SPEAKER_00: 0:01

Welcome to the Healthy Matters Podcast with Dr. David Hilden, primary care physician and acute care hospitalist at Hennepin Healthcare in downtown Minneapolis, where we cover the latest in health, health care, and what matters to you. And now here's our host, Dr. David Hilden.

SPEAKER_01: 0:19

Hey everyone, and welcome to episode 5 of season 5 of the Healthy Matters Podcast. We've all been there: sniffles, sore throat, and the hope that antibiotics will fix it. But do they really? Today, we're talking about that game changer of modern medicine. These tiny pills have saved millions of lives, but they've also caused some pretty big problems when used the wrong way. So, how do antibiotics actually work? Why don't they help with the cold or the flu? And what's really behind all the talk about antibiotic resistance? To help us sort it all out, I'm joined by Dr. Caitlin Eccles Radge. She is an infectious disease physician and one of the smartest people I know when it comes to germs, bugs, and the medicines we use to fight them. Caitlin, thanks for being here. Welcome to the podcast.

SPEAKER_03: 1:05

Thanks for having me. I appreciate the uh intro. Thank you.

SPEAKER_01: 1:08

So I've worked with Dr. Eccles Radke for many years, and through the COVID pandemic, she was our hospital's point person on infection control during a pandemic that nobody knew anything about infection control. So you're the perfect person to talk us through this stuff, Caitlin. Um, start us out. What are antibiotics? How do they actually work in the body?

SPEAKER_03: 1:29

So antibiotics on the simplest level, they treat bacteria. And so as an infectious disease specialist, we think about different kinds of infections. One are bacteria, we think about viruses, parasites, fungal infections. But here, as we're talking about antibiotics, those only treat bacterial infections. So it's important to note that.

SPEAKER_01: 1:50

So penicillin, the first one, at least the first one that most people know about. Is it actually true that that thing was invented kind of by accident? And a long time ago.

SPEAKER_03: 1:59

Yeah, I can't remember the exact timeline, forgive me, but I do know it was developed by a Scottish physician named Alexander Fleming, who had known or found out that for many years, actually, they were using molds and in sort of these environmental things that could kill certain types of infections. And so out of that, out of a mold called penicillium, which That's the mold. Convenient, correct? Yeah, they developed and found out that they could make antibiotics or a specific one called penicillin. And that's sort of where the advent of antibiotics came from.

SPEAKER_01: 2:33

That was a game changer. Prior to that, you got an infection, you didn't you didn't do so hot. So it is a true statement that they have been a game changer. They have changed the course of human health around the whole world. But we're gonna get into some of the modern uses of them in this episode. Briefly, if you could, Caitlin, explain what the difference is then between a bacteria treated by antibiotics and a virus, which is not.

SPEAKER_03: 2:56

Yeah, as I mentioned, there's various types of microorganisms, two of which are bacteria and viruses. They work differently in different parts of the body. There's many different bacteria, there are many different viruses, and how they reproduce and grow and change help distinguish them from each other. And then as you noted, there's there's going to be different treatment recommendations depending on what you have.

SPEAKER_01: 3:18

You guys in infectious diseases geek out about germs and bugs and organisms and pus and all that stuff. Could you tell us what some of the common bacterial infections that people see in their life?

SPEAKER_03: 3:30

Yeah, yeah. A lot of them, um, you may think of urinary tract infection or UTIs, as people call them for short. Certain types of pneumonia can be bacterial.

SPEAKER_01: 3:39

But not all.

SPEAKER_03: 3:40

Not all. Uh, you can have fungal, viral, you know, other types of pneumonia as well. Yep, which is a virus, exactly. And so those are kind of the common things you may think of, like a boil on the skin. Basically, think of any part of your body you could theoretically get a bacterial infection. But the most common ones that people may think about are a sinus infection, which can be viral or bacterial, certain types of pneumonias, urinary tract infections, skin infections are probably what you'd think of.

SPEAKER_01: 4:07

Stuff that people get all the time. How about some of the stuff that people get all the time that aren't caused by bacteria?

SPEAKER_03: 4:13

Yeah, good question. So there are a lot of things that we actually think we need antibiotics for, we don't, because they're viruses. So the common cold, which is usually different types of rhinovirus, enterovirus, coronavirus, to name a few, the flu. Everyone calls it the flu, right? But really that's short for influenza virus. And so that also does not require antibiotics.

SPEAKER_01: 4:36

Which is different from the stomach flu, which isn't flu at all, right?

SPEAKER_03: 4:40

Correct. Yeah. I don't know how the stomach flu got named as it was. It's not flu at all. No, it it that's usually could be viral or bacterial uh stomach infection or GI infection as well. But to your point, I think it's important to note that a lot of things that people think they need antibiotics for that are pretty common actually are viruses and we don't.

SPEAKER_01: 4:59

Is one more serious than the other? And it's kind of a funny question, but you know, are viruses more serious than bacteria or the other way around, or is it something different?

SPEAKER_03: 5:10

I think they're just two totally different things. I mean, certain viruses can be very deadly, as you remember in the beginning of the COVID pandemic when we had this new novel virus and people were dying from it. Whereas, say maybe a small skin infection, which could be bacterial, might not be as big of a deal. So I don't know that you can compare them. I think there's a lot of things that go into severity, right? The type of infection, the location of infection, the host, right? Us. Um, do we have good working immune systems? Are we immune compromised? And so there's a lot of different things that play a role in terms of, you know, how severe is this infection?

SPEAKER_01: 5:50

I want to, I wanna go back just for a second to 2020. And I know this is about antibiotics. We didn't have an antibiotic for COVID. It was a virus. That's what it stands for. It stands for coronavirus. And that's what the V is. And we didn't have an antibiotic for it. So that deadly thing then, if we only had an antibiotic for that thing at that time, it maybe wouldn't have been so deadly. But it was a virus that was deadly. You remember those years and what how we were just we didn't know what to do about them.

SPEAKER_03: 6:19

I do remember them. I try and black them out a little bit.

SPEAKER_01: 6:22

I think you were working about 120 hours a week. And that was a that was a it was probably what they were dealing with a hundred years ago when epidemics broke out and doctors stood around kind of wringing their hands, not knowing what to do because the anime, there was no nothing to treat it with.

SPEAKER_03: 6:37

Yeah. I think the difference between then and now is the information age, right? And so we had a lot easier, more available ways to transfer information, research, who's doing what, where, across the country, across the state, you know, telephones, communication, et cetera, that allowed us to be able to share and learn how to deal with this quickly. But you're right, it was really hard at the time. We didn't have any treatment options before some of the antivirals and monoclonal antibodies were developed. And so we we'll talk more about this later, I think. But just thinking about sort of like the pre-antibiotic era, if we get back to antibiotics and bacteria, like what did that look like? It was scary and you couldn't do anything about it.

SPEAKER_01: 7:20

Couldn't do anything about it. We were kind of building the plane as we flew it just in 2020. And that's what they were doing 100 years ago. So I'm a patient, I come into your office. How do you decide or how do doctors decide when an antibiotic is needed?

SPEAKER_03: 7:33

That's a great question. So I think the first steps are to go back to the basics, right? We wanted to patient. So, how long did you have these symptoms? What symptoms are you having? Did you have any exposures to anyone else who was sick? Uh, are some of the big things that we ask. And and then depending on sort of what type of infection they have, whether it's a sinus sort of infection or an upper respiratory infection, a urinary tract infection, then we'll decide if any additional testing is needed. And based on that, then we'll sometimes prescribe antibiotics or antivirals, but a lot of times we don't even need testing, right? If you came into my office and said, I've had cold symptoms for two days, a little runny nose, a cough, you know, everyone in my family is sick. My assumption is that that's gonna be a virus. You know, most symptomatic illnesses that sound like that, right? That have that sort of syndrome are going to be viral infections.

SPEAKER_01: 8:33

But doctor, mine's different. I know my drainage is green when it for me, it's always a bacterial infection. I know everybody else is sick too. I need an antibiotic, doctor. So how do you answer that? I'm being a little facetious here, but that's a kind of the message doctors get asked all the time. But for me, couldn't you just give me an antibiotic for this?

SPEAKER_03: 8:58

Yeah, you're not you're not wrong. That does happen. And usually how I counsel people is that if this were to be a bacterial infection, you're right, antibiotics are warranted, but it's a little too soon to tell, right? And the majority of these are viruses. And so I would highly recommend going home with supportive cares, rest, symptom management, you know, chicken soup. Chicken soup, some fluids, all that. And if you're not getting better within a week, or at least on the mend, you don't have to be perfectly better, but at least sort of moving in the right direction. Let's talk again, right? Because I want to know what's going on and treat you if there's a bacterial cause.

SPEAKER_01: 9:35

Right. So your bronchitis, your cold, your upper respiratory infection, most sinus infections, you just don't need one, especially in that first week or so.

SPEAKER_03: 9:45

Correct.

SPEAKER_01: 9:45

So what does a self-limiting infection mean?

SPEAKER_03: 9:48

Well, it's exactly what you're saying, right? It's it's limited in its timeline and that it goes away on its own. It doesn't, you don't need additional things to stop the infection, right? So most viral infections like common colds, the flu, even quote, uh other stomach illnesses, stomach viruses, and things like that, those will go away on their own over time. You don't need antibiotics, you don't need other treatments other than things that might make you just feel better throughout it, right? Rest, a decongestant, uh, something for your runny nose, et cetera.

SPEAKER_01: 10:21

So let's assume now that I do have an infection that requires an antibiotic or that you're prescribing to somebody. They have community acquired pneumonia, they have bacterial pneumonia, for instance, and you give them an antibiotic. Why is it important or why do we tell patients, take them all and take them till they're gone, do it for this many days. Don't just take, you know, we say, here's how long you're gonna take them, do it for that whole time, don't stop. Why do we do that?

SPEAKER_03: 10:45

I have two answers to that. So, one, we do it because we want to make sure the infection is fully cleared. And when we prescribe antibiotics for a set period of time, you know, the hope is that we give you the exact right amount to clear the infection, hopefully not more than you need. And we don't want you to stop early if you're feeling better because we don't want you to partially treat that infection and then have it either come back or develop resistance to the antibiotics. Now that said, there's a little bit of a that statement I would say is also a little bit outdated because I think the message that it gives when we say like take all your antibiotics and don't stop early sometimes kind of makes people think like more antibiotics are better than less, right? And the thing that's really important to note is that every type of infection is a little bit different, right? So seven days for one or five days for another or 14 days for another, like aren't really comparable from one type of infection to another. And so I think it's important to note that one, you should take the prescription as your doctor prescribes it, because that's quite important. But also know that different types of infections have different durations of treatment.

SPEAKER_01: 11:52

Are they safe? That is a broad question. But in other words, are there big problems with taking antibiotics for adverse effects? And and and this the follow-up then is what are some of the common side effects people might get when you take an antibiotic?

SPEAKER_03: 12:06

So in general, yes, they are safe. Like anything we do or prescribe, nothing is a hundred percent without risk, right? Everything we do in our life, even out outside of the infection world, like you drive in a car, we think in general that's safe, right? We wear a seatbelt, we follow the traffic stops, et cetera. But you know, it's not without risk. And and the same goes for any medication, not just antibiotics. You know, there's always some risk for side effects, and certain people respond a little differently to medicines, but in general, they are safe. And what I would say is right now we have a number of different antibiotics and antibiotic classes that we can choose from for different types of infections. And so the nice thing is we often will try and choose one for your skin infection, urinary tract infection, pneumonia that will be safest for you, right? So let's say there's three different ones and you have kidney disease, three antibiotics that work, and you have kidney disease, and one of the antibiotics has a side effect of kidney problems. You know, we're gonna stay away from that one and use one of the other ones. So there is a lot of thinking that actually goes into making decisions about what the best antibiotic is for you when you're being seen by your healthcare provider. And then you also asked about sort of common side effects. So I tell every patient any antibiotic can give you a rash, any antibiotic can give you diarrhea.

SPEAKER_01: 13:26

That's common, isn't it?

SPEAKER_03: 13:28

Whether it's just an upset stomach or something more serious called Clostrodium difficile or C. diff. You know, that can happen with any antibiotic. And so I tell that to everybody. And then depending on the specific antibiotic, I usually go through the risks or adverse side effects that people can have with that specific one.

SPEAKER_01: 13:45

Yeah, that queasy tummy intestinal issue seems to be so common. We're not gonna get into clostridium today, but I just tell folks that you don't want to get that either. That's a diarrheal illness that comes, it's a different organism, but it comes after you took antibiotics. So it's something that you kind of want to avoid if you can. We have been talking about antibiotics with infectious disease physician Dr. Caitlin Eccles Radki. We're gonna take a short break, but when we come back, we're gonna discuss the growing problem of antibiotic resistance, what's being done about it, and maybe even what you can do to help curb resistance. So stick around, we'll be right back.

SPEAKER_02: 14:22

When Hennepin Healthcare says, we're here for life, they mean here for you, your life, and all that it brings. Hennepin Healthcare has a hospital, HCMC, a network of clinics in the metro area, and an integrative health clinic in downtown Minneapolis. They provide all of the primary and specialty care you'd expect to find, as well as services like acupuncture and chiropractic care. Learn more at Hennepinhealthcare.org. Hennepin Healthcare is here for you and here for life.

SPEAKER_01: 14:59

And we're back. So Caitlin, let's talk about antibiotic resistance and why like your average listener should even care about antibiotic resistance. So to start us off, can you explain to us what that means?

SPEAKER_03: 15:12

Yeah, so antibiotic resistance uh really is the phenomenon where bacteria develop resistance to certain antibiotics. So that means that while an antibiotic may have worked in the past for a certain type of bacteria, now it doesn't work. That bacteria has grown, changed, mutated to function in a way that doesn't allow the antibiotic to work anymore.

SPEAKER_01: 15:36

So what you're talking about is that the bacteria, the universe of the bacteria, grow resistance to our weapons, if you will. Yeah.

SPEAKER_03: 15:43

Yeah. If you think about it, I mean, we can think about it on an individual level or a big scale, but in general, what leads to antibiotic resistance is when we're using more antibiotics than we need, like as a population and as individuals, I would say. And so really the goal of preventing antibiotic resistance is to not use as many antibiotics unless you really need them.

SPEAKER_01: 16:08

So that that is true for humans, you know, where doctors don't prescribe you antibiotics partially to avoid this phenomenon. But what about sort of in the food supply in agriculture and the global use of antibiotics? Does that contribute?

SPEAKER_03: 16:22

Yeah, it's a huge deal, actually. And it's not something I think we, the general public, we think about on a regular basis, but there are antibiotics used in livestock, poultry, pick your animal food source of choice in an attempt to keep those flocks healthy and produce more. And that actually can lead to antibiotic resistance as well. And so there are a number of initiatives globally, you know, in Minnesota, in the US, across the world, that are looking to curb antibiotic resistance and really looking at sort of how humans and animals and the environment all interface in an attempt to decrease resistance.

SPEAKER_01: 17:03

I even heard the World Health Organization has talked about it as antibiotic resistance as one of the top public health threats globally.

SPEAKER_03: 17:11

It is. Yeah. So so the fear is a pre-antibiotic world, right? And unfortunately, the way resistance is arising, or at the pace at which resistance is arising, is moving faster than our ability to create new antibiotics. And so while there are new antibiotics and research and development currently, the drug companies sometimes, and I don't want to speak for them because I don't know all the nuances of how they decide who does what, but you know, it's quite expensive to make new drugs. And so they have to decide where to put that money in those priorities. And sometimes antibiotics aren't the priority, right? And so it's hard to keep up with making new antibiotics when we're running out of old ones.

SPEAKER_01: 18:08

Yeah, yep. That that makes sense. So can you provide us with some real-world examples of where resistance has occurred?

SPEAKER_03: 18:15

So many years ago, if you heard the term MERSA, which stands for methicillin resistant staphylococcus aureus or staph aureus, everyone thought, oh my gosh, super bug, so scary, don't ever want to get it. Well, all of that is true. You don't ever want to get it, but it's actually quite common right now and it has become sort of mainstream. I mean, we see patients with MERSA all the time in the hospital, and it's you know, you don't really blink an eye.

SPEAKER_01: 18:42

I did when I was training. Yeah. I um to see an MRSA, a MERSA case was a big deal. Just 25 years ago. And now it we never saw it in people who weren't in the hospital. But even in the hospital, it's kind of a big deal. Now there's people walking around with it.

SPEAKER_03: 18:59

Yeah. A number of us are actually probably colonized in our nails and our noses with it. And it's much more prevalent even in the community. And so that kind of seems like not as big of a deal now. And I don't want to downplay it because again, any infection and resistance is a big deal. But we have bigger, scarier bugs, if you will, with more resistance to more drug classes and and that are changing quickly, uh, that are of bigger concern.

SPEAKER_01: 19:26

Yeah, but even MRSA can kill you. It can you get a bad pneumonia with MRSA and you have you get septic and septic shock, gotta give you different antibiotics now, the not though because it's resistant to the other ones.

SPEAKER_03: 19:40

Yeah, exactly. We do see that sometimes. And and I think you bring up a good point is that the uh the World Health Organization, I was just looking at some stats recently, and it looks like if we continue uh with the current trends of development of resistance, that antimicrobial resistance could contribute to as many. 39.1 million deaths in the next 25 years. So between now and 2050. 39 million deaths just from antibiotic resistance. That's a big number and a big deal.

SPEAKER_01: 20:10

That's a really big deal.

SPEAKER_03: 20:12

The other thing I think is important is that because this is, I mean, we think about it all the time in the infectious disease world, but because it's sort of like a slow-moving, in some ways, changing thing, right? It's not like a big pandemic in your face that you have to deal with right away. People don't think about it as being as important or don't even hear about it sometimes when it actually is a really, really big deal.

SPEAKER_01: 20:35

It's yeah, I was gonna ask you about that because you and I in our daily lives, particularly you, you probably think about this every day about the appropriate use of antibiotics and what happens if you don't use them appropriately. And we do that all the time, but the average person doesn't. It's sort of like global warming. It's a crisis for our planet. This is a crisis for our planet and our ability to care for humanity that has infections, but it doesn't affect your day-to-day life so much. And so I think that's really important that we're talking about it today. And then I'm gonna ask you now, I'm gonna shift about um the path forward. How can we act in our own lives to do our part, if you will? So if you could talk to us about what does antibiotic stewardship mean?

SPEAKER_03: 21:19

We actually have an amazing antibiotic stewardship team here at the hospital. So the first thing I'll say is that hospitals and clinics and medical groups are thinking about this. And the goal is to really evaluate, you know, how many prescriptions are being given? Are they appropriate? You know, are we using too many antibiotics or not? And on a day-to-day basis, you as an individual, I think it's important to learn, as we talked about at the beginning of this podcast, that not everything needs antibiotics, right? So be more aware when you go and talk to your doctor about your symptoms and asking for antibiotics that that maybe you don't need it. And the hope, too, is of course that your doctor is educating you on when antibiotics are appropriate and when they're not. So that's from an individual level, I think, is one thing you can do. And then just taking your prescriptions as prescribed, right? And not taking them intermittently, missing a bunch of doses, things like that. But I think that's on the individual level. And then I want to look to sort of bigger levels. Like we as a human population need to be working with our policymakers, our medical scientists, our agricultural scientists and leadership and looking across the globe, right? Not just here in Minnesota or the state, but looking across the globe because there are no boundaries for resistant organisms. And so, you know, we'll see people here at our hospital in Minnesota who had health care in a third world country or a foreign country, and they come back with a resistant organism and a really bad infection. And we're having to deal with that, right? And there's there's no borders for these things. And so we have to work together as a world and a human population and across disciplines to be able to create policies, put funding towards research and development for new antibiotics and looking at look at ways to sort of curb this really bad situation we're in.

SPEAKER_01: 23:12

That was well said. I want to unpack that a little bit. So when I was practicing um 20, 25 years ago, I wrote a lot of prescriptions from my clinic for antibiotics. A lot. You know, everybody wanted a zithromycin, and it was so easy. It even came in a little blister pack. You just came, it was easy. It was four letters on a prescription pad was so much easier to do. Just write zithromycin done than having a 10-minute conversation with the patient about why they didn't need that. So I was guilty and the medical system was guilty. I think we didn't have antibiotic stewardship programs back then. And now I think I can't recall the last time I wrote an antibiotic prescription in my clinic because you just almost never need them for your sore throats or your bronchitis or whatever. So I like what you said about that, but some of it's individual and some of it's on the global scale. So I'm gonna get into both of those a little bit more. So the individual patient, what would how would you sum up your recommendations about what they should be thinking about with their illness?

SPEAKER_03: 24:18

I think it's important to really review with your doctor what symptoms you're having, how long you've had them, what exposures you may have been exposed to, and work with your doctor to kind of decide, you know, what do we think is causing this? Right. And not requesting antibiotics for every sinus infection, upper respiratory infection.

SPEAKER_01: 24:40

Just in case. I need them just in case. Maybe that's not what you'd say.

SPEAKER_03: 24:43

Yeah. Usually the advice I give to patients is if you're still feeling sick, you have easy access. You know, we have the my chart system here where patients can message you easily. And I say, you just give me a heads up. If you're still feeling sick in a week or whatever the timeline is based on kind of where I saw them in their illness, you reach out to me and we'll touch base. And if we think you need an antibiotic at that point, that's fine. And so, but I think your infection will probably go away or be getting better in that period of time.

SPEAKER_01: 25:11

Time heals in many cases.

SPEAKER_03: 25:14

Correct. And I actually want them to tell me that too. Like, hey, I'm doing better. You know, I think that's a good way to reinforce. Hey, look, that was probably viral and you're doing better. That's great.

SPEAKER_01: 25:24

Or the the opposite thing has sometimes happened to be whereas somebody said they were at an urgent care or somewhere, they got this antibiotic for whatever their upper respiratory illness was. They had a cold. They got an antibiotic and then they come to see their regular doctor and say, I need another prescription because I'm still sick. Well, you didn't need it the first time. You simply don't need it a second time. So it's some of that awareness, I think, that is helpful. I don't want to put it on patients that this is up to you, but it's just to be aware that when your doctor is not giving you antibiotics, it's not because they're withholding something that you need. You just never needed them in the first place.

SPEAKER_03: 25:58

Yeah. And I think the other point that's important is with these self-limiting viral infections, they can last. Some of the after effects, I should say, can last more than a week, right? There's some people, myself included, who will get a cough for two weeks that just kind of lingers and the infection itself is gone. It's just that residual irritation of your airways that will go away, but it's just annoying. It's annoying.

SPEAKER_01: 26:23

Give it time and some chicken soup. So before I let you go, let's recap with a quick game of true or false, or just about true or false.

SPEAKER_03: 26:29

All right.

SPEAKER_01: 26:30

First, if you start feeling better, you can stop taking your antibiotics.

SPEAKER_03: 26:33

I would continue your course based on whatever your doctor prescribed.

SPEAKER_01: 26:37

Okay. Antibiotics can treat viruses.

SPEAKER_03: 26:40

That is false.

SPEAKER_01: 26:41

Broad spectrum antibiotics are stronger, so they're better.

SPEAKER_03: 26:45

They are stronger in the sense that maybe stronger is not the right word, in the sense that they cover more types of bacteria, so they're broader, but they're not always better. If you know what you're treating, you want to actually go with the most narrow antibiotic you can find to decrease risk for resistance.

SPEAKER_01: 27:01

How about this one? Taking antibiotics just in case can't hurt.

SPEAKER_03: 27:05

It can hurt, right? As we said, there's risk for side effects, there's risk for resistance. And if they're not doing anything, why? Why take him?

SPEAKER_01: 27:14

Last one antibiotic resistance only happens in hospitals.

SPEAKER_03: 27:17

Not true. As we talked about earlier, it can occur in the community. And so it's just important to be good stewards of our antibiotics.

SPEAKER_01: 27:25

We have been talking with Dr. Caitlin Ecklesracky. She is an infectious disease specialist and a physician at Hennepin Healthcare here in downtown Minneapolis, a colleague of mine for some years now. It is so good to have had you on the podcast. Thanks a ton, Caitlin.

SPEAKER_03: 27:39

Thanks for having me.

SPEAKER_01: 27:40

Listeners, thanks for listening. I hope you learned something, and I hope you'll join us in two weeks' time for our next episode. And in the meantime, be healthy and be well.

SPEAKER_00: 27:50

Thanks for listening to the Healthy Matters Podcast with Dr. David Hilden. To find out more about the Healthy Matters Podcast or browse the archive, visit healthymatters.org. Got a question or a comment for the show? Email us at healthymatters at hcmed.org. Or call 612-873-TALK. There's also a link in the show notes. The Healthy Matters Podcast is made possible by Hennepin Healthcare in Minneapolis, Minnesota, and engineered and produced by John Lucas at Highball. Executive producers are Jonathan Comito and Christine Hill. Please remember we can only give general medical advice during this program. And every case is unique. We urge you to consult with your physician if you have a more serious or pressing health concern. Until next time, be healthy and be well.