Could addressing hearing loss be a key factor in preventing Alzheimer's? Dr. Young Trinh joins us to tackle this critical question, sharing a deeply personal narrative from the final days of the Vietnam War. We examine the shortcomings of our reactive healthcare system and discuss the urgent need for a shift towards preventive care and early detection, particularly in the realm of Alzheimer's disease.
Dr. Trinh recounts his transition from a general internist to a focused dementia care practitioner, driven by his firsthand experiences with the inadequacies of current Alzheimer's treatment and prevention. We highlight the crucial role of primary care physicians in integrating memory assessments and preventive measures into regular health check-ups. By addressing the 12 modifiable risk factors identified by the Lancet in 2020, we can make significant strides in Alzheimer's prevention. Our discussion calls for a proactive approach to healthcare, emphasizing the need to prioritize prevention just as we do for heart disease and cancer.
In our final discussion, we explore the profound impact of lifestyle changes on reducing Alzheimer's risk, with a particular focus on managing hearing loss and other modifiable factors. Dr. Trinh sheds light on the latest advancements in Alzheimer's treatments, including anti-amyloid medications, and the importance of early intervention. We end on a heartfelt note, reflecting on the importance of community and support in this journey, eagerly anticipating future meet-ups to continue this vital conversation. Join us for an episode filled with insights, expert advice, and a call to action for better Alzheimer's care and prevention.
While we know all hearing aids amplify sounds to help you hear them, Starkey Genesis AI uses cutting-edge technology designed to help you understand them, too.
Using innovative Neuro Sound Technology, Genesis AI mimics how a healthy auditory system hears. This allows the hearing aids to better replicate how the human brain processes sound.
Click here to find a hearing care professional near you to try Genesis AI!
Could addressing hearing loss be a key factor in preventing Alzheimer's? Dr. Young Trinh joins us to tackle this critical question, sharing a deeply personal narrative from the final days of the Vietnam War. We examine the shortcomings of our reactive healthcare system and discuss the urgent need for a shift towards preventive care and early detection, particularly in the realm of Alzheimer's disease.
Dr. Trinh recounts his transition from a general internist to a focused dementia care practitioner, driven by his firsthand experiences with the inadequacies of current Alzheimer's treatment and prevention. We highlight the crucial role of primary care physicians in integrating memory assessments and preventive measures into regular health check-ups. By addressing the 12 modifiable risk factors identified by the Lancet in 2020, we can make significant strides in Alzheimer's prevention. Our discussion calls for a proactive approach to healthcare, emphasizing the need to prioritize prevention just as we do for heart disease and cancer.
In our final discussion, we explore the profound impact of lifestyle changes on reducing Alzheimer's risk, with a particular focus on managing hearing loss and other modifiable factors. Dr. Trinh sheds light on the latest advancements in Alzheimer's treatments, including anti-amyloid medications, and the importance of early intervention. We end on a heartfelt note, reflecting on the importance of community and support in this journey, eagerly anticipating future meet-ups to continue this vital conversation. Join us for an episode filled with insights, expert advice, and a call to action for better Alzheimer's care and prevention.
While we know all hearing aids amplify sounds to help you hear them, Starkey Genesis AI uses cutting-edge technology designed to help you understand them, too.
Using innovative Neuro Sound Technology, Genesis AI mimics how a healthy auditory system hears. This allows the hearing aids to better replicate how the human brain processes sound.
Click here to find a hearing care professional near you to try Genesis AI!
We don't have really a health care system. We have a sick care system. We have a reactive system that is reactive after your diagnosis, after your advance. We don't have a good system on prevention maintenance and we don't have a good system on early detection, especially when it comes to Alzheimer's.
Blaise M. Delfino, M.S. - HIS:
You're tuned in to the Hearing Matters podcast when it comes to Alzheimer's partners. Redux faster, drier, smarter, verified. Sycle: built for the entire hearing care practice. Otoset, the modern ear cleaning device. Fader plugs the world's first custom adjustable ear plug. Welcome back to another episode of the Hearing Matters podcast. I'm your founder and host, Blaise Delfino, and, as a friendly reminder, this podcast is separate from my work at Starkey. On this episode of the Hearing Matters podcast, our co-host, Dr. Douglas Beck, speaks with our guest, Dr. Young Trinh, about cognitive decline being linked to untreated hearing loss, the research, and other related matters. Now, as I was editing this episode, I learned so much and I truly do believe that, as hearing care professionals, we really need to listen to this episode with an open mind, open ears and get your pen and paper ready to take some notes. So, without further ado, here's the conversation between Dr Beck and Dr Trinh.
Dr. Douglas L. Beck:
Hi, this is Dr Douglas Beck and you're listening to the Hearing Matters podcast. My guest today is Dr Young Trinh, a chief medical officer for Cognivue and internist in Southern California. Dr Trinh is the chief medical officer of Healthy Brain Clinic, which is a board member for Alzheimer's Orange County, a physician with Memorial Clinic, which is a board member for Alzheimer's Orange County, a physician with Memorial Care and is a medical missionary with Tongue Out Medical Missions. Over the years, dr Trin has developed a passion for educating his patients and the community. He provides numerous lectures on a variety of health topics throughout Orange County, which is in Southern California. In his early days of medicine, he became frustrated with the limited medical treatments available for Alzheimer's patients and he is deeply involved in all aspects of Alzheimer's care, including clinical trials. So, dr Trin, if you don't mind, let me start by asking you. You have an amazing story to share about April 29th 1975. I wonder if you can give us the thumbnail sketch of that.
Dr. Dung Trinh:
Good to see you again, doug. And yeah, so here's my story. On April 30th 1975, it was the end of the Vietnam War, and that was when the South lost to the North. The South lost to the North on April 30th 1975. I was five years old at the time, and the day before the end, which is April 29th 1975, on that day I remember being at the Saigon airport, being on the runway, not inside the airport, but we were on the tarmac, five-year-old kid, and with me was my two sisters. One was three years old, the other one was two, and then my brother was a few months old and mom was with us and we were all on the tarmac.
Dr. Dung Trinh:
It was a gray day, it was drizzly, kind of gloomy, and it wasn't just us, it was hundreds of Vietnamese just sitting outside on the runway. And what I saw and what I heard was I heard the sound of war, I heard shooting, gunfire, going off mortars, I heard lots of screaming and yelling, lots of confusion, because it was the day before the end, so they were fighting street to street already. And I saw in front of me these large black Chinook helicopters, and so the Chinooks were the double-rotored and they were several hundred feet in front of me and I saw these Chinooks land on the ground. It was very loud because we had no ear protection. It was very windy and we had no overhead protection either from these big blades. And I saw the back of the Chinook would go down as soon as it landed and a lot of people, a lot of Vietnamese, would run toward these helicopters and run into the helicopter and the helicopter would take off. And then I saw another helicopter land and the same process would happen the back would go down, be super loud, super windy, lots of people run in. It'll take off and then eventually, probably about 200 feet in front of us, large black Chinook, loud, windy. It would land, the back would go down and we were told it was our turn to run.
Dr. Dung Trinh:
And so I was five years old, I grabbed my sister's hand she was three and we started running toward the helicopter. I didn't know if I would make it because as a five-year-old kid, I thought just the wind from the rotor blades would just blow me away. And we were just going toward it. And then my mom had both kids in each hand my younger brother, a few months old, and my other sister was two years old and I was running toward the helicopter. I got to the back of the helicopter and on the right side was a US serviceman and I didn't see his face because he had his helmet on, but I saw his gun. He's got a pistol. There was two rows of seats. I ran inside and I sat on the left side and I buckled up. And I ran inside and I sat on the left side and I buckled up and you know I was only five, but it was the first time that I felt a sign of relief, even as a five-year-old kid.
Dr. Douglas L. Beck:
It's a remarkable story. I was 20 years old I'm a little bit older than you are and I remember watching that on TV on CBS News in New York, and I just couldn't believe it because there was a line. And if you Google Saigon 1975, you know you'll see some of these videos. Have you gone back and looked at those videos?
Dr. Dung Trinh:
I haven't, but we were there.
Dr. Douglas L. Beck:
So here's a quick quote from. I don't know why we're talking about this, but it fascinates me. The largest Chinook that operated in Vietnam had a gross weight capacity 46,000 pounds. That's gross weight, so 23 tons. In the last days of the war, a single Chinook was able to evacuate 147 South Vietnamese refugees at once. Now, just to put that in perspective, a Boeing 737 carries about 220 people.
Dr. Dung Trinh:
It's hard to forget those kind of things. Yeah, I remember like not sleeping on top of our bed, but we would. At night we would sleep underneath our beds, and so we knew they were fighting, and so we were always afraid that the roof would collapse, the house would fall down. So I spent a lot of my childhood underneath our beds. And how, where did you go? Where did they take you? So the back of the Chinook would close. The Chinook lifted up, I saw this city of Saigon and then, as it got higher, I saw the green jungles of Saigon and then I saw the blue waters. So I went over the ocean and I was like, oh okay, I have no clue where we're going. It landed on the USS Midway, which is now docked in San Diego.
Dr. Douglas L. Beck:
San Diego yep, it's permanently docked there and you can tour it, and it's as big as a small city.
Dr. Dung Trinh:
Yes, I've been back to tour it, but I remember being on deck on the Midway on April 29, 1975, five-year-old kid and tons of refugees on deck, and we would see these. We'd see the Vietnamese helicopters flying escaping the war and the Vietnamese helicopters would land on the midway, the pilot gets off, his family gets off, and then I would watch people push these helicopters overboard into the ocean.
Dr. Douglas L. Beck:
And it was right in front of me.
Dr. Dung Trinh:
I was just standing there watching these huge helicopters go overboard, crash into the ocean, incredible, like all afternoon.
Dr. Douglas L. Beck:
Unbelievable. And then you went to school in the States. Obviously, you learned English. And where did you wind up going to medical school? Yeah, New York. Did you when? In New York?
Dr. Dung Trinh:
Yeah, up in the White Plains area that's the Downstate Medical Center. Yes, yes, my Westchester Medical Center, new York Medical College. I was there and I did all my rotations throughout New York.
Dr. Douglas L. Beck:
That's fantastic. I grew up actually not far from there. I was up in Yorktown, so Really Yorktown. Yeah, yeah, I used to cross that Tappan Zee Bridge by accident and then go back Now it's called the Mario Cuomo Bridge, it's no longer called the Tappan Zee, and if you haven't seen it because you live in California, you won't believe it. It is very, very different, it's much more modern and it's a very beautiful bridge.
Dr. Douglas L. Beck:
So you did all your medical training and you became an internist through the New York program. How did you get interested in dementia? Because as an internist that's not necessarily hand in glove. I mean people go into other areas.
Dr. Dung Trinh:
Absolutely.
Dr. Dung Trinh:
I was a general internist in primary care and had taken care of patients for close to 20 years, and as an internist, the majority of my patients were older adults, and so I just happened to see the entire spectrum of Alzheimer's over and over and over in my own patients and these were patients of mine who initially came in healthy, drove in, they had their brains.
Dr. Dung Trinh:
We were cracking jokes and I saw the slow changes over time where eventually I saw their loved one would bring them in and they would no longer drive, and then they needed help at home and we would, you know, put in orders for home health and all that, and eventually their disease progressed to where they ended up in a nursing home.
Dr. Dung Trinh:
And then I was the one that signed off on their death certificate and with the diagnosis of Alzheimer's on it. And I did this over and over throughout the years and I felt really bad because almost 20 years of being an intern as primary care, I was able to reduce the risk of heart attacks, reduce the risk of stroke, reduce the cancer risk. I was sending everyone for their colonoscopies and mammograms and all that, and when it came to the diagnosis of Alzheimer's it felt like it was a one-way road for our patients and, as a matter of fact, currently in Orange County, alzheimer's is the number three cause of death, right behind heart attacks, and cancer is based on what's written on that death certificate and then you mentioned home health and nursing homes and back in the day.
Dr. Douglas L. Beck:
you know that's what you did, but right now, I was just listening to a report yesterday on NPR saying that home health is much more selective about which patients they're going to take and nursing homes are kind of crowded and if you can get a spot and they were saying that some of the protocols now is when somebody is sick and they have dementia, don't take them home, leave them in the hospital. That way they stay in line for a bed. Is that what you're finding in Southern California?
Dr. Dung Trinh:
They got to stay at least three days in the hospital for Medicare to start paying for some type of rehab care and things of that sort.
Dr. Douglas L. Beck:
And still, despite the insurance companies, I'm under the impression that the largest part of home health care for patients with dementia is still going to be supplied by the loved ones, the family the caregivers, absolutely.
Dr. Douglas L. Beck:
Billions and billions of dollars of unpaid caregiving is made by a loved one, and it's remarkable because it's a problem that I think has been looked at for a couple of decades now and there's no clear solution based, I think and I don't mean to be snarky, but I think it's our health care system in general, which is, you know, a profit-oriented system for better or worse, and it's just not very profitable when you have to have somebody that requires 24-7 care or even, you know, 12 hours of daycare. That's a lot of care and it's hard to make that work financially, I think.
Dr. Dung Trinh:
Yeah, we don't have really a health care system. We have a sick care system. Yes, we do Tell me about that.
Dr. Douglas L. Beck:
I agree entirely but, I, want to hear your thoughts.
Dr. Dung Trinh:
Yeah, we have a reactive system that is reactive after your diagnosis, after your advance. We don't have a good system on prevention maintenance and we don't have a good system on early detection, especially when it comes to Alzheimer's. I was lecturing this morning at an annual conference here in Anaheim at the Marriott and with a number of folks at the lecture, I asked them how many of you guys get an annual memory assessment from your doctor during your physical exam.
Dr. Dung Trinh:
It's got to be less than 5%. It was about 1%, and I'm not surprised, because I asked this question over and over to many audiences where I stand in front of and it's just not there. What?
Dr. Douglas L. Beck:
is your protocol. What would you like to see PCPs internal medicine, primary care? What would you like to see them do with their patients over, let's say, age 65?
Dr. Dung Trinh:
on an annual basis. Absolutely, I like to take Alzheimer's as serious as they're taking other conditions, and what I mean by that is this is if Alzheimer's is the number three cause of death. In Orange County, the number one cause of death is heart attacks. So that's nationwide. So what do we do for heart attack prevention? We check cholesterol, we check weight, we check blood pressure, we tell people to exercise, we tell people to lose weight. We're doing everything we can for prevention of heart attacks, right? That's number one cause of death. Number two cause of death is cancer. That's number one cause of death. Number two cause of death is cancer. We're sending folks for colonoscopies, for mammograms, for pap smears, right, prostate exams we're sending folks for all this testing to look for cancer. So my question is what are we doing for the number three cause?
Dr. Douglas L. Beck:
of death. Dr Trin, I think this is a very important point, so let me ask you directly, as an expert in dementia care can we prevent cancer dementia in some people by adhering to some of the basics, like the 12 potentially modifiable risk factors?
Dr. Dung Trinh:
Yes, Published in the Lancet in 2020,. During the pandemic, the Lancet Commission had a huge publication showing that 40% of all Alzheimer's is contributed by 12 modifiable lifestyle risk factors 40%, 40%, and the number one among them, of course, is hearing loss, and that's an 8.2% PAF, which is population attributable factor.
Dr. Douglas L. Beck:
You know, one of the things they didn't even mention in that Lancet was people who have dual sensory loss, like visual loss, glaucoma or cataracts or whatever that's untreated, and they have hearing loss. What are your thoughts on those people? Would a dual sensory loss contribute significantly to a dementia risk?
Dr. Dung Trinh:
The risk is cumulative based on the number of risk factors you have. So if you have hearing loss, only right there's a risk factor there. If you add on the other sensory losses it becomes a cumulative risk. So is Alzheimer's and dementia preventable? The risk factors are manageable and by reducing the risk factors you lower the risk for Alzheimer's. But genetics play a small role, not a huge role. The bulk of the risk factors is lifestyle modifiable lifestyle.
Dr. Douglas L. Beck:
And this is a very important point because, again, nobody's going to promise that you can prevent dementia, because the largest two risk factors are DNA and age right, your deoxyribonucleic acid, your genetic predisposition. However, for some people, just avoiding drug abuse would be enough to not have dementia. For some people, just not not smoking for something. But. But those are tiny risks, they're three percent, two percent, one percent. But in some people you can prevent it by adhering to these social potentially preventable risk factors. Absolutely.
Dr. Douglas L. Beck:
And tell me about, you know, um gosh, when I started studying Alzheimer's, probably 15 or 20 years ago, and back then I remember reading, you know, if only we could lower amyloid plaques and tau proteins, that we would, we would not have Alzheimer's anymore. And then I started reading some reports from people who were saying well, the amyloid plaques are not the cause of Alzheimer's, the amyloid plaques are the result. And so I'd like to get your thoughts on that, because now that we have three or four FDA approved medicines which attack amyloid, I think we can remove amyloid pretty successfully in many people not all, but in many. Yet it doesn't seem to change the course of the disease itself, or does it?
Dr. Dung Trinh:
Good point. It Good point. So last year 2023, we have the first fully approved FDA medication Lekembe to remove Alzheimer's plaque. We have one sitting on the table now the FDA for review for approval. That's Donanumab. That's an Eli Lilly medication.
Dr. Douglas L. Beck:
And it's been in trial now for about 18 months right.
Dr. Dung Trinh:
Yeah, it's done with its stage phase three data that was sent to the FDA for review, and there are several others anti-amyloid antibodies currently in the pipeline to be evaluated with that. So what can these medications do and what can it not do? So what can these medications do and what can it not do? Now, looking at the research, looking at the data, what we know is that these medications work best. The earlier we catch or the earlier we find this condition, the earlier we go in the disease process, the better results we get. And so what are these results? With Lekembe, we have seen that, compared to the placebo group, the group that was getting Lekembe treatment, we were able to slow down the rate of memory loss by about 27%. After about 18 months, a year and a half or so we reviewed the data 27% slowing down of memory loss. So we're not bringing back memories that are completely gone. We're hoping to do this. We're hoping to straighten out the curve and to save the brain cells that are there.
Dr. Douglas L. Beck:
And this is an infusion, I believe, once a week, twice a week, and it's rather expensive. I mean it's not, you take a pill, I mean you have to go to a facility.
Dr. Dung Trinh:
Yeah, infusion twice a month, or like MB, and it's an infusion once a month for the nanomab, so those are typical. Yes, amyloid plaque can be removed. Yes, we can slow down the rate of memory loss. No, we have not made memory go way back up. Here's the reason why we're not seeing this. We're not seeing this is because over the years, even before the first memory loss is detected with Alzheimer's disease, if your first memory loss is here in the mild, mild stage of Alzheimer's, subtract 20 years, that's when you first have the amyloid buildup right, the amyloid, beta amyloid plaque.
Dr. Dung Trinh:
A few years after amyloid builds up is the tau, neurofibrillary tangles, the second protein that's associated with Alzheimer's, that moves up, and this is while you have perfect memory, by the way. And then, a few years before the first memory loss, we start to see the loss of brain cells. We call that neural degeneration. So brain cells are going away, they're dying. Essentially, brain cells are dying, and we know that because in the brain of an Alzheimer's patient the brain shrinks over time. We see the brain volume kind of go down. So as brain cells are going, so are your memories right, they're all kind of going with that, and so we're not bringing dead brain cells back, that's for sure.
Dr. Douglas L. Beck:
And so this is kind of remarkable because, as you mentioned, just to recap and this is in Sanjay Gupta's book from about two years ago he was talking about this that it's about 20, maybe even 30 years before you have the first manifestation of signs and symptoms of Alzheimer's. In particular, that's when the microcellular changes start, and so by the time we detected 20, 25, 30 years later, those memories, those neurons, they're gone. And so if you can slow the progression and make the memory loss occur slower, that's a big deal because it gives the patient and their family time to plan, time to figure out what they're going to do, time to figure out houses and finances and wills and all the very important things that lead to what I would like to call a successful or at least a satisfactory death. I mean, we're all going to die, but dying of dementia is particularly difficult and if you can prepare for it and manage it better, that's a huge step in the personal lives of the patient and their families.
Dr. Dung Trinh:
Yes, alzheimer's is a family condition, not just the patient, because over time the patient isn't going to be aware of what's going on. It becomes a burden on the family and the entire family goes through it.
Dr. Douglas L. Beck:
And tell me. You know you and I, years ago, were speaking about using cognitive screeners. There's quite a few of them out there now and they're all reasonably good. It's not one is better than the other. But whatever one you're using, you have to be trained. You can't just go ahead and do a cognitive screening. You have to be trained to do this appropriately. I used to always say that the minimum training to run a cognitive screening would be 10 to 12 hours. So I want to ask you do you see referrals from audiologists, or does that information usually go to their individual PCP?
Dr. Dung Trinh:
Usually the PCP will get those results. It normally goes back to the PCP because the PCP is the quarterback. Who to send that patient to next oftentimes requires a referral from the PCP to get that patient over to a neurologist or to another specialist. None of these cognitive assessments are diagnostic. We're not telling anyone that this is a diagnosis of Alzheimer's obviously not. It just is a yeah, it's a screener. It's designed to detect the need for further workup. So if you have an abnormal, you know cognitive assessment, let the patient know that. You know. I'm glad we caught it now rather than a year. Now let's notify your doctor, if you're okay with it, of these results. Here's maybe a copy for your doctor to check out so that they can do some further workup.
Dr. Dung Trinh:
It's handled on the front line and it's not handled very well at all actually, and I can't really blame it on the front line and it's not handled very well at all actually, and I can't really blame it on the PCPs when the system gives you 15 minutes to see a patient.
Dr. Douglas L. Beck:
Yeah, that's terrible. I mean, most audiologists spend an hour and a quarter with the patient, right, and so I've got that time, that luxury, to do an in-depth evaluation, to have a conversation, to answer questions, and then I can write a referral and send them off to whomever is the most appropriate person. The PCP still has to worry about coronary artery disease. He or she still has to worry about arthritis. They still have to worry about diabetes. They still have to worry about cancer. Yeah, and it's quite a lot to cover in 15 minutes.
Dr. Dung Trinh:
This is why this is probably why there's there's zero screening for Alzheimer's going on right now. Yeah, the cognitive screening is built into the annual wellness exam, right, which is the Medicare annual wellness exam. That, uh, unfortunately, most PCPs actually aren't even doing. They're doing physical exams, but that's not an annual wellness exam. But the cognitive screening is built into the annual wellness exam Not being done very well, most patients aren't getting an annual wellness and the question is, even if they do get their annual wellness and the cognitive assessment aspect of it is abnormal what is the PCP going to do? Half the time they're just going to say it's because you're in your 70s or 80s, because that's a patient perception as well. You know, of course, I have memory loss, I'm in my 70s or 80s, I may expect to have memory loss, and that perception oftentimes is the same perception the PCP has. So no work gets done as the Alzheimer's plaque continues to build up. This is why we miss this diagnosis of Alzheimer's many times until that patient is at moderate stage.
Dr. Douglas L. Beck:
And at that point it's a little late, because when you think about that Lancet study from 2020 by Dr Livingston and his colleagues, they were talking about catching these 12 potentially modifiable risk factors in midlife. What we're saying is that we are pretty clear that hearing loss is a significant potentially modifiable risk factors in midlife. What we're saying is that we are pretty clear that hearing loss is a significant potentially modifiable risk factor and people with untreated hearing loss have a higher susceptibility to problems later. In other words, untreated hearing loss tends to exacerbate cognitive decline.
Dr. Dung Trinh:
Absolutely. The brain's like a muscle, right, muse it or lose it. So you stimulate your brain when you have data input coming in the five senses what you see, what you hear, what you taste, what you touch brain stimulation. It's going to be PCP, dependent in their comfort level on working up an abnormal cognitive assessment, but at least it brings it onto the radar, whereas before it wasn't even on the radar. And bringing it onto the radar earlier is better because these medicines that are coming out it works best. The earlier you catch the condition, sure.
Dr. Douglas L. Beck:
And if you're talking about somebody in late stage Alzheimer's, there's really not much we're going to do other than hygiene right and I don't mean that in a negative way. That's important to do, but we're not going to slow it down or reverse it on somebody with advanced Alzheimer's.
Dr. Dung Trinh:
Yes, being proactive, early detection is everything, and especially by implementing the lifestyle changes, the education to our patients Now that they're alerted that this isn't working 100%. Here are the list of things you can do without taking a pill right Exercise, sleep, nutrition, stress reduction. There's a lot of things that can be done without taking a pill. There's no natural law that says you have to die at age 85 or 90. We just wear our own system.
Dr. Douglas L. Beck:
Yeah, I think that's true. You know, there are some landmines that you just hit because of bad luck. There's some landmines you might hit because of genetics. But by and large, when you talk about cardiovascular disease as number one killer, cancer number two, Alzheimer's number three, there's quite a lot we can do to slow these things down, impact them and maybe prevent them in some people.
Dr. Dung Trinh:
Lifestyle, modifiable lifestyle, dr Trinh, it is a joy to hang out with you.
Dr. Douglas L. Beck:
I wish we were closer and we could share a beer or something, but I will look forward to seeing you in Southern California next time I'm there, and you've always got an open invitation in San Antonio.
Dr. Dung Trinh:
Thanks so much. Good talking to you time I'm there and you've always got an open invitation in San Antonio.
Dr. Douglas L. Beck:
Thanks so much Good talking to you and I'm sure we'll continue chatting, you bet Thanks.