Sleep Apnea: The 21st Century Epidemic

So I'll talk to you about sleep apnea and I have a particular interest because we use a device called Nightlase, which is an FDA approved laser to treat or reverse sleep apnea, at least reduce it substantially. We've been doing this since about 2015. And I'm gonna go over some, some kind of highlights of the book I wrote in 2022. It's called Sleep Apnea the 21st Century Epidemic. You can get it if you want to allure medical books, Google medical books, you can come across it. Sleep apnea is a defined. This is obstructive sleep apnea we're talking about for this discussion. So obstructive sleep apnea means that somebody is under breathing or not stop breathing for at least 10 seconds so many times per hour. So let's talk about some definitions of sleep apnea. Obstructive sleep apnea, there's central sleep apnea, which we're not going to talk about today. That's where something wrong with the brain and this person stops breathing. That's pretty uncommon. Then there's obstructive sleep apnea, a person usually laying down and sleeping maybe on their back and their tongue slides backwards, their airway collapses, they choke. There's the apnea hypopnea index, AHI apnea, hypopia, apnea hypopnea index. And the apnea means stopping breathing. Hypopnea means under breathing index means a score. So you go to a sleep lab and you get a test done and that's traditionally we have other ways to do it now. And the test will show that you have a sleep apnea or not. We defined it as number of times this occurs in an hour. So it's fine as having a 10 second period where you stop breathing or under breathe and your oxygen count drops 3 or 4% depending on which measurement's being used for 10 seconds. And if it happens once an hour, that's considered normal. In fact up to 4 an hour is normal, 5 to 15 is considered mild apnea, 15 to 30 is considered moderate apnea and 30 and more is considered severe apnea. And to put in perspective a AHI score, Apnea Hypopnea Index score 3030 means that you stop breathing for 10 seconds every other minute. So 30 seconds or 30 minutes per hour. So back in 1988, the National Institutes of Health wanted to find out what is sleep apnea? What should we do about it? Do we need to worry about it? Does it have any effect on people's longevity lifespan? And we didn't really recommend treating it back then. So they went to the University of Wisconsin Madison and they polled workers in the state residents records that were 30 to 60 years old, so relatively young people. And they asked them to do a sleep study. And they got about 1500 people to do the sleep study. They had a control group as well, it did not get the sleep study. And they measured the incidence of sleep apnea based on a ahi apnea, hypno index of 4% desaturation, 4% drop in oxygen for 10 seconds occurring so many times per hour. And what they found is that about 25% of men, or 1 out of 4 men had obstructive sleep apnea. And about 1 out of 10 women had obstructive sleep apnea. Now since that time there's been two newer studies done in other countries. We're not going to repeat that in America usually do those types of studies once established incidence. Again, it was 1988. Other countries, Sweden and Germany both did. One was called Hypnolaus study and the other one called the Shiptrend study. And they found a higher incident sleep apnea because they did it more recently when people were a little heavier than they were say back in 1988, roughly 30 some years ago. So the incidence of sleep apnea probably is more like 50 to 60% of men and 20 to 30% women. As we get over 50, it's probably more like 60, 70% of men and probably 40, 50% of women. I have obstructive sleep apnea. So back to the Wisconsin cohort, Wisconsin study. So they did this study in 2000, I'm sorry, 1988 and they gave the people results, but they didn't treat them or anything like that. And they put the study asleep for 20 years. They went back in 2008 and looked at the death records and what they found was that people that had a score over 30, in other words, severe sleep apnea, compared a score under 5, no sleep apnea, no clinically significant sleep apnea, were three times more likely to be dead. Three times more likely dead. And the causes were cardiovascular death. Now keep in mind they were 30 to 60. That means 20 years later they were 50 to 80. And what's the most common cause of death? Cardiovascular disease. There's no increase instance of cancers that we can see. It's really a little early to determine if there's neurocognitive decline or Alzheimer's because they weren't at that age, let's say so three times more likely. Now they subgroup down to the people who there were. Some of those people end up getting treated for sleep apnea because they tell their doctor and they say, well, let's try this CPAP machine. CPAP is a treatment for sleep apnea. It's a device that goes over your mouth and nose and helps force air when you stop breathing. When they separated out into people who did not get treated for sleep apnea, they were five times more likely to be dead of cardiovascular disease. And even when we adjusted it for other causes that might shorten somebody's life, like smoking, body mass index, obesity, hypertension, diabetes, they were still three times more likely to die. So that is an independent risk factor for death. In fact, it's postulated that if your score is over 30, you lose 6.4 years of healthy lifespan. Lifespan compared to somebody that does not have sleep apnea. Now in the groups that had mild to moderate sleep apnea, they did have an increased risk of death, but it was not statistically significant. Means it's not clear if there wasn't enough people in that group to say that were more likely to die. Possibly, we don't know. Severe, definitely, unequivocally mild to moderate. It's not clear. So we really want to focus on people with severe sleep apnea. But people with mild moderate apnea, we do want to maybe address that because it was trending towards a 50% increased risk of death. That's significant. So back to the Wisconsin cohort. We established the incidence of sleep apnea is about one out of 10 women, one out of four men. And now we know it's probably much higher than that. Maybe double for each, maybe one out of two men and one out of three, three to five, two to three women, those are this unknown. The Germans and Swedens, do they really have more apnea? No. Probably because the study was done, you know, 10 years later, 20 years later when we were heavier. So sleep apnea is an epidemic and we're not testing for it. Interestingly, the US Preventative Healthcare Task Force, which is a non government organization, paid for by the government, recommends against routine screening for sleep apnea, something that can shorten your life by 6.4 years. The government's agency, it's a non government organization, when they fund, recommends against insurance companies paying for routine screening for sleep apnea. Sleep apnea. Now your doctor can do a questionnaire and if questionnaire is positive and there's clinical significance to it, then they can order the sleep study, which is about $2,000 for your insurance to pay for so obviously they want to save money. But what's changed since then? Well, now we have wearable sleep apnea devices that are very inexpensive. The wholesale costs $100 for some of them. There's the watch, Pat. Watch, like the word watch Pat. Pulse amplitude technology, Pat. That's a wearable device. It's kind of like an Apple watch. And it goes as a sensor on your finger and one on your chest. That's when we use those cost US$106. So we sell those to our patients. Our cost. They can get your insurance covered, but then you got to jump through some hoops. It's just 100 bucks. And there's another one that's a more of a fingertip one that's reusable, that is maybe $300, but I think you can get a few uses out of it. We haven't used that one yet. I'm interested in it. And then there's going to the lab, which unless you have morbid obesity, atrial fibrillation, heart failure, emphysema, you don't need to go to the sleep lab anymore. You can do it at home with these tests are adequate when you don't have those other conditions. So I think that these should be done at home. And we shouldn't have such a high threshold, you know, for getting it done. You can just pay for it if you want to. Again, that's without insurance. That's a wholesale cost, about $106 for the watch pad with shipping. So you can measure your sleep score. And if it's high, you know, obviously take intervention. Now, what are the treatments for sleep apnea? The gold standard in the last 20 years has been called a CPAP. CPAP, continuous positive airway pressure device. It's a mask that goes on over your nose or mouth or both. And when you under breathe, it helps push the air in. And these have a very good tolerance for some people, but the majority of people are not using them because they don't tolerate them. So we look at the. What's the likelihood of somebody having sleep apnea and getting a diagnosis? It's about 1 in 10, maybe 1 in 5 if we're conservative at best. And what's the chance of them getting treated? One in three. Take that together. About 6% of Americans with sleep apnea are being treated. 6% of people that have apnea are being treated. That are 94% either don't know they have it or they're not being treated. Compliance with CPAP is considered. Wearing the device at Least four hours half the week. So in only one out of three people will do that. So we can accept the fact that this is something that a lot of people just aren't really accepting. Lure logo mug that's a child smokes mug call 800. It's got the phone number there. So the it's easy to diagnose inexpensive diagnosis. You can do it on your own. And I'm really switching my thought from, you know, kind of butchered by healthcare where we're thinking we can only do stuff that health insurance companies pay for to you can do it yourself. And if you love yourself more than your money or possessions, then pay $100 and get a sleep study done. CPAP might be covered by insurance, probably some out of pocket costs around 1,000 to 2,000 a year. But it's generally covered if it's medically necessary. So let's take a step further than that. Cardiovascular disease, this is the number one cause of death in America remains. So you know, we do all kinds of intervention and we know that having a score over 30 triples your of cardiovascular disease. If you have a score of 30 and you don't treat it. 5x risk of dying of heart attack versus somebody that doesn't have apnea. So let's address this now. We know that from sciences since that time. So Mayo Clinic did a review of Medicare records of people that had both sleep apnea and cardiovascular disease. They found that they treated the sleep apnea. Cardiovascular disease incidents went down substantially. Hospitalizations went down substantially. They saved a lot of money. That's what they're looking at. Can we save money by treating this condition? The answer is yes. Patients more likely to live, less likely have events to have a heart attack hospitalization or less likely have an event that leads to death. So we should be treating that. We look at Schneider Trucking, they did a white paper on this where they looked at looking at their truck drivers which tended to be men tend to be heavy sick as they're in a sedentary job. High incidence of sleep apnea. About 84% of the men they tested had sleep apnea. So much higher than the Wisconsin cohort of 25% or the German and Sweden cohort of about 60%. And they, you know, had their guys, they would pay for all their supplies and offer them cpap. And they found not only reduction in preventable car truck accidents, which these are, you know, sometimes 80,000 pound killing machines, they found an increase in their hospitalizations. Health care costs dropped precipitously, less hospitalizations and less, fortunately less fatalities associated with truck accidents. So cardiovascular disease is a big one. We don't know exactly the mechanism. Why central. I'm sorry obstructive sleep apnea increases cardiovascular disease, but it does. It's proposed that it could be because of decreased nitric oxide, could be stress in the heart, could be lack of deep sleep and the barely for heart to repair itself. Whatever it is, it's impactful because we know that sleep apnea is causative by strong observational studies and treating sleep apnea reduces events. So we can say from evidence based medicine, treat your sleep apnea to reduce your chance of dying. Treat your sleep apnea potentially get maybe up to 6.4 years longer of longevity of health, of lifespan and health span. So those are really biggies. Looking at the big three causes of death, other than. I don't talk about the minor causes of the big ones are cardiovascular disease, cancer and neurocognitive clients, Alzheimer's per se. Sleep apnea doesn't seem to have a link to cancer. So that's what it is. It does have a link to other things such as obesity. So let's talk about obesity and sleep apnea a little bit. Right now we have a. We treated about 10,000 patients with these drugs called GLP1 agonist, semaglutide, tirzepatide. The weight loss has been very successful with it. The patient's been very successful. We're seeing substantial weight loss. We're seeing more weight loss than in the clinical studies because our patients are motivated, they're paying for this medication. These drugs are generally not covered by insurance for weight loss. So we've developed a system where it's very affordable and you can get onto it for a reasonable amount of money and lose weight that you want. But we are really addressing all the causes of their weight gain in the first place. So our patients are having their obese or overweight. They want to lose some weight. We're getting them on the semaglutide. Are we routinely measuring their sleep? The answer is no. We need to. But we're not, we're not doing that. So I'm going to look at how we approach this and I'll tell you why. If you are overweight or obese and you have sleep apnea, your best efforts, I'm not talking specifically about using the medication, but your best efforts are sometimes futile until you treat the sleep apnea. Now the flip side of the coin is if you're obese and you do a CPAP machine. The weight doesn't just fall off you. Arguably it might be something where you're not burning as many calories a night because you're working so hard to breathe. Now there's no study saying that sleep apnea treatment puts weight on, but we do have studies showing that if you treat your sleep apnea, your ability to weight, to have weight loss effectively, it goes up substantially. We also know that the canary in coal mine for sleep apnea is poor sleep, poor sleep, short sleep, poor sleep. And prior to say that 80s, we weren't measuring sleep apnea and we could just measure sleep. So the nurses health study, which is then way before the 80s looked at short sleep, was associated with much higher incidence of obesity, much higher incidence of gaining weight, much higher incidence of even extreme obesity. And we look at studies looking at people specifically that have obesity that are on weight loss programs with sleep apnea. If they treat their sleep apnea, the weight loss programs are successful. If they don't treat their sleep apnea, weight loss programs really not that successful. So it's bi directional obesity causes sleep apnea because there's more tissue in the neck obstructing the breathing. But the flip side of the coin is that if you have sleep apnea, very hard to lose weight without treating it. So I suggest if you're going on GLP1 agonist, you know, the cost can be anywhere from a couple hundred dollars a month, a couple thousand to a thousand dollars a month. Buy the watch pad, get a sleep study done, ask your doctor about it or come come to us and get it. We were able to sell them at our cost, $106. I think they cost $98 plus shipping. So it's $106. You can probably go to online telehealth, you know, for about two or three hundred dollars which include doctor's visit. We don't have a doctor's office visit for it. So if you're in Michigan or North South Carolina, you can get them through one of our practices or you can go to sleep lab if you, if you want to, your doctor might, you know, be more comfortable with that. And then there's other devices even I have a Oura ring. This is a Oura ring. It's got a little sense. I don't know if you can see. Let's see, I'll hold this up here. Can't see the sensors, little green sensors. And it measures if I have sleep apnea and I, my score is 1.7, which means 1.7 times per hour I have a 10 second episode that's considered clinically insignificant means I don't have the definition of obstructive sleep apnea. But if I'm up late or I have a bad night or me I drink alcohol more normally would I'll have some, I'll see some strikes on my oral report in the morning that I had some episodes maybe four in the night. That's okay. Get a lot of them in the night. Obviously you know you have sleep apnea. They're not allowed to give you a sleep apnea score because not FDA approved for sleep apnea. But we'll see that in the future where wearable devices are going to let you know. Getting back to the weight loss. If you're looking at losing weight we might look at your stats, your hormones. Low testosterone and men causes weight gain. Menopause and women causes weight gain. Sleep clear association with weight gain. If you have sleep apnea obstructive sleep apnea past sleep apnea. Let's talk about this longevity. There's not specific studies to define what I'm going to tell you. It's the other way around. We have observational studies. Sleep apnea is associated with a shorter lifespan likely primarily due to the increased risk of cardiovascular deaths. That being said untreated obstructive sleep apnea 5x increased risk of heart disease over a 20 year period than somebody that does not have sleep apnea or somebody's treated their sleep apnea estimate is about 6.4 years. If you get your score from 30 down below 15 that's you know there's very few checks you can write for get buying 6.4 years. I'd say you know CPAP machine in our case we do the night lays procedure. I talked about the different treatments for sleep apnea and let's, let's talk about what they are. We do the night lays procedure which is called a non ablative laser. It doesn't burn things. It's FDA approved for what it does and it shrinks the tissues for the mouth shrinks the tongue opens up the airway lifts up the uvula, makes the airway bigger. This has been studied pretty extensively. First for snoring. It was FDA approved for snoring and for the treatment for snoring in 2011 and about five years ago doctors started studying it for apnea which is a next step from snoring. And we found we can also treat sleep apnea open the airway up. So that's my favorite one and it's not the Best. It's as good as the other ones, I'll tell you that. It's as good as CPAP or the surgery or different devices. It's just one of the options. With the nightlace procedure, we do it typically three times for most people, five times for people that are already on a CPAP machine because they have a softer airway, obesity, smokers or copd. And when we look in the airway and it's very, very tight and score over 30. So those are the times we do five treatments about two to four weeks apart and last for several years. I did mine in 2015 and at the time I never measured a sleep apnea score, but my wife knew I had. You know, she could tell me when you stop breathing. I was snoring. I was snoring a lot. I got a and a half inch neck and men with an 18 neck, most of us have snoring and sleep apnea. And I measured myself. I did treatment back in 15. My snoring went down, almost gone. And then I started snoring again in 22, 20, 22. And I did a sleep lab which is a snoring, snoring measurement. And I was snoring about 30% of the night. It wasn't super loud, but it was enough to be aggravating to anybody, you know, in the area. My kids could potentially hear it or something like that. And I did a sleep study and my score was okay. I was not having sleep apnea, snoring again. So I did another treatment seven years later and my snoring went from, from 30% down to about 9% which is totally tolerable, probably never be zero. We don't really see that. We usually see about 60, 70% improvement storing and sleep apnea scores. So that's the nightlase, that's our favorite one. Doesn't mean I'm telling you to do them, saying that's the one that we offer. We're not going to prescribe you CPAP again. I'm not really familiar with that. Your doctor can work on that. So we're a night lays clinic. Cpap, that's the device that goes over mouth and nose. Continuous positive airway pressure. That's one that's most likely to be covered by insurance meeting certain criteria. And that's been the standard care for years. About a 60, 70% reduction in sleep apnea score. Just like nightlights. Next one is a surgery called Inspire. It's like a pacemaker device that goes in your right chest wires, goes up to your hypoglossal nerve and when you stop breathing it stimulates that to open up. Generally not covered by Insurance. About $40,000 got some major morbidity or complications with the surgery such as loss of waste. So we're not recommending that right now. But that's something that will come of age. And then dental appliances which I'm the least familiar with dental appliances. I have friends in the dental world that they get a lot of sleep apnea consults and there's a lot of times with the jaws is sliding backwards. They can put appliances in to make the person that's something they're wearing at night to help them breathe. So you can see your dentist about that. And interestingly the most common doctors to do the nightlights are dentists. This is a laser that has, we have. It's called a fotana laser. There's different families of it. We have a medical one that does different things. But the sleep apnea machine also is something they use to cut teeth and stuff with different settings, different maybe different wavelengths in some cases. So those are the four treatments. Losing weight that does help, doesn't make it go away. When I had my snoring, I was normal weight. My body fat's always been below 10% and I started snoring because I have a big neck and I'm a guy and I'm well over 50. So the, those are the treatments. Next step. So longevity, heart disease, neurocognitive decline. We didn't know this from the 2000, from 1998, I'm sorry 1988 and 2008 studies because the people in that group were not old enough to get Alzheimer's. So we wouldn't have known this. But later on we found out that people with sleep apnea are about three times more likely. Untreated people with sleep apnea three times more likely to get Alzheimer's. They also get on average 10 years sooner than their non apneic peers. 3 times more likely 10 years sooner. This is very impactful. When we look at. We're in the wellness business. We're trying to get people to live longer. And one of the horsemen is scarce. Sneaking up on you is neurocognitive decline. And by the time you have it, that is clinically visible. Sometimes it's too late to do anything about it. Early on when your brain is deteriorating. We can measure that with MRI called neuroplantative imaging. There's a clinic right here in Michigan that's doing it now. Just started offering it. When your brain Starts aging and it's early on. You can intervene and I will. I've done podcasts and videos on this before where we're taking individuals whose brain were in the lower 20, 30 percentile for their age and got to above the 50 percentile, which is, you know, the better number, higher numbers better. By treating the sleep apnea, the brain is plastic, meaning it can grow back. It's called neuroplasticity. The brain can repair itself and grow back. And there's things you have to do. One of them would be treating your sleep. There's other things you can do as well to restore your brain in addition to sleep. But we need that deep sleep for the brain to repair. So we have a lymphatic system. People have heard of your lymphatic system and lymphedema of your legs. Your brain is called a glymphatic system with a G. And it has a big activity during deep sleep. We see that people with deep, with significant sleep apnea, their deep sleep is impaired, they have deep sleep impaired. And that's a restorative part of sleep. And interesting. When I talk to patients that have sleep apnea, even severe sleep apnea, their perception is they're sleeping great. They go, get home from work, they pass out on the couch, start snoring away and choking away. Wife kicks them awake, send them to the bedroom, they, they're out until the morning. They wake up, feel like crap, they're tired all day, but they know they slept eight hours, didn't wake up, just bam, out. They're not getting quality sleep. They're constantly being partially awakened by this sleep apnea. So they're getting the eight hour sleep, but it's poor quality sleep. They're not getting deep sleep. And my oura ring gives me a report of what kind of sleep I'm getting. Last night I got a 95 score on 95, 100 because I got hour and a half of deep sleep, two hours of REM sleep. I went to bed at 9:30, got up at 5:30, good sleep score and no apneic events and no snorting because my ring does record that. So does my bed. I use an eight sleep bed. It's a cooling bed, but it also gives me a snoring score and a movement score, a deep sleep score, REM sleep score, light sleep score, knows I went to bed when I got up, knows my temperature with my heart rate, my heart rate variability. These are all things that we can start monitoring now. In my case, I'm using The eight sleep bed. Because I want to increase my deep sleep, which as we age, it kind of shrinks a little bit. My deep sleep was bumping down to about an hour a night. I went about hour and a half. When I got the eight sleep bed, that went right up. And even when I'm not sleeping on it, it stayed high. It's very interesting. So I travel a lot. My deep sleep's been pretty good for about a year and a half since I've had the eight sleep bed. I have the mattress cover, not the whole bed. I remember it cost me, I think it was about two grand or so. I saw Joe Rogan at one time had a code to get a discount and so did Peter Attia on their podcast. You look at their podcast, see if they still have it. I paid full price. I didn't know they had them. But that's an opportunity to get a discount on it. It cools the bed down. And so I get the bed. You know, it's like when you get in bed and you turn your pillow over, get it cool. It's about that cool. It's not cold bed and I have a heavy, heavy blanket on top of that. And just get better sleep. Don't wake up as much. Sleep is very important for longevity. Okay, getting back to neurocognitive decline got off track a little bit ten years earlier. Three times more likely. Sleep apnea being people that have early signs of neurocognitive decline. If they have sleep apnea retreat it. It slows down the rate of neurocognitive decline better than any drug. And these drugs cost a fortune. And we're not testing these patients for sleep apnea. Maybe because when you have neurocognitive decline, they might not tolerate the CPAP mass because they have some degree dementia. When it's advanced, they will definitely not tolerate it. So you want to catch that early and turn that around. But in terms of benefits for Alzheimer's disease, there are no drugs thus far that are working as good as treating sleep apnea. Should they have, which most of them. Most of them do. That's near and dear to me is my mother died of sleep apnea. We didn't know this and I haven't written this book yet. We didn't understand that because it's a timing issue. You know, back in the 80s and 90s, we didn't know this stuff. We didn't know the risk of cardiovascular disease. We weren't treating sleep apnea. And now we know. So now that you're informed you really have an obligation to yourself to do it. And if your insurance doesn't cover it, what do you love more? Yourself or your possessions? You can't take them with you. Love yourself. And I've observed that it didn't matter what people's wealth are their perception of whether or not they love themselves more than their possessions based on where they put their values at. And I've seen wealthy people that have a lot of possessions that are obese smoking, alcohol, drugs, not exercising. And I've seen people that are of modest means are taking care of themselves. They're exercising, trying to eat healthy and they're taking care of themselves. So it's not a class warfare, it's just our own mindset. I'd say not the majority of population does not love themselves more than their money or their things. I like to change that like see that change. I really practice that is has people that pretty much exclusively love themselves more than their money. Because we have a practice that we're treating people through their appearance which is not covered by your insurance. It's not free and they're interested in looking better on the inside. And a good place to start is with your sleep. Oura ring. O U R A ring. They're under fourth generation now. Interestingly I got my first one for free. I was at a meeting in California. It's called the Abundance 360 with a guy named Peter Diamandis. He's like a tech guy that brings. He's actually an MD but he doesn't practice medicine. He's been trying to bring technology to entrepreneurs and he put together this meeting and the guy invented the Oura ring gave him. Gave them out to all of us. There's about three or four hundred people in attendance and we're the first version. And back then the battery lasted about two days and after a year it didn't hardly last at all. So I bought a new one and it lasted about three days or so. And I saw there was a new one out the version 3 my old one's still working so I gave it away and I bought the new one. It lasts like three or four days and gives you more stuff And I see they have aura 4 my daughter was telling me that if they can predict when you're gonna have your baby if you're. If you're pregnant, she was pregnant or sees change your heart rate variability. But it does do well asleep now. I've heard people criticize it. One of my friend Bob Woodfield, he's a Plastic surgeon in Austin. He's saying all the auras are a piece of crap. Well, no, it's not. There's better stuff. But a brain ring that this size, it does pretty darn good. So I'm pretty impressed with it. And there's other devices that might be better. I mean, or is that, I think the king right now. I'm shocked. That's me. Like, Apple didn't buy them. The Apple watch, I haven't used it at night. Mine sits on my charger and I use for exercising. I know that some of these watches do have sleep. Sleep and no sleep. Eight bed. This is measuring your whole body. So it's very accurate. Does help with sleep. There's a little pump that pumps water into it. I really can't hear it. I mean, if I pay attention, I can hear it. But that low in the background, that's quieter than most refrigerators. About the size of a PC case, like a personal computer case. So it sits behind my nightstand and it has a little pump. And I don't feel the tubing in the bed. I can feel a coolness to it. I got to tell you, the company, they supported my. I bought one and after about three months or maybe six months, it stopped working. And my assistant wrote him a letter saying, hey, this stopped working. And they checked into it's not working. They shipped us a new cover and I think it was after a year maybe. So it wasn't even under warranty that they took care of it. They stand behind their product. Very good one. So watch Pat W, T, C, H Pat P, a T. Pulse Amplitude Technology we have for $106. That's her current price. I believe that's her cost. You can go online and get a telehealth visit. I've talked to some national telehealth firms. I think they charge like 3 or $400 for the visit and a couple tests. So get your score. Some people don't want their scores known by their insurance company because it might raise their insurance rates or might affect their health insurance rates. Well, then just get a watch, Pat, and just don't bill it to your insurance, just pay for it. Then the insurance company does it know. We don't run this through insurance. So your insurance company won't know. You won't lose your ability to get health insurance and life insurance. Because the insurance companies know that if you have apnea, you're not treating it, you're going to live shorter, therefore you're not the best risk. So apnea is something I'm very passionate about. Again, go to my website, Allure Medical Books, and download the book Sleep Apnea, 21st Century Epidemic. It's not it's not that big a read, about 100 pages. Try to make it so you can kind of buzz through it. And I basically took the science that we based on 22. I wrote this in 2022. I took the studies based on basically, cardiovascular disease and neurocognitive decline and kind of try to explain in such a way that somebody's not a doctor can get their head around a pretty, pretty good understanding the importance of this. And an informed patient is a healthy patient because you can take action. And I bias towards people who are informed because our patients are motivated to be healthier. They're motivated to look better on the outside of the inside. So I thank you very much.