my bowels or bladder either. I mean, it’s great community TV, but, you know.
Rachel:
Hey, no, no, no. Which one was.
Nick:
Your most watched show? Funny you should ask.
Rachel:
Funny you should ask. The one we talked about.
Nick:
You did have to close down WC TV for a week, but it was. It was great TV. It was great.
Rachel:
TV. Great TV. Oh, but so the whole point is to be able to relax that pelvic floor we hear so much about strengthening and it’s quite the opposite. You can’t strengthen an already coordinated or an already stuck muscle. Right? Right. You have to have that coordination of a muscle because if you are already tight, you cannot you can’t relax it. So we have to work on that coordination first and we do that coordination through breathwork.
Nick:
So so you’re saying just like when you exercise at a gym, you’re going to do some reps and then you’re going to relax, you’re going to let the muscles relax and then you start again. It’s similar with the pelvic floor that it’s not just something like let’s strengthen those muscles. Yeah, a lot of us live tense lives and you’re saying no, you’re tensing those muscles all the time. You need to learn how to relax.
Rachel:
We need to learn how to relax. Because when you take a breath in, your diaphragm drops and your pelvic floor actually lengthens. So think of like old school Toy Story claw machine, right? So it comes down, gets a aliens like that claw machine, your pelvic floor should actually do that. So as you take an inhale in your pelvic floor actually lengthens and then as you exhale, everything lifts back up. Okay.
Nick:
So that’s how we relax the pelvic floor. That’s how you.
Rachel:
Relax the pelvic floor. And once you have that coordination, then you can work on that strengthening piece. Okay.
Nick:
And before we get any further, like what kind of issues are we talking about here? Oh, yeah. The reason that people come to see you because I think what you’re saying too, is that a lot of issues can be traced back to this. Yes. And obviously not everything. I’m sure. You see, some people are like, nope, pelvis is fine. You need to go see somebody else. Correct. But so what kind of why would somebody come see you?
Rachel:
So that’s a really good question. It doesn’t just have to be like I said, women. It can be a male or a female problem. I genuinely generally see more women than men.
Nick:
But I can still refer.
Rachel:
A man to you. Yeah, you could. And then if I don’t, I I’m a big believer. If I don’t have the tools in my toolbox, then I don’t have a problem referring out. So that’s how we keep everybody.
Nick:
Right? Otherwise we have a rusty toolbox. It’s like, Oh, I think I can help you. Where’s that one?
Rachel:
Yeah. Right. Yeah. So but pre postnatal women. So if you’re getting ready to have a baby and need to kind of prep pelvic floor because that you hear old school thinking is oh you push the baby out, you don’t actually push that baby out. You actually lengthen those those muscles by your breath and your uterus pushes out your baby. But being able to kind of learn those that breath work and if you’re having any like round ligament pain, you know, lightning pain that those things during prenatal and then postnatal obviously that whole six week don’t see a doctor until like with or you need that six week follow up. Sure but which is true but you also can work on breath work and things so I like to talk even before baby about kind of body ergo dynamics and getting in and out of bed if you’ve had a C-section. I’m working on that C-section scar. Also people with interstitial that’s such a hard word for me is really difficult. Such a hard word that, you know, speech therapy as a kid cystitis so that painful bladder syndrome. Right. That’s kind of looking at where your bladder it’s often misdiagnosed as a UTI for sure, but it may not actually be. It might be just your bladder and your brain not talking. Right. And that’s something.
Nick:
I deal with a lot too. Okay. It’s one of the rare side effects of high dose ketamine is that you could get interstitial cystitis. Yeah. So something that we’re always watching out for giving supplements for. Yeah. So. Wow, that’s really interesting.
Rachel:
Breathwork would help a lot with that and being able to calm down that nervous system because if you are in constant pain, your nervous system is going to be high, right? So breathwork is a great way to kind of target that nervous system and help calm that body down. And once you’re able to calm that body down, then you can look at ways to functional strengthening, if you will.
Nick:
And you said something really interesting about the six week period of like you’ve had a baby. Yeah, go home, figure it out, come back in six weeks and let’s see what’s happening. And that’s something we talked about in one of our previous episodes was that I feel that one of the most important things in health care is find those crucial times childbirth, surgery, illness, post COVID. That’s actually when you need the most attention. I would agree. Instead of like, Well, we let you go for a month, then we discharge you. And what happened? Do you have any side effects? Right. It’s much better to have somebody paying attention, not just a three minute visit. Right. That can make sure to guide the body through that very crucial time period. Because usually that’s what I see. I mean, I’ve been a nurse since 2004, a nurse anesthetist since 2010. Hundreds and thousands of anesthetics of ketamine infusions. And a lot of it is. Even mental health issues. It kind of boils down to, okay, I had a blood transfusion at this hospital or I had mono or I had this surgery or had this trauma. And like the whole system falls apart and not just the body, often the mind, the spirit, everything is affected by one hit that wasn’t managed correctly. Yeah.
Rachel:
And so that’s why I really like with my my mamas who are pregnant, I like to teach those postnatal skills so that breathwork is such I keep talking about breathwork Nick But there’s no side effects. There’s no side effects.
Nick:
Unless you hold your breath too long, I guess.
Rachel:
Well, yeah, true. And I can’t tell you how many clients I’ve had come back after the first session because usually my homework at my first session is go home and we’re going to do diaphragmatic breathing in the morning. We’re going to do it at night and then come back and and they come back and they’re like, I don’t know, is this did this really help me? Yeah, it did. It did. Just taking that time to like, just listen to your body during that time. Right. And like, oh well, my hip didn’t hurt yesterday. Well, what did I do today that made my hip hurt? Just that that paying attention. Right.
Nick:
So how do you educate? Because in our culture sometimes we do want the quick, magical, amazing fixes like somebody is going to go in there and they’re going to do things to my pelvic floor and I’m going to be great. And you’re saying, Well, just breathe because I try to tell people like, Well, look, let’s start with things that can’t hurt you because if you go to a provider and we choose the wrong thing that has side effects, then when you come back, you’re not where you started. We’ve literally moved you back even farther, right? It’s sort of like let’s say you’re single and you’re looking for someone. You’re still ahead of somebody who’s in a bad relationship. That’s true because they have to break up with that person, get over it and then they’re single. Right? So and I know that’s a weird analogy, but it kind of works.
Rachel:
I followed you. I went with you. I’m glad. I’m glad. Yeah. That’s the thing about pelvic floor is it’s not I mean, probably close to what you do too. It’s a long haul game. It’s not like, yes, you might have some short term relief with what we’re doing in in our sessions, but it really is something that you’re going to need to continue to do and continue to do for the rest of your life. And so that’s I always tell all my clients like, listen, I’m here, we’re going to fix your immediate problem and then we’re going to I’m going to get you reconnected to your pelvic floor and then I’m going to teach you how to get connected to your body as well. And so that way, you know, if we’re done and it’s a year later or whatever and you’re like, oh, like, you know, I had this major thing happen at work and my kids are driving me crazy and all of a sudden I’m like all tense and I’m having leakage again. Right? Well, oh wait, I can remember what Rachel told me to do about my breath and being able to kind of relax my body in a way that I’m not going to have those signs and symptoms. So.
Nick:
So you’re saying, look, if if you do your part, then you won’t have to see my face as often. Yes. If you don’t because. So we do. Spravato It’s a ketamine nasal spray. Okay. By Janssen And it’s meant to be done weekly. Yeah. So I tell patients if you only do this, you will see me weekly for the rest of your life. If you do a little bit of effort, some therapy, some praying or meditation, then we can go down to once a month and after a while you won’t need to see my face. I was like, you know, most this isn’t maybe the the state of philosophy a lot of places, but if you go to see a provider, the goal, the mutual goal should be how can I not see your face after a while? How can you fix me and then I don’t have to ever see you again?
Rachel:
Well, and not maybe not even like see you ever again. But like I want to be want less frequently. Yeah. I want to be a coach on your team, right? Like, so I. I don’t know much about football, but I know that there’s a lot of coaches.
Nick:
Great. Either way.
Rachel:
So perfect. Yeah. So. But I know that there’s a lot of coaches there right on the sidelines. So I want you to remember like, you know, I’m doing my exercise, I’m doing my breathwork, but I can’t get I’m still having that urgency. Oh, I’m going to call Rachel back up because she’s my coach. So and similar thing like if you’re going to I give you exercises to do and you’re going to do them at home, great. I’m not going to see you that often, but if you’re not going to do your exercises at home, I guess I’ll see you a little more often.
Nick:
So what you’re saying is use me for time outs and between cause, but I don’t need to be doing the play by play eventually.
Rachel:
That’s long term game, right? Like that makes sense. Yeah. So initially we probably need depending on what your plan works out. Same with you. I would imagine so.
Nick:
So what about endometriosis or a lot of those ovarian problems where it’s like, wait, is this a metabolic syndrome? What’s going on with this? Because those are often underdiagnosed.
Rachel:
Well, with endo you see a lot of pain, right? So that’s and whether you’ve had surgeries that have led to adhesions or whether the endo is actually causing adhesions. So again, nervous system, right. How can we work to kind of calm your nervous system down, calm your body down and get yourself to relax so that way you’re not having that pain. And then again, because oftentimes. Most all my patients are weak in their pelvic floor areas. It’s not just pelvic floor, right? So pelvic floor is connected to your hips, is connected to your butt, is connected to your abs, is connected to your back. It’s all a canister system. So we need to work on those things so that that with that endo, we work on ways to manage because sometimes you’ll have urinary frequency there because I’m in so much pain or emptying your bladder or your your bladder is smart, right? When you’re born you have this imaginary line that you’re you fill your bladder up, your brain goes, Oh, time for me to go to the bathroom. You go and you go to the bathroom. Right?
Nick:
It’s a great.
Rachel:
System. It’s a great system. So convenient. We as humans screw up that system because.
Nick:
When we have to be potty trained or.
Rachel:
No. Well, sometimes. I mean, it could go back from there, but more so like. So we’re going to lunch after this and you stop me and you’re like, Oh, I wait a second. I have to go to the bathroom. I don’t know how long I’m going to be in the car or I’m going to be going on a hike and I don’t have to go now, but I may have to go just in case. Okay. There’s no we don’t want to just in case, pee. Because as soon as you just in case pee. You’ve now drawn a lower line and your bladder goes and your brain goes, Oh, my line is no longer higher. As soon as I hit that threshold of my low line, I have to go to the bathroom. So now you’ve created an emergency and you’re not using the rest of your bladder. So I always tell my clients that if you feel like you have to go to the bathroom, then really take some breath. Hello. We’re back to the breath and see like, do I really need to go? No, you know what? I don’t need to go. And I feel comfortable that I’ve learned that the skills and the techniques, the breath and those those deep breathing skills that I’m not going to have an emergency. Right.
Nick:
That makes sense. Yeah. Is there a problem with the opposite? Because having worked in the ICU for many years, I’d go a full 12 hour shift without going to the bathroom.
Rachel:
Yeah, well, that’s not healthy either, Nick.
Nick:
This is all for me and my pelvic floor in case anybody’s watching this.
Rachel:
Well, I mean, if you think about, like, back to my inpatient rehab days when we would have patients come over with casts and you’re trying to retrain their bladder, we’re looking at every every two hours. Right. So technically you should be voiding every 2 to 3 hours. So when you’re in the ICU going, you know, 12 hour shifts, probably not the best. I’d also ask how much water you actually drinking then to Nick. That’s true. Yeah. So probably should look at that too. I probably should.
Nick:
That’s really helpful though. But and then the other issue I wanted to bring up was so I do a lot of pain management and it’s known in pain management that abdominal pain and this is a trigger warning for all your abdominal pain can often be from sexual abuse that even though there’s absolutely nothing physical that may have happened, your body will respond with abdominal pain. Yeah. So the the work of trauma and by trauma, I mean like PTSD trauma, not the level one trauma centers. I’ve worked at the effects of trauma on the pelvic floor of how do we parse out what is mental, what’s physical And usually you can’t like at our clinic we don’t bother. We’re just saying here’s our treatment, here’s your therapist you’re going to meet, here’s the medicine you’re going to take for the physical pain. But this is all together. So how do you work with those sort of situations?
Rachel:
Yeah, so very, very gently, right? Because doing what I do there, there can be an internal component. And so we always talk about the fact of before we even like do a physical assessment, we chat like this for a long time because I want to know pelvic floor is not just your pelvic floor, it’s what’s going on now. It’s what’s going on, what your relationships looked like. Again, you said kind of that that sexual abuse. It could be that as well. There’s so much and everything that we do is held in our I’m a true believer that it’s all held in our hips and our pelvic floor. So it’s not shocking when we’re doing the work and we need to stop and and maybe work through that and, you know, find different strategies to kind of help calm your body down. We talk about like ways that you can use cold therapy or tapping or meditation or prayer. There are so many. And my goal is to always find techniques that will work for you because my techniques obviously aren’t necessarily going to work for you. So kind of looking at at those things to help kind of calm that nervous system down again, back to the nervous system, right. So you’re saying.
Nick:
Like not only do we have tool boxes as providers, but a lot of your work is like, hey, let’s get your toolbox set. Let’s make sure that you can take care of some of these things on your own. Yes.
Rachel:
Absolutely. I always talk about and specifically with my my moms. But you’ve heard the term mom rage, right? Like mom rage. Have you ever heard that? Yes. Yes, Mom rage. So that’s a sensory processing thing. So, I mean, there’s a part of sensory processing. So I always give the example. It’s 5:00 at night. My husband is a first responder, so he’s not at home. I’ve got two tiny humans that are screaming in the background. I’m trying to get dinner done. It’s hot, I’m losing my mind and the fan noise is on and I go and open my cabinet door and I lose my mind because it’s not organized like I used to be. But like, let’s think about that. So visually I was overstimulated, right? Auditorily I’m overstimulated. Probably smell is got me too. So there’s, there’s three of your eight sensory systems right there. So I like to help my clients figure out like where might you have some sensory vulnerability in your life so that way I can help you calm your system down. So for me, I get all my I get all my ingredients out prior to making my meal because I know if I go to that cabinet, I’m going to lose my mind, right? I put headphones in as soon as 5:00 happens because I can’t stand the sound of the the fan so I can hear my children. It’s fine. I just need to probably.
Nick:
Can’t hear their annoying TV shows as much.
Rachel:
So this morning we listened to fire trucks all just the sirens. So that’s what they like. Yes. Oh that’s hilarious. No it’s not. It’s real great. But then also I keep an ice roller in my freezer, so it’s $5 on Amazon. Right. And so if I feel myself getting overwhelmed, cold therapy for me is a real quick trigger back. And so I use that that roller to help bring my sensory system back and be able to do that, that breathwork because at that moment my sensory system is off, my nervous system is off, my pelvic floor is tight. So being able to come back and pay attention. So I like to for my clients, I like to figure out where your vulnerabilities are and like how can we help you build your toolbox up?
Nick:
Yeah, that makes a lot of sense. And for example, I got one of those Culligan water things in my office which I didn’t want to do. I thought it was overpriced, but one of the reasons was it’s very cold water so the the patients can take a cup with them when they go in to see their therapist. We do a lot of EMDR work, a lot of trauma therapy. And that way if they’re starting to get more agitated, they can just take a drink of that cold water and everything chills down a little bit.
Rachel:
Yeah, cold therapy is the quickest way to get your emotion out of your emotional brain, right back to your thinking brain.
Nick:
So and I usually don’t do this on the show, but since we haven’t met before, I’ll tell you a little bit about what we do, which I guess would make sense since it’s my show to do this every show. Yeah, why wouldn’t you? But I don’t know. It feels more like And now this mango juicer can also do this. So. So the patients that we could help with is a lot of times when there’s pelvic issues, but you’re not seeing on an x ray MRI like no one knows what’s going on. Right? That’s where something like the ketamine infusions helps being a working on the NMDA system and the way that ketamine works on a lot of different receptors, it can repair nerves. I’ve actually seen one case where a patient could no longer urinate or defecate on her own and she had to come in for a high dose ketamine infusion and it literally fixed everything. Wow. I was going to write a case report and then I was like, I don’t really have an understanding of why this happened. I know the basics that neurogenesis.
Rachel:
Yeah, right, exactly.
Nick:
Neuroplasticity synaptogenesis all of these fancy sounding terms that mean your nerves are repairing themselves. The right nutrients are getting into the nervous system, but a lot of times that’s part of it. And by itself it’s kind of like what you were saying earlier where you might be seeing me a lot, but once you combine that with some more holistic techniques and I think that’s the main goal. Like every so often we need to do some intervention. I might put an IV in you and give you a medicine that’s going to start your nervous system back up. Yeah, but with that we also have the plan of like, okay, well what’s sustainable, right? And some people in some cases of fibromyalgia, patients who come to me like once every two months and they simply need that infusion and they have a normal quality of life and we’re fine with that. Yeah, but in many cases it’s like, well, who else do you need to see? And usually I consider myself like a starting point, like we’ll get the ball rolling, then you’ll go to a chiropractor if the problem seems to be with your back or you if it’s with your pelvic floor. Yeah, because that is the challenge to that. As you go to different providers, you’ll go to the neurologist. Oh definitely your brain. That’s what’s going on here. So how can we get to And I think what helps the most too is for patients, especially like forget your philosophies, like I want to eat vegan, I want to or I want to eat all meat or I want to exercise this way. Well, guess what? We might see that your body’s reacting better to something that you don’t think is legit. You just have to go with what’s working for your body, right?
Rachel:
Yeah. And I feel like that’s a good point. You’re when it comes down to. To it. Like if your provider is saying like, Oh, this is the only way. Like is it really the only way? Or like, let’s go talk to somebody else I guess, Right?
Nick:
And also like let’s explain why something is worth pursuing if it’s not working at first, is it? We just need to give it a little more time. It’ll work, right? Is it Look, we’ve got 3 or 4 other options, so we might as well skip this extra month of trying to see if this works out and go to that. Or is it? Look, we’ve tried everything else. We do need to be patient because we don’t have a great second idea.
Rachel:
Yeah, that’s I always said for OT we’re like the MacGyver of therapy. So kind of similar like, oh wait, that didn’t work. So let’s try it this way or this try do it this way. So, you know, if you don’t have the compensatory strategies that we find adaptive behaviors, right? So or the opposite, I can’t remember.
Nick:
Yeah, but what you’re saying too is that a lot of times you’ll use those muscles in ways that weren’t intended. Yes. And you think you’re normal, but you’ve adapted in such a way that if you don’t deal with it now in a few years, you know you’ve got some hypertrophied muscles on one side, some atrophied ones on the other. Yeah. And unless we deal with it now, when you’re not quite as uncomfortable as you will be, it’s going to be a much more serious problem down the road. 100%. Absolutely. Well, thanks for coming on the show.
Rachel:
Thanks for.
Nick:
Having me. Was Now I understand what you do. Yeah. And now we’re buddies. This is great.
Rachel:
I feel like we could have a good, good partnership. And now you know all about your pelvic floor.
Nick:
I know a lot more of my pelvic floor than I did 20 minutes ago. This is great. Yeah. Well, thanks for coming on the show. You’re welcome. I will lengthen it. Thanks for watching. See you.
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