An Update on Chest Wall Anomalies and Their Treatment: Advanced Practice...

So today I'm talking about chest wall deformities and basically the deformities fall into two different groups. The majority of the deformities that we see here are of course pectus excavatum. Um, so we will spend the majority of time on that. However, I did want to go over um some of the other ones as well. And um I did throw a little bit of history of some of the surgeries in, um, which was kind of interesting because depending on your source, it may tell, tell a little bit of a different story, but at least it can give you an idea of where we've come from and where we're going now. So with um the two types of deformities, basically the one has um an overgrowth of the rib cartilages, and we're not exactly sure why this always happens, um, but then they can sort of buckle and either um press the sternum in or out. And sometimes it's even in a combination, um, to varying degrees. There's also some more rare um aplasias or dysplasias where there's an absence or um an abnormal development, um, of the bones and cartilages. Oh, first starting with um pectus excavatum, you have the, um, anterior wall depression, and it can be, um, varying depths, um, and symmetry. Sometimes it's symmetric, um, sometimes it's asymmetric, and, um, also changes, um, as the patient, um, grows. So, um, often the parent may notice it, um, sometime after birth, um, but it just might be like a little mild depression. Um, and then as they grow, especially through the teenage years, then it can develop into a deeper, um, depression, um, and depending on the depth and also the degree of cardiac and pulmonary compromise, um, really determines on what we are going to do about it. So pectus excavatum again is the most common of all the deformities. However, um, I did note in the literature that Argentina says that carinatum is more common in their country. We rarely see it in African Americans. Sometimes it does follow in families. Once the patient comes in the clinic, they might often say, Oh, you know, Grandpa, I think maybe had this, but not to such a severe degree, and he never wanted to take his shirt off or, you know, maybe a cousin has some type of pectus as well. So we usually do ask about, um, if it does run in families. It's more often in males than females. And um often it seems to be like the tall, thin, um, white boy, statistically. Mm So there has been noted that with females who have pectus, um, that they do have a slightly increased risk of having scoliosis, um, more of a mild scoliosis, and 18% of those with pectus. And, and many of course have a connective tissue disorder that's higher than in the normal population, such as Marfan syndrome, um, which many of you have heard of, and Ehlers-Danlos syndrome, a little bit more uncommon, um, which is, um, when you have a malformation with the collagen processing disorder, and so they have connective tissue issues as well. And also with pectus excavatum, a lot of the patients do um have poor self-esteem and, um, poor image problems. So excuse me. So the studies do show um varying degrees of cardiac and pulmonary compromise, and again, it seems to worsen as they grow and their chest wall is not as compliant and it's not as flexible as when they're young. They can also have cardiac defects where they have decreased cardiac output, and typically we'll see that on the deep defects where the heart is displaced over and so the patient will say that, you know, they start out running fine but they seem to tire a lot quicker than their peers. Also they can have pulmonary effects where they have show almost like a restrictive lung disease and have um have some atelectasis if um it's restricted um that much. So indications for operation, so usually after they come and see us in clinic, then we'll send them for a CT scan um without contrast. Excuse me. Um, Typically with us in the state of Maryland when we get the results of the CT scan. And um the radiologist will calculate the index, the Haller index or pectus index. If it's greater than 3.25, then typically we're able to have insurance pay for that, um, and I'm sure it may be different certainly around the United States and worldwide would be interested to see um what goes on in your countries. Um, I did put um MRI up here because I think it's an interesting. Um, discussion to find out what people are doing. I know that it's a trend to not do as many CT scans because we don't want the patient to have as much, um, radiation. So we were looking into sending the patients for MRIs. However, the MRIs seem to be a lot, um, take a lot longer, and they seem to be much more expensive. So we've been getting some bulk at that on sending them for the MRIs. So I was able to meet with our radiology here at, um, Johns Hopkins, and they actually made a Pus um excavatum protocol where they do like a flash scan. Um, so there's not as many cuts, um, but they're doing it where it's a deeper depth and so they're not using as much, um, radiation, and in addition, we have a separate pediatric scanner, um, at our downtown location that has less radiation as well, so we've been trying to do, um, a pectus excavatum protocol on that, so, um. I can, uh, I can comment. I, you know, I, I've seen a fair number of kids with pectus recently. I, I just use a, a PA and lateral chest X-ray, and I usually just calculate the pectus severity index myself. Um, I don't know if anyone else has any comments about that. Uh, some insurance companies will ask for a CT scan. But um uh you know, after training with Doctor Fonfels root at UCLA um uh I think, I think you can accurately measure it with just the PA and lateral chest X-ray. We also have um calipers that we have in clinic that we can measure as well that work pretty well and so we definitely have a general idea and certainly, you know, on the depth and some of them are so severe that it certainly doesn't matter, but some of the borderline ones, yes, the insurance companies have asked us to have the CT scans, but the protocol's been working pretty well, so we have been doing that. So thank you. We do send the patients for exercise, pulmonary function, um, testing where they're on a, um, um, treadmill, um, or some of the locations actually use a bike and we exercise them and see if they have um restrictive and obstructive disease, um, often though, they are fairly um in the normal um range, but we can see a slight drop and then certainly on the more of the severe cases, um, we do see the restriction. Um, of course, clinically we, um, do a whole history and physical and see if they've had a progression, um, with their physical symptoms and what they're complaining of, asking them if they're playing sports and what kind of activities they're doing. Also, we discuss, um, psychological symptoms, and this is, I, I feel a little, uh, it's more difficult. I also feel that even though we can have a good, um, you know, outcome with the surgery, that I find some of the kids who really are bothered severely by the psychological symptoms that it seems that no matter how great we get the chest, it's just not perfect for them. So we do have a discussion that You know, they're going to have some, you know, slight scarring and that, you know, there may be, you know, a little misshapen or scalloping of maybe the lower rib cage or that it might just not be perfectly flat just so that they're not disappointed. Usually the family's happy and, you know, most of the time we're happy with the outcome, but I find that interesting and wondered if any of you have that same issue. And you can type in if you have any questions as well. So also if we have a patient who's had a um failed um rage or nest repair, um, which occasionally um we do or we've had um patients come from other um places or internationally, um, and it's deep enough, then we will consider um you know, redoing the repair, but we actually see a lot of patients in clinic and we'll see them yearly as they grow, and many of them do not require operation if they do not um. You know, become deep enough. So we do have quite a few patients that we just see every summer and um check in on them. So, um, looking through some different history books and literature, so chest wall deformities have been described for quite a while, and initially in the early 1900s, um, the costal cartilages were removed, you know, different, um, they were um excised out. And of course in 1946 um was when Doctor Ritch was doing the um complete um cartilage excision um that many people refer to that surgery um today um and then in the 1950s and 1960s, some different types of um bars and um bridges were starting to be used. And um I found of interest in 1970, um, Doctor Wada of Japan was actually removing the whole deformed, depressed sternum, flipping it over so it protruded out and grafting that on, um, so I found that was pretty interesting and creative. And then of course it brings us up to. Um, 1988 with Dr. Nuss from King's Daughter Children's in Virginia, and he began the minimally invasive operation where he places the stainless steel rod underneath the chest wall and then elevates that and wires it into place. So this has been helpful by not interrupting the growth plates as much without excising so much out um so that we don't have um incidents of potential like acquired genes where the chest wall does not grow. Um, also, it's helped by doing surgery later on when the patient has actually grown more versus doing it, doing surgery at a very young age. Um, the bar is usually, um, placed, kept in place for 2 to 3 years, and although it's an inpatient procedure when it's placed, um, typically institution it's an outpatient procedure to have it removed. We also leave our bars in close. Closer to 3 years we've had, we've found that we have a decreased recurrence rate the longer that we are able to leave it in, especially if the child was repaired at a younger age, and we think that they still might go through a pretty large growth spurt. But I would say the average age for surgery is about 14 years of age, um, and really, um, I think by doing the surgery overall the patients do have um an increased confidence and self-esteem and um I do have a pretty long reference list at the end so um I'll refer to some different studies and you all can take a look at them as well. I also wanted to put some other potential types of things to do with pectus, although we are not doing these at Johns Hopkins, and if any of you are using these, you can certainly jump in here and add anything, but there is a vacuum valve. That was introduced by a German engineer, and there are two types that I could come up with, which was the Costa and the Clobi vacuum belt, and it basically has like a, you can see on the slide, um, a little, um, pump there to pull the air out and to, um, pull up the sternum. So you actually wear it for several hours. A day, um, it would probably need to be a younger patient or one who does not have a stiff chest wall so that you can actually um get the chest to move up. It may cause bruising. That's one of the side effects because you're, you know, creating this suction on the patient. And there is a need for some long term studies, um, of note, um, I know that, um, Doctor Nuss and colleagues in Virginia have also used the vacuum valve intraoperatively. So if there's a really deep pectus and it's hard to pass the bar through, they'll actually, um, use the bow to pull. Up the chest wall so that they can get in easier, you know, flip the bar over and wire it in place, and then take the bell off so that way they can clear that space in there and make sure that it's safe to put the bar through. Has anybody used the vacuum bell and want to share their results with us? Not in Los Angeles. No, not in, not in LA. Yeah, not, uh, not here. Although the only thing I'll tell you is that, um, the, this is just a small point, but there was another person that presented last year that they, uh, do, there's a lot of, um, creative ideas that people use for external elevation in the operating room if you don't have the bell, um, to, to make it a safer, uh, pass through. OK, thank you. Um-hum. Um, I also did a little research on magnet therapy, and we are not doing this at Johns Hopkins. However, um, out at UCSF and Shriner's, they have begun. Um, a study called the magnetic Mini Mover trial, um, and there's a couple of references at the end of this, but you can also Google it or go to the UCSF site, um, and it's a pretty, um, interesting site. So, um, basically, there's two magnets, one that's placed, um, internal. As you can see on the diagram, and then there's an external brace with the other half of the magnet to create this, um, force field over several months, um, to try to elevate this as well. Um, again, as you can see, it's for 8 to 14 year olds, so they're obviously doing it when they're younger and there's more chest wall, um, compliance. Did anybody else um out there, has anybody, and I know a couple of you are from California, does anybody have patients participating in that study or has anybody else tried the magnet therapy? No, we haven't tried it. Um, you know, Mike, Mike Harrison is a big fan of magnets, so I think this is probably his brainchild. I was actually talking to Diana Farmer when she was in San Francisco, and I know that, you know, they, they published some preliminary results, but she was telling me that it actually is quite, quite effective. So Dean, this is actually, you're right, this is Mike's idea, um, and I was surprised, um, by hearing that it's actually out there. I, I saw only his video a couple of years ago when he was conceiving of it, but I didn't know it's actually available and available for use. Well, it looked like when I did the research on it that um there's some 3 articles out there basically like a very small like pilot study, and then um they did start this, um, the actual, um, I guess I flipped past it sorry they did start the um magnetic mini mover trial study is what it's called so and I guess obviously potential side effects are that it could erode, you know, erode through. Again, just that compliant chess wall compliance is very helpful, so it'll be interesting we can kind of follow along over the next couple years and see what kind of results they see. Um, one thing, um, it's not very common, however, um, here at Johns Hopkins we did do, um, we did follow along, um, with some patients who. Did have some um other Marfans and connective tissue disorders who also had cardiac issues and we have been for the the few that we've had we've been trying to repair them. Um, Doctor Kambani has done surgery at the same time as, um, the cardiac surgeons, and that way we don't have to go back and, and open them up and do, um, two surgeries at the same time, and, um, that has, you know, been the whole, um, several disciplines and appointments, but able to get that together at the same time and we've had good results with that and the parent, the patients fared well during the actual surgery. So moving on to pectus carinatum, um, where the, the typically the, they actually have a prominence, um, of the sternum and again, um, like, uh, excavatum it can be varying. Um, degrees and along the sternum, um, different places, one side, etc. um, not always noted at birth, but typically when they're in their, um, when they're in their adolescent growth spurts, some complain of tenderness at the protrusion, um, especially if they play sports with pads or they like to sleep on their stomach. And again, um, occasionally associated, um, Marfans and scoliosis, etc. So we used to um have send them, send the patients for surgery um however, in a minute I'll discuss more of the bracing which has become um more of a standard of care um but with the um surgical treatment. And we usually have minimal postoperative, um, problems, uh, some of the hospital stay, I mean the stays are really short and recurrence has been rare. Um, typically if we do have them have a surgical procedure, we wait till they're, um, basically, um, done growing with their growth spurt. We've now um moved um towards bracing um to prevent actually having the patient have surgery. There's many different um types of braces out there. I've put a couple pictures um up here. Um, now some of them actually have, um, compressor systems on there where you can measure the amount of pressure, um, and now, um, I've read that they're trying to put time sensors on some of them, which I think is actually um a fantastic idea so that we can actually check compliance because really I think the biggest thing with the bracing is that we need to have good compliance. And have the um patients actually wear the brace. Um, the brace that we use has is pretty low profile. Many of them just wear like one of the compressed compression shirts. Um, that fits tight and then, um, the brace is put on. And they seem to do really um well um with that and they you know want to be able to um hide it under their clothes for the most part typically. We'll have them wear it 23 hours a day, um, initially and then wean off to so that they're just wearing it at night and they can have it off at school and take it off for sports, etc. They do need to wear it usually for about 9 to 12 months and then occasionally we've had to have them, excuse me. Actually put it back on occasionally or adjust the brace if they've grown and they've tried to and they've started to have a recurrence typically we don't have a full recurrence if it starts to come back out and they've had a big growth spurt, um, then we'll just, um, you know, readjust it and up the wear time. But um there are a number of um articles now that are, um, have been, um, you know, out there in the journals um talking about um pretty good results um with the bracing. Uh, can I make a comment about the, the brace before you move on? Yes, sir. Um, so I'm just curious. I don't know what types of braces. First of all, I was trained to do the Ravage, uh, maximally invasive surgical procedure for carinatum. Since then, I pretty much, I only use bracing. But I wanted, uh, one point that was, uh, that it's interesting for everyone to know is that there's a, actually everyone knows there's a lot of braces out there as you just remarked on, and the one that I, I think that, uh, you guys use there at Hopkins is Marcelo Martinez Ferro's brace, uh, from Argentina, and that's becoming the, it is the best brace out there. It's, uh, I'm looking it up, it's called the dynamic compression device, and it's what you were describing. It's sort of the smart brace. Um, the problem is it's hard to get and, um, uh, I've been trying to get it here and you have to have a real commitment with uh a program that has enough, uh, where a dedicated person that knows how to use it, but it's specifically measured. It's the one in the middle there I believe, is that right? Or the one on the right. It this one here, yes, it's the same thing on this one and then there's a different type of brace. So actually we here at Hopkins do not use this one. I know, um, Doctor Nuss uses this one. we, um, I mean we have too much, we have a difficult time getting it, so we use like a low profile one and we just sort of do the test, you know, if I press on her chest and I, I can't, you know, get it in, or, um, occasionally. We've put um a brace on and you know their chest is really stiff and they've had wounds then occasionally um they have gone um for surgery and we've had a couple a handful that just flatly refused to to wear the brace um but yes this um this dynamic compression system um. You know, from report is a great system and does measure the pressure and will do and will do some time censoring as well. Yes, I mean, like you said, Don Nussen and all the people, a lot of people I know in Kansas City and then out in Colorado, they just say it's incredible, and I've not tried. or used it. I just, I'm, I, I, I just want to mention that that's probably going to be emerging as the best brace out there because everyone that does high volumes is starting to try to use this. And then one more question, do you, what do you know about insurance coverage? Are these always covered by or usually covered by insurance? Yes, we have good, um, we've been able to, well, this year is getting a little trickier, but up until now we've had good coverage, you know, just putting in the codes, um, basically, you know, I've had to make the phone call and do the medical necessity letters stating that, you know, this is to prevent um surgery and we've been able to get the majority of coverage um. I do. We've used a number of different bracing companies that are out there. There's orthotists who make the brace and will place the brace on. I do feel though that if we are able to use a physical therapist to apply the brace and actually massage the chest and. Um, push in the defect before putting the brace on and tightening it down, um, that we seem to have better compliance and results versus, um, some of the orthotists don't want to really manipulate the chest wall and so they slowly try to tighten, tighten, tighten, and it seems to not work as well and to cause more pain and compliance issues. Yeah, thank you. So if we, if you could get the um the dynamic compression one I think that would definitely um be helpful and and if you have good physical therapy team at your um facility I think that's helpful as well. So, um, also to note, um, there's a pectus carinatum minimally invasive repair, um, with a little bit of data out that I thought I should mention, um, again, we have not done that here at, um, Johns Hopkins, um, but there is an Abramson technique or reverse NU where there's actually a bar placed over the sternum and wired to help, um. Um, you know, to, to, uh, push that down, however, um, initially they had a handful of good results, a good handful of patients, um, although there's been a wire, um, eroding through the bone due to the force, um, which you can imagine, so it'll be interesting to see, um, what happens with that, um, over time. Just to mention a few of the more um rare things that may pop up in your practice um occasionally and sternal clefts have been noted in the literature for hundreds of years and basically it's a um. Midline defect of the upper torso and to a varying degree where you actually have um the cleft there you can see in the picture um ectopic cortis where um it's actually open and the heart um can actually be sitting out on the chest and the outcomes in surgery are are based on the extent of the problem and what needs to be fixed and it's more of a case by case basis. Um, Cantrell's pontology, um, which we occasionally see every couple of years, um, again, where it's a pretty big defect and you can have, you know, several cardiac defects, the diaphragmatic hernia, um, everything is laying out on the, um, chest, um, with the sternal cleft. Um, I actually did not have any good, um, photographs, however, I noticed there's a ton on the Internet if you would like to see, um, what this looks like. And again surgical goal to try to cover um the defects and see what we we can repair um there can be high mortality depending on um the extent of everything. We also, um, um, along the lines of the different rare, um, anomalies, um, Polon syndrome, um, where you have dysplasia of the breast, pectoralis muscles, ribs, um, uh, possibly underdeveloped arm, hands, and fingers. And a lot of these kids are mainly um we send them to plastic surgery so if you have the um under the um underdeveloped fingers or etc. then we usually send them to plastic surgery um at a fairly young age you know if they have syndactyly, etc. there's some things they can do um when they're young. But as far as the um chest wall, typically plastic surgery here um likes to repair that you know later on when they're um when they're about done growing um so that they can do different types of um possible flaps to help make that chest wall um chest um chest wall or breast tissue if it's a a woman. Um, and they, um, the plastic surgeon here does like a tram flap sort of like what you would do, um, for a woman who has a mastectomy. Has anybody had any, anything different they've done with the Poland syndrome patients that they've seen? Los Angeles, um, yes, they operate on the hands and the young children, and they wait on the girls to do implants until they're about 15 years of age. They're doing about this, I think we're probably doing about the same thing on that so and in the end they have pretty good um surgical outcome and luck. So with um pediatric surgical nursing care. Um, I'll speed up here a little bit, so of course it's important to have um a good understanding of the defect physiology and, um, pathology and what the surgical, um, technique and repair is, you know, going to be at your facility and with your surgeons. Um, education and reassurance is very important. Pain management, um, is really, um, a big issue, um, with our pectus excavatum patients, so. Reportedly the NU repair, although you know you have less incision, um, line, etc. seems to be that the pain is actually more than the ravage repair, um, and it's very important to talk about pain management ahead of time and then, um, for us we our patients, um, have a PCA. We did try to do um epidurals for a while, but that really delayed our early ambulation and the patient um couldn't get out um of bed um as early and it didn't seem to um cover the pain um as much as we would have liked, so we have, um, good results with the PCA. And we do not um place Foleys and we actually get them out of bed like that night um and start having them ambulate to go into the bathroom. And um I understand that compared to some facilities we are uh much earlier on that than um other places um we have them use the incentive spirometry to do deep breathing and really um have them do that um every hour or if they're watching TV. I tell them every time a commercial comes on. And then post-op, um, we typically have our patients, um, discharged by day 3 or 4 and we take off, um, their dressing at that time and then what's left is the, um, Steri-Strips, and they can shower and pat those dry and then we'll see them at, um, 2 weeks, um, post-op. Um, we send them home with, um, oxycodone, um, and usually the day after surgery, um, if they're eating well, then we start to transition off of the PCA and over to PO pain medication and, um, you know, because obviously we're gonna send them home. So, um. I was going to just run through um a case study on one of our typical patients, so we had 14 year old Mark who had pectus excavatum that was noted shortly after birth, but this past year, uh, with his increased with his increased growth, he noticed that the dent in his chest is appearing deeper. Um, he likes to play video games and swim, but he actually quit the swim team this past year because he was having shortness of breath and having difficulty keeping up with his peers. Occasionally he has chest pain, but not a lot of complaints about that. And basically he's embarrassed to take off his shirt because everybody asks, you know, what's wrong with him, um, and he, they actually thought that his great grandfather may have, may have had pectus excavatum, um, but he never, um, would take off his shirt, so he was, um. Referred to us um from his pediatrician to be evaluated for this and um so we send send them for an echocardiogram, the exercise pulmonary function test, and the chest CT um without contrast for the PCus um flash protocol. And um when we're doing their physical and workup, um we do go over allergies, including if they have any allergies to any um metals so obviously we're doing um a metal um implant and we wanna make sure they're not allergic to that. We typically do not send them for allergy testing for metals, um, unless, um, they do tell us that they have a problem. Um, with that, um, although I know some, some, uh, facilities routinely, um, send them, um, to dermatology for allergy testing, um, but we've had, I don't know, maybe like one a year who's actually, um, had, um, an allergy to metals, and there, um, was an article or two out there on that. Um, the echo, um, we wanna make sure and we just wanna see if they have, um, mitral valve prolapse, and we wanna make sure that the, um, aortic root and valve is normal and that they don't have any, um, other problems, and again, um, his Haller, um, index is 4.4, and we typically repair if it's greater than 3.25. Um, we, after the studies are done, we report the results to the family, and typically most families because of school issues want to have the repair in the summer or sometimes over winter break, and I encourage them to really eat well. A lot of them are really thin, and many of the patients, um, may lose, you know, 5 or 10 pounds with surgery, um, and also I encourage them to exercise and stretch, um, especially if they, um. You know, a lot of them will tell me that they just like to play video games and don't go outside and play, and we have found that the patients that um are really in better physical condition and play sports and stretch and do upper body work um actually fare better with the surgery and um recover faster. So when they um return for their pre-op visit um you know typically during the summer um we do um go over everything again and talk about pain and um you know what to expect after surgery. And the stainless steel um bar is placed um his without complications um typically it takes us about an hour for the surgery and we do not give, um, I mean we give um intra-op antibiotics but not after um surgery. And again, the PCA no Foley early ambulate and um we position with whatever whichever way they are comfortable. um I know some places, you know, do have a bed up or they have to be um a certain um degrees, but we let them, you know, use pillows and get into whatever position that they are comfortable with. Do you, do you let them sideline? Yes, we tell them they can lay any way they want as long as they're comfortable. Now, typically I can tell you that they like their head to bed up and they don't like to side lie, um, a lot. Um, many of them will tell me when they go home they like to sleep in like a reclining chair like a lazy boy, um, for a couple weeks until they feel better, and part of it is, of course, because it's hard to, um, get up to, you know, go to the bathroom, etc. um. It's a little easier, I think, for them to get out of those kind of recliner chairs versus trying to log roll, um, out of bed. And you let them log roll? You, so you really don't have any restrictions on how they can lay and one of the surgeons here doesn't let them, won't let them log roll, won't let them lay on their sides. So, we don't, we don't give them a lot of restrictions and we find that really some of the stuff they're not going to do because it does hurt, um, but we have not. We have not had complications by um you know getting them out of bed. In fact, they've just been discharged um you know, the more we've let them do, they've been able to be um discharged sooner, um. The other thing is because of the narcotics, of course we do discuss, um, bowel management a bit because it's even worse if not only does your chest hurt but you can't have a bowel movement so we do discuss that um as well um to make sure they have medications for that. Um, we do, um, no heavy lifting like greater than 10 pounds for 6 weeks and of course, you know, no contact sports during that time. Then once the 6 weeks is up then we tell them to slowly ease back into their activities. Obviously if they do something that's really painful, they need to back up, give it a couple days' rest, and then start to ease, um, back in, um, back into it. And then we typically see them at 2 weeks, 6 weeks, 3 months, etc. and then every year until we are around 3 years, um, of age. Um, We used to just do oxycodone, but we did add Valium on and that seems to help um not only with the anxiety um but some of the patients will get almost like muscle knots like in their back, etc. I think from changing their um posture and position. and I do have them back up against a wall and make sure that they put their head back and that they're standing up nice and tall because a lot of them don't even realize that they're hunched over and I want to make sure that they're, you know, standing nice and tall as they walk around. Um, they do make, you know, the, um, ID bracelets that you can wear, but we do give them, um, a little card for their wallet with the, um, instructions. Um, I've had a couple patients tell me they've set alarms off at the airport. Um, I've only had like 3 patients tell me that, and all 3 of them were coming back to the United States and were going through Paris, so they must have a highly sensitive, uh, machine there, so I thought that was kind of funny. Um, and I did call the manufacturer in regards to CPR. And they said that if you do chest compressions you can indeed um press, you know, press on the chest um and so, so that is fine so we do have the wallet card for them and I've had a handful of patients who have um ordered the ID bracelets um but we do not make it um a requirement and as far as schooling. You know, once they're off the narcotics, which hopefully is in 2 to 4 weeks, then we'll have them, um, go back to school again while a lot, why a lot of them, um, go to school, um, or have the surgery during the summer is what I meant to say. Did anybody wanna add anything into that or what you might do differently or have any questions? I just had a question. um, oh sorry, sorry, Dean, um, go ahead. My question is, is how often are you guys needing to see, I think one of the big things that we have problems with is once these patients go home, oftentimes it's hard to know, um, how long we need to continue them on the pain meds and what is normal and what is not normal and kind of what, uh, constitutes needing a pain clinic referral or if you guys do refer to pain clinic. We occasionally refer to pain clinic if um you know if we're hitting the 6 weeks and we're not um you know heading, you know, close to being off the medication, um like I said, most of our patients between 2 and 4 weeks they're off the narcotic, you know, most of them don't really um like to be on it because of all the other side effects. Um, but after we get to that point, you know, we'll definitely, I mean, we write out, I write out a wean, um, so that every couple of days, you know, we're weaning, um, by 10%, and, um, just what we do is just have them transition over to the, um, ibuprofen, you know, around the clock, and then once they're on the ibuprofen, um, and feeling better, then they'll wean off of that. And then if they hit the six-week period and they start to exercise, they can get sore and have a little bit of pain and I tell them to um try the ibuprofen because I don't want them because they're exercising to suddenly start taking narcotics again. Thank you. I have a, I have a comment and a question. Number one, I completely agree with the use of benzos and anxiolytics, um, in, in these patients, and, and many patients. I do think there's a large component of pain and the experience of pain that is anxiety, and I, I, I like the use of, um, of Ativan, and I think I'll probably start using Valium in some of these kids too. Um, my question is, what are you telling kids as far as, uh, contact sports? So you said that after 6 weeks, no contact sports, but for the duration of the, the time that they have the nut bar, are you letting these kids playing football and tackling and, and uh. Because I, I, I, I get a little worried about the, the bar shifting, um, migrating, especially with contact sports. Tell them that they can ease back in and go to um contact sports um you know luckily I guess a lot of our patients um. Um, you know, statistically aren't on football teams, etc. Um, however, we have had a few and we tell them they can, but there's a risk to it, and we have not had a problem with it yet and hopefully we won't, um, but I have a number who do, um, you know, karate, play soccer, etc. Uh, we did have a problem last year with one patient. She was actually in a car wreck, unfortunately. And um the steering wheel went into her chest, um, but, um, you know, we haven't had, we haven't had a whole lot of issues and they don't typically go back to the contact sport right at 6 weeks because again it's more of a gradual um ease into it so. It is a tough call though. And what is, what's your, what's been your compliance rate, would you say with the use of the. The brace for pectus carinatum. I most, most, most of your patients are compliant. I would say 85% of them are compliant, um, but it's a lot of support like those first two weeks, um, because it is, it can be painful and you know some of them right from the get go in clinic I can tell that they're that they don't wanna do this, they're not on board and I'll actually tell the parents, you know, just because you're on board. Doesn't mean you're gonna get them to wear it and um and I'll actually just tell them to think about it and discuss it and come back in 3 months. Sometimes then the chest, unfortunately will get a little worse and then it'll really start to bother the kid and come back in, um, but I just feel like the ones who fail, like I can tell right from right from the beginning. Kimberly, thank you.