• Neurodevelopmental Optometry with Dr. Amy Pruszenski

    Neurodevelopmental Optometry with Dr. Amy Pruszenski

    In this visual world, we do need a healthy eye, but we also need to make sure the connection between the eye-brain is working well. Neurodevelopmental optometrist Dr. Amy Pruszenski focuses on the eye-brain connection and the health issues connected with it. As a kid, Dr. Pruszenski has suffered from a lazy eye which was eventually corrected. Now, with a lot of research focused on the area, there’s more and more information for doctors like her to do their job. In this episode, Dr. Pruszenski shares how neurodevelopmental optometrists are helping patients who have no hope in getting better vision, and how she also branched out to treating brain injury patients. She also shares the future of the field and what she hopes to achieve for the betterment of her patients.

    We have Dr. Amy Pruszenski. She is a neurodevelopmental optometrist out of New Hampshire. Dr. Amy is a brilliant doctor that graduated from MIT, that is now helping people heal from brain injuries, concussions, balance and dizziness issues and other neurological conditions by recalibrating the eye and neurological pathways. Dr. Amy also breaks down neuroplasticity and the difference between an eyeball doctor and a neurodevelopmental optometrist. This field is relatively new and new discoveries are being made every year, so it’s very exciting to sit down and talk with Dr. Amy on how she is able to heal people and do the work she does. Please welcome, Dr. Amy Pruszenski.

    Listen To The Episode Here:

    Neurodevelopmental Optometry with Dr. Amy Pruszenski

    Healing Brain Injuries

    Dr. Amy, how are you? It’s such an honor to have you on.

    I’m very well and it’s a pleasure to be here.

    Dr. Amy, where are you from originally?

    I’m from Maryland.

    What were you into growing up as a kid?

    I was going to be an engineer, like my eldest brother, the genius engineer at MIT. Everyone spoke with such reverence, so I decided that was a good thing to do and everyone was very supportive and I got all the way to MIT and realized, “No, I am not an engineer.”

    What was it when you got to MIT that you were like, “This isn’t for me?”

    I’m sure it was probably thermodynamics.

    Did you end up staying at MIT?

    I did. I fortunately procrastinated applying for a work-study job and I couldn’t afford to be there without a work-study job. My randomly assigned advisor created a position in his lab doing vision research. I fell in love with cognitive science and brains and eyes and how it all worked together. This is back in the mid-‘80s when neuroplasticity was just beginning to be accepted in the neuroscience field.

    That’s pretty amazing that field was almost like gifted to you.

    God works in mysterious ways I think.

    From what I remember of you talking at the Blair Conference, did you have vision issues or just health issues in general? Can you go into that a little bit?

    I had a lazy eye, which I had totally repressed and forgotten about, so my eye would turn out toward my ear. Even the pediatrician couldn’t figure out something was wrong. I got lucky that the doctor rotating through the Navy eye clinic at the time not only did patching and glasses but taught my mom how to get both eyes working together and so my eyes are straight non-surgically.

    Do you recall what they did to make that happen?

    EM 106 | Healing Brain Injuries

    Healing Brain Injuries: We do need a healthy eye obviously, but we need to make sure the connection between the eye-brain is working well.

     

    I don’t remember. I think it was torture back then. The whole patching thing I hope is declared barbaric. There was no surgery. It was doing exercises and showing my brain where the error was so my brain could recalibrate. In the old days, we thought there’s a good eye and there’s a bad eye and so we’re going to tie up the good eye and patch it and let the other eye get stronger, which it does. If you don’t have a choice, your brain will get that eye good for detail. If you untie the bully eyes, it’s going to take over again. What is happening is your brain is choosing to park the eye over to the side because you haven’t learned how to get both eyes working together. If we instead teach the patient how to get both eyes working together, it no longer needs to be parked off to the side.

    Dr. Amy, tell me a little bit about your first eye internship that was set up for you.

    I’ve had to seek out education on my own. When I graduated from MIT, my advisor suggested going to optometry school rather than getting a Ph.D. because I’m too much of a people person. Being stuck in a lab the rest of my life would not have worked well. This way, I have the flexibility of teaching or seeing patients or doing research. I went to optometry school and they made me an eyeball doctor were very much in the old days, had more of an eyeball model of vision. Thankfully, that’s beginning to change with the neuroscience research coming out. I very much was taught about the ocular disease and eyeball problems as if the visions in the back of the eyeball. The retina is part of our brain, so it’s not as simple as just getting the image clear on the back of the eye. We do need a healthy eye obviously, but we need to make sure the connection between the eye-brain is working well and that the brain is using the information from the eyes as well and directing the eye as well.

    You were trained as an eyeball doctor. What made you go outside of that paradigm shift and figure out that the brain was running more than thought?

    Essentially, I opened my practice and I thought, “Now I can help other children like myself, get their eyes working together and help them with the reading and other skills that are required using the eyes and I sent letters to all of the school nurses.” They all said, “Thank you very much. We’ve got this ophthalmologist we work with who is more of an eyeball doctor in general.” I’m obviously simplifying it for the audience. I realized we couldn’t ram it down people’s throats. I became an eyeball doctor and did basic exams and checked for eye health problems. Over time, I would find patients who have these binocular skills issues, trouble getting their eyes working together and I would treat them. We started getting patients who were getting better and the occupational therapists in the schools were the first ones to notice this and begin to send more patients to me as they found patients having trouble with eye coordination.

    The practice gradually grew. I had no intention of being a brain injury expert. I knew it would be difficult and I knew it would be much more brain than an eyeball and I was a little afraid of it at first. When the occupational therapists at the local rehab found out that I could do vision training with the children suggested, “Why don’t you just see this one brain injury patient?” That was all it took. Anyone of us could slip and fall on the ice or have a car accident or have an aneurysm or something happened. I realized, “This could be me, this could be my loved ones, this could be anyone on the street.” I had to learn more about how to help them because the vision is a big piece of what our brain uses. I sought out education. The optometric extension program is one of my core linchpins of what I’ve learned. I found Dr. Deborah Zelinsky out in Chicago through the book that her patient Clark Elliott wrote about his concussion and how she helped cure him after ten years of suffering. I realized, “This woman knows how to do things with lenses and prisms and tints that I don’t know how to do and I need to learn it.”

    The majority of your patients are brain injury patients?

    These days, yes, because there are so few of us doing this work. I rarely do a normal regular eye exam anymore. There are so many doctors who can provide that service to the patients. I have a lot of optometrists send patients to me, physiatrists, neurologists and occupational therapists. Anyone involved in the rehab team basically understands now the importance of the vision and how I can help using the retina as part of the brain to get the brain working better and feeling more comfortable, so I’m a part of the team.

    Can you run me through what exactly the rehab process is like? Is every patient a little different where you have to tailor their own exam findings to that patient so you get the results you want?

    I imagine it’s similar to your work where all of the patients have similarities. There’s something called Post-Trauma Vision Syndrome where we typically expect to see people having trouble getting their eyes to converge. They have light sensitivity and dizziness and headaches and various other issues like that balance problems. Many times, their perception of straight ahead is skewed because the brain is getting bad information. Everything we perceive around us is an illusion our brain creates. If the system is working well, we get an accurate roughly impression of what’s around us and how we’re moving and how other things are moving around us.

    When we have an injury, we get bad information because the eyes aren’t coordinating accurately. We get the problem that we’re drifting sideways down the hall and we think we’re going straight or we’re dizzy or we think the ground is not flat. Whatever other perception our brain is creating based on what it’s getting. That’s what we want to help recalibrate. It’s more what I call the where the visual system, “Where am I? Where are you? Is the ground flat? Am I moving straight down the hallway? Where’s the next word?” All of these things are more of the where of the visual system versus the what visual system. All of us are familiar with the 20/20 is good vision. What you’re seeing on the eye chart isn’t necessarily affected in a head injury. I have plenty of patients who can tell me letters on an eye chart, but they can’t function in life.

    You mentioned recalibrating the brain and the eyes. How exactly do you do that? You mentioned prisms. Can you walk us through that?

    One of the main things I’ve learned from Dr. Zelinsky is the retina is part of the brain. Literally by manipulating how we hit the light on the retina, even through a closed eyelid, we can manipulate how the brain perceives things and where it thinks things are. One of the first things that I’m looking at is can I come up with a lens, a prism, a tint, an occlude? I can even block light from part of the retina to stimulate different parts of the brain to give the patient comfort and get things calmed down so they can now work on healing. You can’t even begin to heal if you’re stuck in your sympathetic nervous system and you’re in your fight or flight mode all of the time. We want to get more to the parasympathetic rest and restore mode to get things working again. At that point, we might teach some basic exercises to show the brain that this is what’s going on. You think this is what’s happening, but this is what’s happening. Your brain can work on recalibrating it. Not all patients are able to do that right away depending on how severe the injury is.

    You probably have patients that tend to heal up pretty fast and then you obviously have the patients that it takes a little bit longer. How often do you have to reassess and readjust the prisms to keep the healing process going?

    It takes three months to get in with me, so we almost don’t have a choice as far as how often the follow-up can occur. There are some patients I’ll try to squeeze in sooner or where we can be a little more flexible with the timing but for the most part, people see me once every three months. Some patients are able to do more of a home-based program where I teach them things to practice. Their loved ones help them or OT can help them. They practice it and then they come back and I give them new things to practice. Other patients in a more difficult situation or we’re not getting the results we’re expecting. I might have come in and work with one of my vision therapists once a week or once every other week, and then still getting home things to practice. The home practice is key, just like learning any other skill. I could have the best piano teacher in the world or the best baseball coach. If I don’t go practice what they give me, I’m probably not going to learn the new skill. That repetitious practice is what makes the new brain pathway, but we have to figure out what they need to practice and tweak it depending on their situation.

    EM 106 | Healing Brain Injuries

    How to Feed a Brain: Nutrition for Optimal Brain Function and Repair

    You work with a team of vision professionals. First and foremost, do you see what’s going on the eye exam? See what’s going on with the eyes and then how soon do you pass them onto your other team for the vision therapy? Do some people not need vision therapy right away?

    Some people can’t tolerate the vision therapy right away. These are the people who come in and they’re wearing two pairs of sunglasses and dark, brimmed hat and can’t tolerate any light or movement. They’re in a torturous situation. We have to get that under control first. Other patients are moderately functional, but they’re suffering. Often at that first visit, I’ll make therapeutic lenses to help their brain function a bit better and get things working again. We’ll also give them some simple exercises to practice. I usually have one of my technicians or assistants teach them the exercises so that I can move on to the next patient so we can see more people.

    You also work with a couple of Blair Upper Cervical doctors, Dr. Mychal Beebe and Dr. Tyler Evans. How do the two systems work together and has it helped your practice get more people better by sending the upper cervical work and the division specialty?

    I was a fan of chiropractic care in general because my chiropractor cured my vertigo. I went to ear, nose and throat testing. I was told I was fine. I said, “That’s great but I’m on the floor and the room is spinning.” I had an MRI, which was negative. My general chiropractor finally figured out my C5 was out. I was already a fan of chiropractic. When Dr. Evans and Dr. Beebe moved into town, they connected with me to let me know that they were here and what they do and how it’s a little different. We’ve had a number of mutual patients where the way I look at it, and you can correct me if I’m wrong, I feel that the brain is what controls all of our body and then gets information from our body to figure out how to do things. If there’s a roadblock in the neck, you’ve got trees down in your highway. You may be getting cars around those trees, but it’s not efficient and it causes problems and you may get miscommunication. If the upper cervical chiropractor is able to get that cleared for me and were getting waste products out of the brain and getting nutrients into the brain and getting those signals clear and easy again. I can make more progress with what I’m doing and the patient, in general, improves better.

    That’s a perfect analogy and it definitely also works vice versa. I’m sure they are thrilled to have you to refer to because we do still have people that maybe vertigo gets better but the brain fog and other vision problems are still there. It is phenomenal to have another specialist to refer out to.

    I do think it needs to be a team effort. One of the things I also recommend is Cavin Balaster has a book called How to Feed a Brain. We have the nutrition aspect of high fat, low carbs. Get rid of the inflammatory foods, gluten, sugar, and dairy. The patients often make much more progress then because we’ve stopped throwing gasoline on the fire. Once they’re under control, then they can gradually reintroduce foods and do better, but I do think nutrition is a piece of it. Cervical health is part of it. The visual health is part of it. OT and PT have their role. There are a number of different professionals that I think are required in certain cases and it’s just a matter of figuring out who needs to be on the team and who can I trust that gets good results?

    What is going on with the eyes that might be causing migraines or blurred vision or dizziness that you can correct with prisms and it goes away and resolves? How does that work?

    There are a couple of ways of looking at it. Sometimes the eye coordination is challenged. The brain thinks the eyes are aiming in a certain position but they’re not, so the input of the brain getting is off. We sometimes use a prism to redirect the image so that the brain can get the eyes working together more easily. On a deeper neuroscience level with Dr. Zelinsky is figure out literally, we can redirect light to different parts of the retina to stimulate different parts of the brain. In some cases, I want to stimulate a part of the brain that’s healthy, that can take over for a damaged part. In other cases, I want to stimulate the damaged part so we can get stronger again and improve. It just depends on what was the injury, how severe is it, what else is going on? That’s half the trick of it. I’m not perfect at it. This is one of those things I’ve studied with Dr. Zelinsky for two and a half years and she’s certainly at a very high level. She’s been going to the neuroscience conferences for 25 or more years. She’s able to do things much more quickly than I can. I can usually get pretty good results, but it takes me longer and I have to think it through a bit more.

    I’m sure your field is still discovering some phenomenal things that change the way you treat people.

    I’ve started going to the Society for Neuroscience meeting with Dr. Zelinsky. It’s overwhelming. You’ve got 15,000 researchers presenting their research in a five-day period of time. Some of the work is on Parkinson’s and Alzheimer’s and dementia, which is another huge public health concern. Some of it’s on TBI, other developmental issues. It’s a lot of information that’s coming fast and furious. We live in an amazing time where it’s the hot topic and so we have lots of research that’s being done and getting more information all the time so we can do a better job.

    Were your treatments available fifteen years ago or is this a pretty much recent ten to five years?

    The answer to that question is Dr. Zelinsky has been developing her techniques for decades. She attempted to help people become aware of it, but I think the profession of optometry wasn’t ready for it yet. One of those things where when neuroplasticity was so early on, a lot of people were still skeptical. We had a much harder time accepting some of the concepts. She has a Z-Bell Technique which helps integrate the auditory and visual processing together better. We’re using light through those closed eyelids and manipulating it with different lenses and people just can’t wrap their heads around, “My eyes were closed.” If you’re out camping and the sun comes up, you can’t see anything but your body knows to wake you up because it’s responding to the light and we’re using that light to manipulate how the brain is working.

    That’s one of the things that I would say within the last probably five or ten years, certainly since Clark Elliot’s book came out, The Ghost in My Brain, people around the world want to seek out Dr. Zelinsky because she cured him. There’s hope where people have been told by some professionals they will not get better. It’s been too long after their injury and getting used to the new normal. Thankfully you don’t necessarily have to. I never guaranteed perfection or pre-injury status, but I can usually guarantee improvement. I can usually give them better than what they’ve got when they first come into the office.

    It’s been a couple of times you mentioned neuroplasticity. For those who are reading, what exactly is that?

    The idea is that in the old days, we thought the brain is hardwired. It is the way it is. You are the way you are.

    EM 106 | Healing Brain Injuries

    Healing Brain Injuries: We take it for granted when things work well. We don’t need to think about it until it doesn’t and then becomes disruptive to our lives.

     

    There’s no healing. There are no new neurons being developed.

    Neuroplasticity simply gives us the idea that you can change the way the brain is functioning. You can change the way it’s wired and improve things. The way I look at it in simple terms is it would be like saying someone my age can’t learn a new foreign language because I’m past the critical period at which I would normally learn a language when I’m five years old. I can still learn a foreign language. I may have an accent and it will take me longer than a five-year-old unless I’m gifted or learn a new sport or learn a musical instrument. We have examples of neuroplasticity all the time. In fact, what I’ve read is to prevent Alzheimer’s, it’s not enough just to be active. You have to learn new stuff. You don’t want to just reinforce the existing pathways. You want to develop new pathways. You might pick up a new sport or pick up a new musical instrument or a language to be able to keep your brain functioning at a higher level.

    It’s very mind-blowing what you do because I didn’t hear about this until you came to the Blair Conference. Where can people find other practitioners that do what you do?

    The source is the Neuro-Optometric Rehabilitation Association, which is NORAVisionRehab.org. They have a lot of information about brain injury and that’s also a multidisciplinary group where we have OTs and PTs and optometry and ophthalmology and neurology. Anyone who’s interested in rehab collaborating and what’s been working, what’s not working thing. Teach practitioners who were the more eyeball health how to help using the visual system. I also recommend Dr. Zelinsky’s website, it’s fascinating, the MindEyeConnection.com. She has a lot of information about mind, body, vision, connection and how it affects our daily lives and how she can help people.

    I know we’ve been talking a lot about brain injury patients. Are there any other type of situations, illnesses that people might seek you out for other than brain injury?

    We take it for granted when things work well. It’s like breathing or blinking, it just happens. We don’t need to think about it until it doesn’t and then be disruptive to our lives. I have helped patients with cerebral palsy, with Down syndrome and with other developmental issues. I’ve got people who have had aneurysms or strokes, any condition which can affect our neurological function. There are times I can help using the eyes as a conduit.

    Any patients with Parkinson’s or Alzheimer’s as well?

    I think that you’ve got a degenerative process going on there. I’m certainly not going to cure the disease, although the interesting thing is the World Brain Mapping and Therapeutic Society is a group of neuroscientists, neurosurgeons. Optometrists are attending that meeting and presenting at it where they’re pooling their resources. Instead of each lab researching independently, they’re all collaborating and coming up with strategies to how we find answers sooner. They are looking thankfully to Dr. Zelinsky’s work at the eye not only for early detection but as a treatment modality. “Can we come up with ways of manipulating the light hitting the retina to help either slow down the process or cure the disease?” That’s the hope they’re working on it. We’re years off as far as the research goes, but maybe not. You never know when a breakthrough where we hit.

    What type of equipment do you have in your office to help test to see if the light is sitting in the retina in the right way? If you need to direct it, what kind of measures are you taking to fix the problem?

    My office looks like a normal eye doctor office. We have a big phoropter. It looks like a big bug pair of glasses with all the lenses in it and everything. The key is Dr. Zelinsky’s Bell techniques. She’s patented her bell. She’s got a high pitch bell and a low pitch bell and it obviously requires training. She’s looking at ways of how we can teach optometrists how to do this work and get them certified so we know that they’re doing it safely and with proper procedure. It sounds simple but with the bells and then I have different filters, different colored lenses that I put in front of people’s eyes and different prisms. Even the glasses prescription is to get the image clear on the back of the eye.

    When I prescribe a lens, I’m looking at not only can they see the eye chart, but how is it affecting the basic functions of the body. It’s interesting, she has lectured to the International Cardiac Society with the cardiac surgeons because light affecting the retina can affect how our heart functions. How our endocrine functions. It’s an amazing thing where I think we’re at the tip of the iceberg where we’re learning how we’re affecting things. One of the things I’ve experienced as an optometrist before I got into the most of the brain work was a patient would come back and say, “These glasses aren’t working.” You would do all your math, and we checked the lens and you say, “No, the lenses are fine.” All you’re doing is getting the image clear on the back of the eye.

    What most are not trained in is you could be affecting so many other things. For example, Dr. Zelinsky will talk about a patient who had all these GI issues, these stomach problems and they went to the doctors who test for that and they’re tested. Just like with me and my vertigo, they’re told they’re fine. Their tests didn’t happen to pick up the problem. They’ll end up in her office somehow and she’ll say, “What else happened around the time these symptoms started?” Often, they’d just gotten their new pair of glasses or they’ve gotten new contacts and that’s affecting the gut, which is our second brain. I know it’s mind-blowing. She’s the leading-edge neuro-optometrist. I think that she’s far and above all the rest of us and there are many good practitioners in my profession who have pieces of the puzzle. The thing I respect about Dr. Zelinsky is she acknowledges. This doctor has this piece of the puzzle. This doctor has this piece of the puzzle and she is trying to encompass it all with the knowledge she has from going to the neuroscience conferences.

    I have a question for you. This is more of a personal question. In my office, I do have people that go to vision therapy. I have a couple that says, “I love it. It’s helped me out a lot.” I have a couple that says, “I felt so much worse after that appointment.” I think you mentioned it, it’s the patient that’s got two pairs of sunglasses on that can’t tolerate any light. I’m trying to think to myself when this person is ready for this therapy? Is it making them worse? Is it making them better? What are your thoughts on general vision therapy? I know that’s a blanket statement because you have no idea what these people are doing exactly. I just want the best care for my patients and when to refer them out.

    That’s the challenge. All of us have the best intentions. Even the doctors who are more ocular disease-oriented have the best intentions. They just don’t have the knowledge in this particular area. I think the reason sometimes the vision therapy works is that doctor has that piece of the puzzle, which helps this particular case. A different case may not need that. They may need the lenses, prisons, tints, filters that Dr. Zelinsky can offer. She’s working on it. I’m excited to be part of her team where we’re working on developing a network of offices across the country for sure and across the world who will do this technique. The concern is making sure that it’s responsibly done. These doctors are certified, they know what they’re doing. I imagine it’s very much like the upper cervical work that you do with the Blair technique. You don’t want someone messing around with it if they don’t know what they’re doing.

    People claiming that they’re doing it and they’re not.

    EM 106 | Healing Brain Injuries

    Healing Brain Injuries: Neurodevelopmental optometrists are not just eyeball doctors. These are doctors who do study the brain at a certain level.

     

    I think that there are many optometrists who are neurodevelopmental optometrists or behavioral optometrists who have a piece of the puzzle and often can help. There’s a doctor locator on the Neuro Vision Rehab site. They’ve changed the name of the website, so I have to keep reminding myself of what it is. The other website that sometimes is helpful is the College of Optometrists in Vision Development, where they have a doctor locator. At least these doctors are not just eyeball doctors. These are doctors who do study the brain at a certain level. I’m excited that Dr. Zelinsky is working on getting a bunch of doctors certified as quickly as possible, but as responsibly as possible, who can do her work and carry on after her eventually. This is hopefully going to change the profession of optometry so that at least it is a highlighted field within my field that people can choose just like you might choose to be a glaucoma expert or something else.

    I know it takes three months for people to get in to see you, but where are you located? Does your practice have a website? Where can people find you?

    I have two practices, three locations because people are driving two and three hours one way to see me. I’m in New Hampshire, I’m on the Sea Coast most of the time, but I do have a satellite office in Concord, New Hampshire at the capitol. One helpful website is HarborEyeCare.com and that’s where I do a lot of brain injury work. We don’t have onsite therapy going on but most of my patients, I’m partnering with the OTs anyway because there are so few doctors doing this work. I need as many patients to get help as I can. Many times, there’s a lot of overlap with occupational therapy.

    I like to say they use the visual system to get the motor system working better. I use the motor system to get the visual system working better. We’re good partners. Often, my guys I’ve worked with for many years, sometimes over a decade where they understand where the line is and what they can do without me and what they need to consult me for and when they need help with prisms and lenses and stuff. It’s a good team effort. I do have respect for other professions as you know and I think that if we each contribute our piece of the puzzle, the patients get better faster. That’s my main office. I am still contracted with insurances there. My other office is Visual Victory Training and VisualVictoryTraining.com is that website. I’m not contracted with insurances because most of the time the insurances don’t acknowledge what I do.

    It takes a while for the third-party payers to catch up with things that often are the successful thing to do, but they’ve got their rigid requirements and criteria that they’ve followed for years and they seem to be resistant to changing that. I negotiate with patients at that office. I’ve done payment plans, I’ve done CareCredit, I’ve done health savings plans, I’ve bartered. I’ve got some beautiful handmade wooden tables from a patient’s family that I treated the patient and they helped me get some tables for my equipment. It’s one of those things where I do what I can to give back. When I was a child, I was raised by my parents during the depression era. You could bring a chicken and have your eye exam back then, but I need a little more than a chicken these days. I am happy to work with people in getting them the care they need in whatever way that happens.

    Dr. Amy, at the end of every show, I like to ask all my guests, what is one piece of advice that you would like to give the audience that’s resonated with you through the years? It could be absolutely anything.

    I would encourage patients to understand and please take this with a grain of salt. I tell my patients, you’re not dead yet. Once you’re dead, I can’t tell you. As long as you’re alive and breathing, we can influence the brain connections that you are making. Let’s try to influence them in a positive direction. I can’t guarantee perfection, but please don’t give up hope. Please continue to picture yourself well and healthy. My help can’t hurt and get practitioners who can give you things that you haven’t had yet that might help you with your recovery.

    Thank you so much. I enjoyed this episode. I love your field. I’m excited if you find anything cutting edge, please let me know. I would love to have you back on anytime.

    Thank you so much. It’s been a pleasure.

    Thank you, Dr. Amy.

     

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