This article is based on episode #25 of A Bridge To Wholeness podcast. You can listen to the episode on iTunes, Stitcher, and on our website.
Jennifer Crisp: As one of the first physicians in the Baltimore-Washington-Annapolis area to perform the Venous Closure procedure. Dr. Calure is now a national leader in the technique. He holds two certifications by the American Board of Medical Specialties. He is Board Certified in General Surgery and he is Board Certified in Thoracic-Cardiovascular Surgery.
Dr. Calure is trained in both classic open surgical technique and is broadly trained in minimally invasive, video assisted and catheter based techniques. He has performed over 2,000 major surgical cases including open heart surgeries, vascular and general surgeries. He is a lifelong resident of Maryland and Dr. Calure has had the distinction of practicing cardiac surgery in the hospital of his birth, Washington Adventist Hospital.
Dr. Calure completed his undergraduate degree in Aerospace Engineering as a Chancellor’s Scholar at the University of Maryland. While working part time as an engineer at the NASA Goddard Space Flight Center, he earned his Doctor of Medicine from the University of Maryland School of Medicine. Dr. Calure completed his General Surgery Residency as well as his Cardiac Surgery Fellowship at the University of Maryland Hospital in Baltimore.
So good morning, Dr. Calure, and welcome to A Bridge to Wholeness.
Dr. Jonathan Calure: Thank you. Glad to be here.
Jennifer Crisp: Well, your accolades go on and I can just tell everybody now if you want to read more about Dr. Calure, you have to visit the website, which is the mdveinprofessionals.com is that correct?
Dr. Jonathan Calure: Mdveinprofessionals.com, yes,
Jennifer Crisp: Yes, yes. And I have to say that this topic of conversation came up because I, myself, have vein disease and I’m going to just put it out there. I did go to see Dr. Calure and I had to have the vein surgery on my legs.
When we got to talking, because during the surgery you’re awake when you have this procedure done, I was really amazed at some of the things you were telling me about vein disease. And I finally said to you, you know, we need to do a podcast on this because this information is really important to get out to the general public.
So tell me, what are some of the statistics about vein disease?
Dr. Jonathan Calure: Well, I mean it’s a very common problem and it commonly gets mischaracterized even by really good primary care docs as just a cosmetics or a skin problem. It afflicts about 30% of the population at some point. You can see all kinds of signs of that: varicose veins, swelling, aching, throbbing, et cetera, et cetera.
But the way that we approach vein disease has changed because in the past there wasn’t a lot to offer. I remember coming through surgical training in the ’90s and we didn’t have the technology we have today.
As surgeons we sort of shied away from vein disease because there wasn’t a lot to offer the patients. We put people in stockings, we put people that had ulcers in the wraps and things. And then we had the surgery called the vein stripping operation, which was pretty medieval, pretty barbaric.
And then in the mid to late ’90s, early 2000s, the technology had evolved to transform the way we treat this. So it’s minimally invasive treatment now. It’s out of the hospital. It does not require general anesthetic.
So it’s really changed the paradigm from one of the traditional react, the problem type medicine, to being proactive and preventative.
Jennifer Crisp: Yeah. And I find that really interesting. I remember that medieval procedure because I remember one of my relatives having to to go through that and she had had nine children. And so one of the interesting things that you told me were together was that do more women tend to have vein disease than men? Or is it about equal?
Dr. Jonathan Calure: Well, no, absolutely more women. It’s about two to one in the general population. And I would say in the patients that actually come to my office for treatment, it’s probably about three to one. And as you mentioned, pregnancy is a big game changer there.
Jennifer Crisp: Yeah. One of those downfalls of pregnancy. I was really surprised, because I just did not know that. I didn’t know it. And I was like, “Wow.”
I know when I worked in the hospital, I worked on the cardiac floor and we often saw the issues with vein disease and people coming in with vein disease and having the wraps. They were elderly, so they had not had the techniques done that are available now, so they were really, really suffering with that.
And the stockings. That’s the first line of defense, from what I understand, is wearing the support stockings. What does that entail? Why would we want to even begin to do that if we start having pain in our legs? Or what are some of the other signs and symptoms? Is just putting a pair of stockings on going to be good enough?
Dr. Jonathan Calure: Well, let’s talk about that. What are compression stocking? Graduated venous compression stockings are actually an ancient invention. I think they’re credited to a guy named Jobst from Germany in the late 1800s and it’s still a brand of stockings today.
But the idea is it sort of combats the basic problem, which is blood pooling in the legs, gravity pulling the venous blood back down towards the feet. So the graduated compression stockings will squeeze the feet and ankles harder than the calf. It’ll squeeze the calf harder than the knee. It’ll squeeze the knee harder than the thigh.
It creates a gradient to help push that venous blood back up to the chest where it belongs. And that speaks to the basic problem, the underlying cause of vein disease, which is gravity.
When we think about the circulatory system, it really has three basic components: the heart, the arteries, the veins. The heart pumps the blood, your arteries carry the blood away from the heart to the tissue under pressure. When we measuring a blood pressure, we’re measuring the arterial blood pressure. The blood then circulates into the tissues and that pressure drops off. So the pressure in the veins is much, much lower.
So imagine that there has to be a driving force to push that blood back up to the chest, especially if we’re standing all day, our legs aren’t moving. Because the pressure’s so low, we really need some help to move that venous blood back up to the chest. So the veins have little valves in them. The valves act like one-way check valves that allow the blood to move one direction only,
As we age, and there’s many factors that affect this, but as we age, those vein valves tend to wear and tear. When the valves wear and tear, they separate and then the venous blood starts to stagnate or doesn’t really move up effectively anymore and then it starts to reverse. So it backs up into those veins.
If you think about, say, a pipe and you fill it up with water and if you were to check the pressure at the very top of the column of water, the pressure is going to be fairly low. But at the very bottom it’s very high.
So imagine the driving force or that pressure backing the venous blood back up into the leg. That pressure backs out to the skin surface where we can see lumpy, bumpy varicose veins. We can see the little spider veins. We can see skin color changes. But it also backs it up into the deep vein circulations.
You may have heard of the term deep vein thrombosis. That refers to the deep venous circulation. And then pressure backs up into the deep vein, so it’ll affect the muscles and everything in the leg, really. So it’ll cause other symptoms like achiness, fatigue, swelling, restless legs and so forth.
So basically the basic pathology, the basic problem, with the veins is that gravity’s pulling that blood back down towards the foot and ankle and the compression stockings act to sort of counteract that abnormal flow.
But compression stocking help. I am wearing compression stockings as we speak. I’ve had vein treatment here myself. But at the end of the day, compression stockings are sort of a bandaid. When you take the stockings off, you still have a vein problem.
Jennifer Crisp: Right. Right. I think that’s really important that you said that because we don’t want people to think that, “Okay, I just have to wear the compression stockings.” Because if you’re still having those symptoms, you really need to be checked out, don’t you?
Dr. Jonathan Calure: Absolutely. The important thing about vein disease is it’s a chronic condition. So it often, as you commented, can begin with pregnancy and then oftentimes patients will notice the first signs as vein disease with pregnancy will be bumpy veins symptoms. After pregnancy, the legs seem to go back to normal, but the damage has been done. And then a decade or two later, then the symptoms return and then along with the signs and so forth, if it’s not addressed.
And as you commented earlier about elderly patients with ulcers and so forth, they had vein disease probably in their 20s and it gradually progresses. So at the point when a patients are starting to have symptoms and then it progresses to visible skin changes and then breakdown and so forth, it’s leading to complications.
So again, vein disease is seldom a life or death emergency. Although we do see people that come in for evaluations that have blood clots and have vein rupture and things and that’s more urgent. But in general it’s more of a chronic progressive condition, so when you develop symptoms and it’s starting to impact your life, you really should consider getting it treated.
Jennifer Crisp: Yeah, and I know that when I came in to see you, I pretty much suspected that’s what it was. I was really amazed at just the whole process of how this comes about. Because when you go into your office, it’s really nice. It’s a beautiful place. And when you go in, the first thing we do is we go through a questionnaire, but then they also do an ultrasound, don’t they?
Dr. Jonathan Calure: Yeah. Ultrasound is absolutely critical to define the anatomy, to map out where the problems are. And our sonographers are fantastic. That’s all they do all day is venous scans.
Venous sonography is really an art form. I don’t think it’s generally appreciated, because if you go out into the medical community and you get a venous scan, basically what that means is do you have a clot or not. 95% of the evaluations are clot or not and that’s about 1% of the venous exams.
Of course if you come in here, we’re going to look for clots. Of course, but we’re going to be focused on more subtle findings about the vein anatomy and which way the blood is moving and so forth. So the sonography is absolutely critical to do an accurate diagnosis.
Jennifer Crisp: Yeah. I agree with that because I think that, again, because this is specialized, this is your specialty, it is important to really come in and see a vein specialist, absolutely. And the sonographers, these ultrasound techs, they really know their stuff. There’s no doubt about that. And they’re very open. It’s not an uncomfortable procedure. They put the gel in the legs and they run the wand over. And the chair is comfortable. So after that’s done and then they will tell you right then and there, “Okay, you have a vein here or you have two veins,” or whatever it is and then if you are a candidate for the surgical procedure, what happens next?
Dr. Jonathan Calure: We do start with the sonography because that’s really the focus and to make the diagnosis. Then we’ll review all of your symptoms. We’ll look at the physical signs of venous disease. If you have not tried any conservative measures, and by that I mean compression stockings, elevating the legs, anti-inflammatory medications, if you have not tried any conservatives measures, then we’re going to recommend a trial of that. I mean, virtually everybody will get some relief with those interventions, but, again, it doesn’t fix the problem.
Jennifer Crisp: So it’s really treating the symptom but not the underlying cause.
Dr. Jonathan Calure: That is exactly right. So we’ll have a evaluation. Many times we have patients that are pretty savvy. They’ve already tried this stockings. They’ve already done the conservative things. And then we can talk about what the best pathway for treatment is.
We specialize here in minimally invasive vein treatments. The focus of our practice is a treatment called thermal ablation. We use radiofrequency energy to ablate the damaged source vein. So that’s our main focus here.
Jennifer Crisp: So explain that a little bit more as far as what does that do to help a patient when they do go in? Let’s say they’ve done all the conservative things, they’ve tried everything, and the next thing is that the ablation. But what does that actually do so that we can heal?.
Dr. Jonathan Calure: Right. I think in order to understand what it does, we have to really visualize the anatomy. It’s hard to describe this in an audio format. If you hit our website, mdveinprofessionals.com, you can see some really cool graphics, but I’ll describe it for you.
Basically we have two systems of veins: a surface vein system, and a deep vein system. At the outset, I will tell you we’re not touching your deep veins. We cannot, will not, do not touch your deep veins. But the surface veins are amenable to treatment.
So to visualize the surface veins, I’d like you to visualize a tree. There’s a trunk, there’s main branches, there’s secondary branches, all the way out to the leaves and twigs at the end. So you can imagine your leg, the veins you see at the skin surface, the lumpy, bumpy veins or the little spider veins. Those are sort of the leaves or twigs at the end of the branches.
And then that leads back to the trunk, again, of the surface vein system. The trunk of the surface vein system is usually one of the saphenous vein. So the great saphenous vein, the saphenous vein runs from the ankle all the way up to the upper thigh where it connects to the deep vein. There’s the small saphenous vein on the back of the calf there that connects to the deep vein of the knee.
So those are sort of the trunk veins and those are the veins that we’re usually focused on for ablative therapy. If you can imagine those veins not working and the valves are kind of blown out and the blood is backing up into those veins, what we would have normally done, or in the medieval times, we would have surgically stripped those veins. We would have taken them out. And the idea is, it’s not brilliant. You’ve got a problem, you take it out, right?
Invasive treatments. What we’re doing is we’re using a very specific targeted therapy to ablate those damaged veins. So we will use a tiny catheter, and by tiny I mean it’s about the size of the tip of a pen. And under ultrasound guidance, we’ll visualize those veins. We’ll insert a little IV. We’ll pass the treatment catheter through that IV and into the damaged vein.
We’ll then position that catheter using ultrasound guidance. We’ll put anesthetic around that vein. And then we’ll ablate the vein with radiofrequency energy. So when we zap the vein, it seals it off. It’s closed immediately. Everything comes out. The treatment takes about two minutes.
As you probably recall, the actual light treatment, the vein seals and the body’s natural inflammation kicks in and the body will ultimately reabsorb that vein.
But when we close down that damaged vein, the blood reroutes into healthy veins and we sort of sealed off that route for all that pressure to be backing up into the leg. So we’ve sealed off the damaged vein, the blood reroutes into healthy veins. And then I’ve had patients comment that they feel better immediately.
Jennifer Crisp: Oh, yeah. It really is. It’s an amazing thing. And of course the human body is so amazing anyway. Its ability to even kind of know what to do after you’ve sealed that off. It’s like, “Okay, well, let’s just reroute the blood and move to a different area.”
I mean, really, I’m always so amazed by our ability to heal. And I have to say when I had this treatment, I think I had three veins on one leg and two in the other. So I was like, “Wow.” I was so ready for this.
But you know, I left the office. My husband did bring me in. Had the procedure, put the stockings on. You have to wear the compression stockings for several days afterwards. Am I correct in that? Is that correct?
Dr. Jonathan Calure: Correct. As I’ve mellowed with my older age, I’ve been doing this now for almost 15 years, but I used to put the patient in stockings for two weeks after the treatment and then I back it down to 10 days.
And then I have a bunch of other docs in the practice and most of the docs in our practice are Harvard-trained surgeons and they came to me and said, “Listen, we really don’t need them for 10 days. There’s really no data to support that.” So I backed off, so now we’re down to just five days.
Jennifer Crisp: Thanks, Dr. Calure. I had 10 days and now you’re doing five.
Dr. Jonathan Calure: But anyway, so five days in them. And you know they’re not fun. I had treatment myself and I planned on doing my treatment in October when it was a little bit cooler. But my leg was hurting so bad, I said, “Listen, I’ve got to do this,” and I wore my, what I call my manty hose for actually the 10 days in it when I did mine. And I survived.
Jennifer Crisp: Yeah. It really is interesting though, because actually the stockings actually do make your legs feel better after the surgery. I mean really. Because it’s kind of like a nice, cushy bandage that sort of holds everything in. Because after you have surgery, you’re always uncomfortable.
But it’s a little bit of a protection thing too. But I have to say, I literally went home and I know I rested like the rest of the day. But the next day I was back to normal. I just continued on with life. So there really isn’t any significant downtime at all when you have this procedure done.
Dr. Jonathan Calure: Well, you’re correct. And I tell my patients, “I want you to be active,” because think about it, when you’re active, you’re moving those leg muscles and the leg muscles are really acting like a pump. So that is promoting the circulation.
So we want you walking, elliptical, biking, light cardio, light weights. It’s not a good day to, you know, do a parachute-jumping class or like a bootcamp-type thing, but I definitely want my patients to be active after the treatment.
Jennifer Crisp: Yeah. I just kept right on and I was very good about the walking and really keep moving, because it does help a lot with the healing.
Then about how long does it take from that surgery to really start feeling the effects? And then really just knowing, “Wow, this has made a huge difference in my life”?
Dr. Jonathan Calure: Well, my experience, you know, the patients that are having the worst symptoms, the swelling, the dermatitis, the real high pressure patients, they notice the most change immediately.
And I would say everyone continues to notice improvements. I would say out to about six months, the legs keep feeling better. So we depressurize immediately but then the body sort of adjusts and when that circulatory pattern is corrected, you continue to notice benefits, for my patients, I’ve seen for about six months till they get the final picture.
Jennifer Crisp: So here’s a question for you and I have to say, I noticed immediately, because I did have the swelling and a little bit of a discoloration and I was so glad to get it done and it’s made an immense difference in my life. Immense. I just cannot say enough about that. But you really did stress to me that vein disease, like you said, it’s chronic.
So what type of follow-up is involved after you’ve had this procedure done? What do you recommend? If you’re someone who does a lot of traveling or you’re sitting for long periods of time on an airplane or in a car, do you recommend wearing the stockings afterwards or what happens?
Dr. Jonathan Calure: A lot of points to talk about there. So for as far as follow-up, the follow-up after the procedure, we have a protocol where we’ll do a couple of ultrasound scan. So we’ll have one immediately after the procedure. I’ll be visualizing the vein immediately after it’s treated.
Then we’ll bring you back sometime within the first week for a follow-up scan. Then we have another one at six weeks. I like to get one at three months and six months. But the idea is we’re scanning to be sure that the veins that were treated are properly sealed, that there’s no other issues and so forth. So we have our routine surveillance following the treatment.
Then after that, it would be as needed. So if you noticed a new symptom, that’s something I’ve found kind of interesting that it’s like a light switch when it’s turned off. It’s like, “Wow, okay, now I see that the veins feel better.”
And then if another vein fails, say, for example, if we treated the vein in the thigh and then five years later a vein in the calf fails, they just like, “Oh, I remember that symptom.” And they’ll come right back. And it’s like, I know exactly what that is.
Over the 15 years I’ve been doing this, I’ve done something like 45,000 procedures. And patients that I treated back in 2006 or 2007 and I’ll joke with them and say, “I’m glad that we have so many patients, but I’m glad that we have loyal patients too, because they’ll still come back.” So there is a follow-up pattern and then when we’re out of that program follow-up, patients will come back as needed.
Then you commented about traveling. I encourage patients to wear stockings. I’m wearing them now, as I said, you know, but we all know people hate the stockings. They’re not good at the beach and they’re kinda hot and stuff.
I definitely would encourage patients to wear stockings for traveling, especially airline travel. So you think about an airplane is a perfect storm for someone with a vein problem, because you’ve got sort of cramped seating conditions and then you’re buckled in and then your legs are not moving.
And then to add that, you have pressure changes on an aircraft, so that’s like a pump to pull that fluid out to the leg. That’s a perfect storm for people with vein problems. So definitely compression stockings for air travel.
I then tell my patients knee-high stockings are okay, but thigh-high stockings are better, so that can get across the knee and all the way up the thigh with that. Staying hydrated, and then just general lifestyle things. Stay active, keep a healthy body weight, be cognizant of symptoms that may evolve over time.
Jennifer Crisp: That’s really good to know because I know that when I travel on an airplane, and I travel about six times a year, so I can tell you one day I experimented. I had a flight that was about four hours and then I had a little layover and I had another, like an hour-and-a-half flight to the next place.
It wasn’t long and I thought, “Oh, I’ve been in these stockings all day. I just need a break. I just cannot tolerate this.” Big mistake. When I got off of that second flight, because I didn’t have the stockings on, my feet swelled. I was like, “Okay, lesson learned.” And this was after I’d had the surgery.
So I’m here to tell you, firsthand experience, wear the stockings on the airplane, absolutely. Because when I get off the airplane, especially if I’m doing like five or six-hour flight, it makes an immense difference in the way my legs feel at the end of that flight. So, unfortunately, you just have to suck it up and put the stockings on and get over it.
Dr. Jonathan Calure: But the bright side, they make the skinny jeans fit a lot better.
Jennifer Crisp: That’s the truth. So I have a couple of more questions I wanted to ask you. What about pregnancy? What about pregnant women? Do you recommend that they begin wearing compression stockings during their pregnancy?
Dr. Jonathan Calure: Right. So imagine with pregnancy, the blood volume goes up, so the amount of blood in the body’s higher. And then as baby grows is pushing pressure on the pelvic veins. So that’s going to put an enormous amount of pressure on those leg veins.
There are actually maternity stockings. So if women notice those veins starting to bulge during pregnancy, that’s absolutely something they should be doing. But also preventatively too, I would strongly encourage that.
Jennifer Crisp: Yeah. I think that’s a really important thing to get out because I don’t think most women know that. I really don’t. I mean, I don’t ever see pregnant women wearing compression stockings. And so that’s going to be something that I’m going to start educating people about because, as a nurse, I get to educate. Yay.
But I think this is really, really important information and I just want to thank you so much for taking your time today, because I think before we started, you told me you had already done three surgeries this morning.
Dr. Jonathan Calure: It’s funny though. Patients will say, “How many of these have you done?” And I’ve done something like 45,000 but I’ll say, “Well, I’ve done three.” And then they’ll get real panicky and I’ll say, “This morning.” So it’s a one-trick pony, but it’s a good trick.
Jennifer Crisp: Yeah. Because I want you all to know that he came on the phone at 8:30 this morning. So if he’s already done three of these surgeries today, you know how busy he is.
Well, please tell us where we can find you. Or I believe you have a couple of offices. Am I correct?
Dr. Jonathan Calure: Right. We’re all over central Maryland. The main office is here in Columbia where you had treatment. I call this Nirveina. This is a brand new … We opened this actually five years ago, but it’s 10,000 square foot facility devoted exclusively to vein care.
We also have a beautiful office in Towson right next to the Towson town center. We have an office in Annapolis, so a beautiful facility down there and we have an office in Chevy Chase, Maryland. And then coming next spring we’re going to be looking out to northern Montgomery County. One of our docs, David Whittaker’s going to be joining us full time and we’re going to have an office for him up there.
But I should mention my other docs while I’m talking about it. So Dr. Liao, the director, Pete Liao. I’ve known him for 20-plus years since we were residents at the University of Maryland. He’s the director in the Towson office.
Dr. Jon Hupp is the director in the Annapolis office. He’s a Harvard-trained surgeon with 25 years experience in the Indianapolis community.
Dr. Jane Lingelbach is the director in Chevy Chase. Again, another Harvard-trained vascular surgeon and she’s in that area.
But anyway, so we have the offices across Maryland and if you’re interested, you can book yourself online at mvpbooknow.com. You can schedule your own appointment. I know people with their iPhones, they want things immediately. So you just jump on mvpbooknow.com and then you can enter your email and you can set up an appointment online.
Jennifer Crisp: And there’s just a couple of other things before I let you go. You also do a couple of other procedures in the office, don’t you?
Dr. Jonathan Calure: Well, yeah. I mentioned briefly, so the focus is the intervenous ablation or vein closure, but then there’s some adjunctive treatments that we can do to address any surface veins.
So for the little tiny spider veins, we do a treatment called sclerotherapy where we inject the medicine in the veins. It seals them off. It’s kind of like a pencil eraser. We also have a laser treatments for the finest of the fine surface veins.
And one of the newer treatments that I’m really enamored with is a foam sclerotherapy that can treat the large lumpy, bumpy veins. We can inject a medicated foam into those lumpy, bumpy veins and it’ll seal them off and clear them away. That’s called Varithena. So I’m really excited about that treatment because, again, we will depressurize veins. Sometimes we need to talk about clearing them from the skin surface.
And that’s the traditional … We have a microsurgery, which is a distant cousin to the old-fashioned vein stripping, where we make tiny little nicks on the skin and remove the vein that way. Because that’s called a micro-phlebectomy. That’s one option. But with the newer foam treatments, there’s no cutting. It’s just a quick in and out treatment.
Jennifer Crisp: Yes. Yeah. And do you recommend wearing stockings after one of those treatments as well for a day or two?
Dr. Jonathan Calure: You know it. Yeah. So with the foam treatment, that’s actually critical because once we seal off those veins, they want to really keep them compressed so they don’t refill in those first couple of days after the treatment.
Jennifer Crisp: Right, right. So just everybody be aware of that, that, yes, your main focus is the indices. But these other adjuncts are there.
And I will tell you that I had the sclerotherapy behind my knee because I still had a couple of veins that would bother me when I would sit in a chair. And after a while, I just kept lifting my leg because the pressure on that vein was just really uncomfortable.
So I went back in and they said, “Well, Jennifer, we can take care of this for you and it’ll stop that discomfort.” And so it was a great adjunct to the surgical procedure I had because that doesn’t bother me anymore.
Dr. Jonathan Calure: Like a lot of our patients, if the surface veins had been there more than six months or a year, they may fade a little bit after we depressurize them. But again, if they’ve been there a long time, then you might need a little extra help to get them cleared. So we’ll depressurize them by doing the closure treatment and then if needed, we’ll reassess at six weeks or eight weeks and then we can talk about the surface work.
Jennifer Crisp: Yes. Yeah. I mean it really is. This is something that people should really be, I think, very proactive about if you have any type of signs or symptoms in your legs. Like you said, the fatigue. I had some itching, which I think is something that’s really interesting. Almost like a little tickle feeling, like something was crawling up my leg.
Dr. Jonathan Calure: Like that. So we’ve see fatigue, restless legs, swelling. You don’t have to have visible veins. A lot of people say, “Oh, I don’t see anything on my legs.” Well, not everybody does, you know, so the symptoms you’ve described, exactly.
Jennifer Crisp: Yeah. So please be aware of this and if you are interested in visiting Maryland Vein Professionals, again, look them up online. And you’re in Annapolis, Columbia, Towson. You’ll have an office in northern Montgomery County soon and I think you said Chevy Chase, is that correct?
Dr. Jonathan Calure: That’s correct.
Jennifer Crisp: Yeah. So they’re in lots of locations across Maryland, so whatever area you’re in, you’ll be able to get to them very easily. You won’t have to travel that far. I just want to thank you so much for your time today. I know you have more surgeries scheduled.
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