Dr. Victoria Maizes: Hi Andy. Dr. Andrew Weil: Hi Victoria. Dr. Victoria Maizes: Today we have Dr. Aly Cohen joining us. She is an integrative rheumatologist and a graduate of our fellowship. Dr. Andrew Weil: Wow integrative, rheumatology. What a wonderful concept. We're doing our best to get more integrative rheumatologists out there, but there aren't too many of them at the moment. Dr. Victoria Maizes: Yes for a little while you had an endowed chair, integrative rheumatology. Dr. Andrew Weil: Odd because I'm not a rheumatologist, but I was very happy to have that title. Dr. Victoria Maizes: Yes, well let’s welcome her. Introduction Music Dr. Victoria Maizes: Dr. Aly Cohen is a board-certified rheumatologist, integrative medicine, and environmental health physician who specializes in arthritis, immune disorders, and women's health. She has a private practice in Princeton, New Jersey, where she focuses on both conventional medical management of rheumatological elements, as well as integrative options for total. She lectures nationally on environmental health and has worked with groups ranging from the environmental working group, academic institutions and major corporations. Eylea is the editor of integrative environmental medicine and the co-author of Non-toxic the Essential Guide to Living Healthy in a Chemical World. Welcome Aly. Aly Cohen: Thank you so much for having me. Dr. Victoria Maizes: So I want to begin with a broad question, which is that many of the rheumatological conditions at their root are autoimmune problems. Can you please explain for our listeners, what is an autoimmune disease and how do you approach them? Aly Cohen: Yeah, it's interesting to be the scope of rheumatology. If I can step back just to second, because you know, when I first got into rheumatology 20 some years ago in training, the, the scope of what a rheumatologist did was much narrower than I think we're experiencing now. And room “ruma” comes from flow. So this flow of joint related issues that seem to go through the body, it's kind of, it's a Greek derived word, but since the time of just joint pain when I was learning very, I think in its infancy, we’ve banded to such a wide swath of, of conditions that are rheumatologic under that heading. I mean, cross over with certain other specialties, certainly. Autoimmune disease, if you'd look at the word, literally, it's, auto-immune, it's your body attacking or triggered or at least responding to the body to itself. So in, when you think about infectious etiologies, for instance, your body is responding to the outside world, something from outside, whether it's a food allergen. Whether it's air pollution, whether it's you know, a cosmetic that you put on your skin and there's a response whereas auto-immune diseases, your body really doesn't almost recognize itself and will attack itself your body because it sort of doesn't know that it's part of its own system and to preserve it. Now, there are certain diseases that are more oriented to certain organs for instance, when you talk about rheumatoid arthritis that auto-immune disease attacks the joints, you're attacking the cartilage of the joints and we have many joints in the human body. When you're talking about lupus pretty much anything's fair game, because there's so many components of lupus for the body attacks, whether it's the bloodstream and the blood cells coming out of the bone marrow, whether or not it's the kidney itself, which can cause things like lupus nephritis. And so there's a much more wider array of areas where the body attacks itself. And when you see multiple sclerosis, you're talking about the central nervous system, you're talking about the brain. So auto really is this unbridled component of an immune system, perhaps even a normal working immune system, but it's just misdirected towards self Dr. Victoria Maizes: So why do we get autoimmune disease? What is it that is making us attack ourselves? This doesn't make sense from an evolutionary perspective. Aly Cohen: Right? Well, you know, that goes back to the question of why do we get sick period? I mean, in, in a way, we have a very intricate dance between what our genetics susceptibility is, right? What we're given with no real, movement on that, you know, the genes, but then we have these other influences environmental components, which include lifestyle, diet, nutrition, sleep, stress, air quality, water, quality as well as those environmental chemicals as I was, then I deal with quite a bit, which is, you know, again, air pollution, endocrine, disrupting chemicals, food chemicals, food, contaminants, water [00:06:00] contaminants, personal care cleaning products. So there's this dance between what we're given and our, our genetic susceptibility. And then of course the exposome, which isthe effect on the proteins that control whether those genes are expressed or not into disease. And as you know, many of your listeners and you of course already know is that the exposome is really quite an area of study now. And what, what we're seeing is that these, these environmental exposures can almost trump the, the genetic component. So in other words for instance, I'm seeing more autoimmune disease in people without a family history. And that's what the epidemiology is showing is that worldwide we're having such an increase in autoimmune disease, that it can be genetic component. It just sets you up for whether or not those environmental exposures really set off the disease. I'm also seeing in my practice, but along with all the literature younger you know, incidents of autoimmune disease at younger ages, which is really true. Dr. Victoria Maizes: Andy you often point to inflammation as a root cause of so many diseases? That of course clearly the, the words that ended i-t-i-s “itis” means there's inflammation. And so many of the rheumatological conditions have that rheumatoid arthritis as a classic example. So why are we so inflamed and what do we do about it? Dr. Andrew Weil: Well, first of all, an auto in auto immunity, the inflammation as a common characteristic, but that's not the root cause it is a manifestation of the action that the immune system there are many influences on our inflammatory status genetic stress, environmental exposures, and as I've written a lot about what we eat has a great effect on how much inflammation is in the body. But it's quite correct. I think a very interesting hypothesis that's gained a lot of ground is that [00:08:00] low level chronic purposeless inflammation is the root cause of many of the chronic diseases that kill and disabled people prematurely. Aly Cohen: And if we just look at COVID as an example, you know, there's lots of literature now, early on in my, my coauthor and I wrote an article that really talked about having this sort of baseline level of inflammatory exposure from, standard American diet, contaminated water, stress, of course chemicals and all of our products that we put on our skin and, in our bodies, that we breathe in on a regular basis and then we get this exposure and it could be anything, a stressful experience. It could be an infection, but something kind of primes the system and then we get hit hard with some kind of outside force. And infection has been shown to be an inciter for many autoimmune diseases. COVID really showed that people with a chronic health conditions they had higher risks for hospitalizations and worse outcomes. And it really retrospectively looks at this condition of inflammation, whether it's obesity or uncontrolled diabetes, or hyperlipedemia autoimmune disease, where that's sort of a lower level a level of inflammation to begin with and then they get hit with an infectious etiology. Dr. Andrew Weil: I've always felt that auto-immune diseases were made to order for integrative medicine. And yet the field of [00:10:00] integrative rheumatology is very nascent, you know, just beginning you're one of the few out there I'm delighted that we've had more rheumatologists come to our Fellowship, but I'd love to see that become a really robust field. Would you agree? Aly Cohen: Yeah I'm a Western rheumatologist as well as a Eastern integrative medicine trained doctor and I think putting those two beautiful sets of, of knowledge together to integrate into people's care is really quite important. And there is certainly not enough of it. Even as my colleagues in rheumatology see patients for, 15 minutes, but just what I was doing for many years there's really not enough time to really get to the root cause of why someone may be experiencing a rheumatologic condition. Getting environmental history, talking about their diet, what do they eat on a regular basis? Where's the water coming from? All of these can be potential hazards that instigates either an immune system disorder or even a flare within the disease. So I'm, I'm thrilled that there's a growing body but I was actually looking, at some of the literature before this podcast to kind of remind people of how rare rheumatologists are let alone integrative rheumatologists. And, a couple of interesting things came to mind, by 2040 adults will with arthritis, it's projected to be 79 million in terms of this country. So by 2040, but by 2030, adult rheumatologists will decline by 25%. So there's this really worrisome mismatch between the supply and demand of rheumatologists alone, not just integrative, but, but Western rheumatologists. And it's becoming quite worrisome because so many are, are planning to retire if they haven't already and are downsizing, their patient loads, many go into academics. Many are foreign residents and [00:12:00] fellows that may go back to their home country. So there's really, you know, a worrisome situation, but integrative medicine is a set of tools that I think we're missing in Western medicine. And I feel so strongly about it that, I'm shouting on mountain tops, all of these other tools that we have besides just pharama Dr. Andrew Weil: And can I just say, it seems to me that in rheumatological disorders, the mind-body interactions hit you in the face, and yet that's almost completely neglected in conventional rheumatology. Now that classic onset of rheumatoid arthritis and a young woman is a flare up of old joints within 24 hours of some major emotional trauma. I mean, that's just a classic story. Body of Wonder General Ad Dr. Victoria Maizes: So I'd love to move to some of the questions that our listeners have called in about rheumatological conditions. The first is from a listener who asked can rheumatoid arthritis be treated by integrative medicine? So what would you say Aly? And then Andy, I'll be curious to hear what you have to add. Aly Cohen: The answer is yes, with a caveat. In my practice, for instance, you can have rheumatoid arthritis, we have to know what kind of rheumatoid patient you are… As an example, is your body aggressively handling it? Or can we quiet things down? Do we have the time and the ability to work on things slowly for the first couple of months to really get diet in order to get main stress in order to get the appropriate evidence-based supplements. And I mean, that evidence-based supplements not just junk that is really predominates the market. The idea is, do we have this urgency? It's like triaging, every patient gets triaged, which type of rheumatologic patient are you compliant? Are you willing to do the work. And if you're willing to do the work, how fast can we get you feeling well and prevent destruction of your joints and dysfunction and manage fatigue, which is also a very subjective component, which no one really talks about…what's the timeframe? Is it two months, three months, six months. When do we start a first drug? And will that support the lifestyle measures that you're seeing some movement on or not? And so it's really this sort of trial and error, but also watching a clock so that joint destruction and dysfunction and life quality life is managed in that timeframe because I'm, [00:16:00] I'm a supporter of medications. I mean, in fact, I use them all the time and I think that biologics that came out 20 years ago when I was in fellowship and some of these newer ones coming in they're life changing. But do they have to be used reflexively initially? That is where I have contention with that because I don't look at must cases exploding, where I would say for lupus patients, you have to be much more cognizant because their disease process is slightly different in terms of how it can roll out. Dr. Andrew Weil: So my feeling is that, you know, remember integrative medicine is not opposed to the use of medication. But we'd like to use the lowest doses of the least post potent agents as demanded by the circumstances of illness. And we'd like not to rely on. Powerful suppressive medication for long periods of time. So I think all of these medications have their place, but by attending to all these other factors and, and especially let me say again, the mind body component, which is usually neglected that it may be possible to shorten the course of medication and use lower doses. And that would be desirable. Aly Cohen: And I think you and I talked about this over dinner, I think not too long ago. One really good example. I like to use just to show Western rheumatologists as well, but it can be done on a sort of on their, in their language a drug like methotrexate which has been around since the 1900 I want to say. Which is used in a variety of illnesses, including for childhood cancers at much higher doses is a wonderful drug within the rheumatology world. But it's been taught to me for 20, or at least it was up to the point I switched that is only an oral. And what I found is the more I learned about the gut microbiome, the more I learned about sort of the vulnerability and how medications even other than antibiotics can really disrupt the gut microbiome. And there's some [00:18:00] wonderful studies on this. Why do we want to drop more medicine into the gut. Into the 24 feet of vulnerable bowel that is so intricately tied to our immune system and in setting it off or not. So the goal was to really remove as much as I can from the gut exposure. And that's why I switched to intramuscular, methotrexate, which is cheaper, it's easier. You can use less medication because it's more efficient. It doesn't have to travel through 24 feet of bowel. It often gives less side effects like GI issues and abdominal pain, which makes people stop the drug that could actually be very efficient for them and quite effective. So that's just one little example of many choices that I think I've, I've tweaked over the years, understanding the underlying component is that the gut microbiome in human evolution and anthropology, what our body needs to thrive really. Dr. Victoria Maizes: So you've given a couple of examples now on how you, as an integrative rheumatologists manage patients differently than your conventionally trained colleagues. For example, you described taking a much broader history paying attention to environmental influences. You described being discerning about which patients. Needs to be put on medicine right away, because potentially their joints could be damaged to the point of destruction from which you can't come back. And therefore they deserve, let's say a biologic versus who can be managed more slowly in terms of the lifestyle change, which takes time to come on. And now you've just described a different route of administration of a medication to spare the microbiome. How else are you different? Like what else do you perceive that you're doing different? Aly Cohen: Well, I think my environmental history is a lot broader than I think most doctors just given my experience, I'm asking things that most people probably don't ask or even think to ask, which is, based on for training, and I'll be one of the first to go after medical school training as a problem. When we think of something as simple as drinking water and the contaminants that are now no are in drinking water because of the failure of our regulatory, safe drinking water act, which is 50 years old and only covers 91 chemicals. And all of our treatment plants, we are drinking dirty water in general I want to know what people are drinking and how to, and simply how to fix it. It's not complicated. I want to know what most of their diets, consistent of. I want to know what their stress levels are, where is their stress? Where can they have to help with that? How is sleep, which is so intricately connected to our immune system. People don't realize that you know, but there's wonderful studies going into this in a deep way. What sets me apart in some ways from maybe conventional Western doctor? Will, first of all, I have more time with patients. I think time is critical because you get that information and that's really information you can use to help the long-term goals of getting these these kinds of environmental exposures from irritating the immune system. I also think long-term with these patients. I'll give another example. A lot of patients come to me for rheumatoid arthritis and a work up in that regard. You know, handling pain initially is very important because no one wants to make long-term decisions when they're struggling in pain. So you have to put the fires out, get them in a place where they can change long-term and then you start working on those issues. But aside from that, you want to think long-term I hate to be quick about this and kind of crass a bit, but what a rheumatoid arthritis patients die from in general. They die from heart disease, inflammatory heart conditions, right. Heart attack stroke. So the question is let's fix the rheumatoid. Let's focus on joints, but let's think about what's the long-term consequences of inflammation on the body. Shouldn't you and my patients, you know, should [00:22:00] you be getting your teeth cleaned every 6 to 12 months? Because we know there's a connection between certain bacteria in the mouth and higher rates of inflammatory arthritis, autoimmune disease, and even heart disease should patients. And I often send my patients for all the cardiac tests that their cardiologists don't do, or the primary care doc doctors don't do. Let's figure out how quickly we have to ramp up our process of protecting not only the joints, but also protecting the blood vessels and the heart and the risk for heart disease and stroke. So again, the human body is a system of multiple parts and you know, my job, I think, is an integrative rheumatology. It's not just to think of the joints it's to think about what are the consequences of not thinking about the whole person? Dr. Andrew Weil: How about dietary change? Do you give dietary advice to your patients? Aly Cohen: Absolutely. Absolutely. In fact, I think that's critical if people don't really think about just consumption of junk food and not only just taking food away. You know, I always talk about this concept where you can, you know, take away a lot of stuff, but you also have to consider what you put into your body that makes the body thrive. So, along the lines of Mediterranean diet, which of course this is a critical internal. I would say, moving patients to a diet that they can wrap their head around there's components of the Mediterranean diet that are anti-inflammatory. So it's not about just taking away, the stuff that's inflammatory, which is, you know, preservatives and coloring and additives and sodium and aspartame and synthetic chemicals. It's also about what do we put into the body in terms of nutrient value that helps the immune system. And also making sure that, that green leafy vegetables and beans and vitamin B9 and folic acid and organic whenever possible, [00:24:00] because you can have a kale salad that's filled with pesticides right? So I also very much focused on the quality of food. Not, even so much more than even, macros, like how much fats you have a day, or how much protein you have a day. I look at quality as the essential issue. Dr. Victoria Maizes: Aly, one of the reasons people come to my practice is osteoporosis and they often come saying the same thing my doctor says, I have to take this medicine. And then they, they name a medicine. And they often don't want to, they've heard about the side effects. And I would have to say well biologics have an amazing reputation for putting rheumatologic diseases into remission. The medicines for osteoporosis have a very, very high number needed to treat, which means that you may have to treat a hundred women to prevent one fracture and 99 women get no benefit and have the risks of the side effects of those medicines. So just to put it in the words of one of our listeners, how would you treat osteoporosis in an integrative fashion? Aly Cohen: Well, my disclaimer is everyone is different and I don't want to certainly tell anyone to do anything that's, against their, their current physician's recommendations, because there's so many specifics involved, osteopetrosis is very interesting there is connections even to the microbiome to bone strength. You know, there's just so much that we can do from a dietary and, weight-bearing exercises. We know that's anthropologic, right. We should be walking more. We should be running more lifting weights. We need to consider how much nutrients. I believe everyone's nutrient deficient. I mean, I literally think every human being is nutrient deficient because we are not eating the way our, our evolutionary template had designed for us in terms of even just running to get food instead of being [00:26:00] front of the supermarket and kind of strolling in and using a cart, you know, we're just not doing what our body was really made for. And those weight-bearing exercises strengthen our bone, of course. And the forces up the legs, because bone is a living tissue and it responds to those forces. One of the things is get people moving and making sure that they're doing it safely, not walking and doing things on icy walkways. You can have two women to get in a bone density machine and they have negative 3.0 T scores, which is pretty bad, right. And one woman is running and jogging and she's not on blood pressure medication that lowers her blood pressure is to control that makes her fall. She's not dehydrated. She doesn't have knee arthritis that makes her unstable. She doesn't have inner ear problems or vestibular problems tinnitus t as, you know, name, all the things that really make people feel. Right. The actual falling reasons. The 3.0 for both women is just to say, watch out, but it's also to say, what do you do about it? Let's fix lifestyle. Let's fix nutrients. Let's get people moving. Lighten up on the blood pressure medicines that's knocking everyone down, like in the elderly, for instance. And let's think about those things as just a means of saving from fracture because ultimately osteoporosis, [00:28:00] the issue is fracture. And if we can take some of those, you know lifestyle risks away, then that 3.0 can be managed to some degree also with a proper bone vitamin. Perhaps even strontium, which, again, this is not for everybody. I want to make sure that that people talk to their doctors, but there are options. that do the same thing as bisphosphonates, which is really to decrease the bone. By osteoblast, so the idea is that you can obtain the same results, at least in my experience by doing non-pharmacological methods, but you have to watch the patient carefully and you have to know their risks and it's very personalized. So the answer is yes, you can get away with not doing medications to a certain point. But you have to make sure that you're watching when those drugs may be necessary. Dr. Andrew Weil: One of the, I would say nice features of auto-immunity and rheumatological disorders is that they have a much higher potential to go into remission than other kinds of disease, which tend to be progressive and not reversible. And it always seems to me that it is helpful when working with patients with these disorders to remind them of that potential. You may not know exactly how to make it happen. You know, one thing that I do, if I can do it is to introduce patients to other patients that have their disease, who are now better. You know, that can override a lot of negative thinking. I can't always do that, but knowing that the potential is there, I think is very helpful and I worry that long-term use of suppressive medication may reduce the possibility of. You know, I don't know that for certain that's my gut feeling, but I mean, very long-term use of powerful suppressive medication. Aly Cohen: Well, it's interesting, having watched the pharmaceutical world over the last 20 years from when they were first introduced when I was in fellowship and it was like the hottest, newest stuff was kinrad and brown Humira all the way to [00:30:00] now where we have literally like a dozen choices for rheumatoid as an example my experience is, is that, first of all, not all these drugs work on the same patient. There's no conscript, where, one drug is meant for one person. We are not there yet. So it's a lot of spaghetti on the wall to see which sticks. But more importantly, which one doesn't give that patient, the side effects, and you watching for all those risks while you're doing these trials. But my experience has been that people do go into remission. And what's interesting is the pharmaceutical or the medical journals are now starting to show published studies that you can go off of certain biologics and maintain remission as they call it. And that was never around in the last, I would say five years ago was first time I saw all the studies and I thought boy pharma is going to be pissed at this one because it's taking market share away by saying, Hey, listen, you can get someone in remission. And then you can pull it away and see what's what maintains them. And that's where integrative approaches will be most suitable because you've already incorporated them and they're likely to help maintain that remission and you're right people, people are very hopeless because of the way it's presented in Western medicine. And you really hear a lot of people on social media are the ones that are not doing well, which are the people that talk the most about their issues. Seems very natural, but happy people, people who are feeling good and healthy, don't usually spend their time now complaining. They, they tend to you know, really be living their lives. And I think that's why there's a selection bias of what, what most people hear in mainstream media. And it's a shame because I spend more time hugging patients and telling them they're okay. And I don't know why your doctor got an A and A, and told you a lupus with a titer of one to 40, it's one of the things where there's a lot of screening and primary tier, but then by the time they need a rheumatologist, they can't get one for three months. [00:32:00] And then there's, they're really crying for three months and they're really scared, which may or may not be warranted, but it's just a bad place to be. Dr. Victoria Maizes: So biologics can send people into remission and sometimes meeting someone who's done really, really well it can inspire and maybe drive that change. I have found that fasting, which you obviously can't do forever, but there's some evidence for fasting to also drive remission. What else can be helpful? Aly Cohen: There's so many things. I really do focus a lot on the environmental component because to me and this will be actually the topic of a book I'm writing over the next year is really how do these environmental exposures, which by the way, do include stress and poor sleep and light pollution and noise pollution, all of the things that are not natural to the human existence, as we've known it for millions of years, how do you pull those away? Little by little, you know, nothing's overnight, it's a journey, but how do you pull those away? Because each one of those potentially could be keeping you in flare or keeping your risks higher for developing auto-immune disease, any, any place on the spectrum. So, certainly fasting can be very helpful. Certainly things like gluten-free diet. A lot of Western doctors, poop pill, a lot of these, you know, Hey doctor, if I got rid of gluten, do you think I'll feel better? Oh, no, that's nothing. Hey, if I get some supplements, do you think I'll feel better? No, it's just expensive urine. You know, I find that that's just kind of ridiculous. Because if you're not trained in it, you shouldn't be making those statements. As least looking at both sides of the, of the literature. So, yeah, I think that, you know, working and removing these exposures that can cause harm to the immune system have been well studied. I think managing stress and getting a lot better handle on that as best we can in the circumstances managing. And trying to really focus on quality and quantity of sleep, because it's both that matter. Not just quantitatively know how [00:34:00] restful or unrestful that can you can be with even an extended amount of sleep. Then I, I really do add in very good quality supplements. And I go with that, you know, I show them labels and I teach them how to read them. I teach them, you know, all of the, you know, I gave them the fishing rod so that they'll always have those abilities for themselves to choose their supplements. And then I tell them why adding in these things really have shown thousands of years of great historical benefit, whether it's, curcumin that's highly, you know, vetted. Or Omega 3 fish oil that has to be vetted because of course, we know that's watered down and a lot of junk out there multivitamin, things like that, where you get a good quality multivitamin, especially if it has, iodine, iodine is very important to the thyroid and we're not getting that as a nutrient deficiency. Now it's not just vitamin D, which is very, you know, sexy in the news, but it's a lots of other nutrients that we're really not getting that support good health, whether you have an autoimmune disease or not. And so I'm very focused on taking away the bad, adding in the good. And kind of seeing what the body, response because the body has a proclivity to heal. We know that we cut our finger and three days later that finger is perfectly perfect thousands of times in a lifetime. Why can't that be also happening inside of our bodies as well. Dr. Andrew Weil: Victoria. I think you know, that I reported two cases that I happened to see at the same time of both middle-aged men who had very severe advanced lupus one was hospitalized and was not expected to live. Both of them had complete remissions one as a result, immediately following a religious conversion to some variety of fundamentalist Christianity. And the other fell in love and subsequently was married. And I often say [00:36:00] that I can't often arrange for my patients to have religious conversions or fall in love, but I think it's really important to know that those are, that that's a possibility. And to let patients know that that's a possibility, we may not know what the trigger for that is. It could be a biologic, it could be some lifestyle change, but it's possible. And I think to give patients that positive a message is very important. Aly Cohen: I think you're right. And I had patients like I said with rheumatoid arthritis they get better with pregnancy but yeah, it's, it's, you know, it's one of those things you have to grab the good stuff, the good stories you have to share with patients perspective. I've had to give perspective to patients who are so so heartbroken about what they think their future is about. I mean, it's just awful to say, and it's every day in my practice and yesterday the idea is that you have to give them perspective because they're in it and they don't know what the outcomes are at three months, six months. So I have to tell them, you will be here in three months, likely there'll be here in six months. Don't expect it overnight, but you will be a different person by the time, you know, the next 6 - 12 months come around. And if you give them perspective, you're giving them. And you're giving them confidence and you are allowing them to say, you know what? I do have a reason to keep pushing forward. So it is critically important to be a coach and a leader within your own field, no matter what it is. Dr. Victoria Maizes: Those are really beautiful reflections on what it means to be a physician. It is more than a diagnosis and it is more than a list of treatment options. It's also giving people the larger perspective and a sense of hope that there is an innate healing system and we're going to do our best to get it working well. Aly Cohen: Yeah, absolutely. Yeah. I mean, I can name a dozen patients that I feel that, you know, are, are on the right way and they're, they're on and they're off and running. And you know, my greatest pleasure is to get people feeling well and doing well and not need me anymore. I'm going to say this very frankly. And like, I want to ya out of here because I want you to tell five friends that need something other than what they may be getting and have those options. Dr. Victoria Maizes: Well, Aly, thank you so much for spending this time with us and sharing your integrative approach to rheumatology. Aly Cohen: Thank you so much for having me. I really appreciate it.