00:00:00:00 - 00:00:00:18
All right, welcome to the

00:00:00:18 - 00:00:01:18
next installment of Live

00:00:01:18 - 00:00:02:23
Well with UCI Health.

00:00:02:23 - 00:00:03:18
My name is Ryan Manno

00:00:03:18 - 00:00:04:24
with KOST 103.5

00:00:04:24 - 00:00:05:28
and iHeartRadio here today

00:00:05:28 - 00:00:07:12
with Doctor Shruti Gohil.

00:00:07:12 - 00:00:08:04
It's great to be here.

00:00:08:04 - 00:00:08:23
Thanks for having me.

00:00:08:23 - 00:00:09:17
You are the associate

00:00:09:17 - 00:00:11:12
medical director of UCI Health,

00:00:11:12 - 00:00:13:19
Epidemiology and Infection Prevention,

00:00:13:19 - 00:00:15:06
also an associate professor

00:00:15:06 - 00:00:16:17
of infectious diseases

00:00:16:17 - 00:00:19:04
at UC Irvine School of Medicine.

00:00:19:04 - 00:00:19:16
Yes.

00:00:19:16 - 00:00:20:23
And recognized

00:00:20:23 - 00:00:22:21
for her innovative national research

00:00:22:21 - 00:00:24:06
to reduce the spread of

00:00:24:06 - 00:00:25:17
associated infections to limit

00:00:25:17 - 00:00:27:00
the use of broad spectrum antibiotics.

00:00:27:00 - 00:00:27:21
Doctor Gohil

00:00:27:21 - 00:00:28:28
Am I am I getting this right?

00:00:28:28 - 00:00:29:21
That's too kind.

00:00:29:21 - 00:00:31:07
Thank you so much. Yes, absolutely.

00:00:31:07 - 00:00:32:12
Okay. Phew.

00:00:32:12 - 00:00:34:08
My first question was going to be

00:00:34:08 - 00:00:35:18
what are antibiotics?

00:00:35:18 - 00:00:37:15
But I want to I want to pre-date that.

00:00:37:15 - 00:00:38:19
And what are biotics.

00:00:38:19 - 00:00:42:27
So biotics are medications

00:00:42:27 - 00:00:46:23
or any type of substance that may affect...

00:00:46:27 - 00:00:50:01
Okay. The bacterial population or

00:00:50:19 - 00:00:52:05
other living populations.

00:00:52:05 - 00:00:53:27
So things that are biotic.

00:00:53:27 - 00:00:54:13
Okay.

00:00:54:13 - 00:00:55:05
So anti

00:00:55:05 - 00:00:55:25
and pro

00:00:55:25 - 00:00:59:19
antibiotics are those that may kill.. Okay.

00:00:59:27 - 00:01:01:01
The bacterial pathogen

00:01:01:01 - 00:01:01:23
for example

00:01:01:23 - 00:01:02:18
or anything

00:01:02:18 - 00:01:04:28
that is living versus probiotics

00:01:04:28 - 00:01:06:21
that promotes growth.

00:01:06:21 - 00:01:08:11
Let's start with the the antibiotics.

00:01:08:11 - 00:01:08:29
What are they?

00:01:08:29 - 00:01:10:22
The antibiotics are

00:01:10:22 - 00:01:13:17
lifesaving medications that help

00:01:13:17 - 00:01:15:28
fight infection. Okay.

00:01:15:28 - 00:01:17:04
That can be an infection

00:01:17:04 - 00:01:18:04
from bacteria,

00:01:18:04 - 00:01:21:10
from virus, from fungus as well.

00:01:22:01 - 00:01:23:23
And it's really important

00:01:23:23 - 00:01:25:15
lifesaving medication.

00:01:25:15 - 00:01:27:16
However they need to be used properly

00:01:27:16 - 00:01:29:23
to affect the right kind of

00:01:29:23 - 00:01:31:01
healthful response.

00:01:31:01 - 00:01:31:08
Yes.

00:01:31:08 - 00:01:32:09
We're going to get into

00:01:32:09 - 00:01:33:27
a lot of that okay.

00:01:33:27 - 00:01:35:23
Why is there so much concern

00:01:35:23 - 00:01:37:18
about antibiotics right now? Yeah.

00:01:37:18 - 00:01:41:06
The antibiotics can really cause

00:01:41:17 - 00:01:42:25
while they can help you

00:01:42:25 - 00:01:44:06
kill the bad bacteria

00:01:44:06 - 00:01:45:24
that may be causing infection.

00:01:45:24 - 00:01:47:28
They can also. They're indiscriminate.

00:01:47:28 - 00:01:50:12
They can affect all the good bacteria

00:01:50:12 - 00:01:52:13
that we have in our body, in our guts.

00:01:52:13 - 00:01:53:06
And we're just

00:01:53:06 - 00:01:54:22
really scratching the surface

00:01:54:22 - 00:01:56:03
on what that means to

00:01:56:03 - 00:01:57:27
what we're calling the human microbiome,

00:01:57:27 - 00:01:58:17
which is,

00:01:58:17 - 00:02:00:18
you know, we're made up of bacteria.

00:02:00:18 - 00:02:02:05
Bodies are just,

00:02:02:05 - 00:02:04:22
teeming with healthy bacteria that help

00:02:04:22 - 00:02:06:11
keep a lot of our systems

00:02:06:11 - 00:02:08:17
moving in the right direction.

00:02:08:17 - 00:02:09:25
Because of that,

00:02:09:25 - 00:02:10:22
because antibiotics

00:02:10:22 - 00:02:11:16
can't tell the difference

00:02:11:16 - 00:02:12:23
between a good bacteria

00:02:12:23 - 00:02:14:18
and a bad bacteria.

00:02:14:18 - 00:02:16:10
It can indiscriminately kill

00:02:16:10 - 00:02:17:18
both the good ones and the bad ones.

00:02:17:18 - 00:02:19:13
And that causes

00:02:19:13 - 00:02:21:12
that can change the balance

00:02:21:12 - 00:02:22:18
of good and bad bacteria.

00:02:22:18 - 00:02:24:10
That's one major issue.

00:02:24:10 - 00:02:28:00
The other alarming issue is resistance.

00:02:28:00 - 00:02:30:00
Antibiotic resistance. Yeah.

00:02:30:00 - 00:02:31:13
Antibiotics

00:02:31:13 - 00:02:35:10
have been responsible for a rising number

00:02:35:13 - 00:02:37:29
of high risk,

00:02:37:29 - 00:02:40:04
antibiotic resistant bacteria.

00:02:40:04 - 00:02:44:13
It is estimated that by 2050, we may see

00:02:44:29 - 00:02:47:24
antibiotic resistant deaths

00:02:47:24 - 00:02:51:10
exceed those of cancer related deaths.

00:02:51:10 - 00:02:54:11
Oh my goodness. So, yeah, really an important

00:02:55:11 - 00:02:56:12
area for us

00:02:56:12 - 00:02:57:04
to focus our

00:02:57:04 - 00:02:58:25
energy to use antibiotics

00:02:58:25 - 00:03:00:05
properly whenever possible.

00:03:00:05 - 00:03:01:25
So kind of put this into

00:03:01:25 - 00:03:03:00
maybe some terms that

00:03:03:00 - 00:03:04:18
that I might understand with this.

00:03:04:18 - 00:03:05:09
So is it

00:03:05:09 - 00:03:07:16
is it basically like you're

00:03:07:16 - 00:03:09:06
you're using it to treat something.

00:03:09:06 - 00:03:11:03
But the longer we do this the

00:03:11:03 - 00:03:11:22
the more

00:03:11:22 - 00:03:16:07
this infection understands how to evade.

00:03:16:11 - 00:03:17:24
Yes. Is that am I on the right track?

00:03:17:24 - 00:03:19:00
That's exactly right.

00:03:19:00 - 00:03:19:15
And, you know,

00:03:19:15 - 00:03:22:09
bacteria are just so smart.

00:03:22:09 - 00:03:23:03
Are they?

00:03:23:03 - 00:03:24:04
Yeah. There's.

00:03:24:04 - 00:03:25:27
You have to be a dumb. But you know what?

00:03:25:27 - 00:03:27:03
Actually

00:03:27:03 - 00:03:29:13
they can learn our antibiotics

00:03:29:13 - 00:03:30:23
quite quickly and adapt.

00:03:30:23 - 00:03:31:11
How does that mean?

00:03:31:11 - 00:03:31:27
How does that work?

00:03:31:27 - 00:03:33:16
Because they don't communicate. Do they?

00:03:33:16 - 00:03:34:25
They actually do.

00:03:34:25 - 00:03:36:06
There’s a couple of things that they do.

00:03:36:06 - 00:03:38:07
So bacteria can actually

00:03:38:07 - 00:03:39:18
there's two mechanisms.

00:03:39:18 - 00:03:41:05
They can learn the

00:03:41:05 - 00:03:44:00
when they're exposed to antibiotics,

00:03:44:00 - 00:03:46:21
they can change their genetic makeup

00:03:46:21 - 00:03:48:09
so that

00:03:48:09 - 00:03:50:28
they can resist the antibiotic that we're

00:03:50:28 - 00:03:52:10
we're treating them with.

00:03:52:10 - 00:03:55:00
And not only that, they can communicate

00:03:55:00 - 00:03:58:00
with their colleagues, so to speak,

00:03:58:06 - 00:03:59:18
and transmit

00:03:59:18 - 00:04:02:18
that ability to resist antibiotics

00:04:02:27 - 00:04:03:23
to each other.

00:04:03:23 - 00:04:05:16
So it could actually infect each other

00:04:05:16 - 00:04:08:07
with the ability to to resist.

00:04:08:07 - 00:04:10:07
Where does the bulk of that communication occur?

00:04:10:07 - 00:04:12:07
So, so if let's say I have something

00:04:12:07 - 00:04:14:04
and you've given me antibiotics,

00:04:14:04 - 00:04:16:13
that whole situation is handling itself

00:04:16:13 - 00:04:17:22
within me.

00:04:17:22 - 00:04:20:22
How does that then affect you?

00:04:20:22 - 00:04:21:11
Right?

00:04:21:11 - 00:04:22:26
Like the information

00:04:22:26 - 00:04:23:25
that my bacteria

00:04:23:25 - 00:04:24:25
is getting

00:04:24:25 - 00:04:26:13
about this antibiotic,

00:04:26:13 - 00:04:28:10
at what point is that then passed to you

00:04:28:10 - 00:04:30:03
so that it becomes a large scale problem

00:04:30:03 - 00:04:32:19
that people are now not right?

00:04:32:19 - 00:04:33:18
Yes, yes. Yeah. Okay.

00:04:33:18 - 00:04:33:29
So that's

00:04:33:29 - 00:04:35:05
actually a multi-layered question.

00:04:35:05 - 00:04:36:13
I'm trying to break it down. I’m so sorry.

00:04:36:13 - 00:04:37:18
It's a good question.

00:04:37:18 - 00:04:39:04
Good. As all good questions should be.

00:04:39:04 - 00:04:41:00
So first it starts with you know

00:04:41:00 - 00:04:41:29
say you're getting treated

00:04:41:29 - 00:04:43:10
with antibiotics.

00:04:43:10 - 00:04:45:24
Your bacterial composition

00:04:45:24 - 00:04:48:17
starts to change the number of bacteria

00:04:48:17 - 00:04:49:28
say on your skin.

00:04:49:28 - 00:04:51:07
Let's take the example of something

00:04:51:07 - 00:04:52:12
called staph aureus.

00:04:52:12 - 00:04:53:22
It's a

00:04:53:22 - 00:04:56:17
well known MRSA is what we call it.

00:04:57:19 - 00:04:58:21
You may not have

00:04:58:21 - 00:05:00:01
started with staph aureus.

00:05:00:01 - 00:05:02:03
That's a resistant organism,

00:05:02:03 - 00:05:03:23
but because we gave you antibiotics,

00:05:03:23 - 00:05:05:15
it starts to be

00:05:05:15 - 00:05:07:04
that the population of staph aureus

00:05:07:04 - 00:05:09:11
which normally lives on our skin,

00:05:09:11 - 00:05:11:03
more and more of them, become resistant.

00:05:11:03 - 00:05:12:01
As they become more

00:05:12:01 - 00:05:14:09
and more of them become resistant.

00:05:14:09 - 00:05:15:13
Then communication

00:05:15:13 - 00:05:18:11
with another individual through touch

00:05:18:11 - 00:05:21:11
can transmit that strain

00:05:21:19 - 00:05:22:27
to another person.

00:05:22:27 - 00:05:24:12
Okay, fascinating.

00:05:24:12 - 00:05:25:29
So then what mine has learned

00:05:25:29 - 00:05:27:12
is now teaching yours

00:05:27:12 - 00:05:28:19
what it has learned

00:05:28:19 - 00:05:29:17
so that yours

00:05:29:17 - 00:05:30:15
now has learned it,

00:05:30:15 - 00:05:32:01
and so on and so forth. Exactly.

00:05:32:01 - 00:05:33:06
Sneaky little devil.

00:05:33:06 - 00:05:35:05
My God. Yes.

00:05:35:05 - 00:05:36:29
When is an antibiotic

00:05:36:29 - 00:05:38:16
not going to be effective?

00:05:38:16 - 00:05:39:29
Is it, when it reaches that point?

00:05:39:29 - 00:05:40:19
Like where...

00:05:40:19 - 00:05:41:28
Yeah. It's kind of like

00:05:41:28 - 00:05:43:29
scoffing at the antibiotic. Yeah.

00:05:45:01 - 00:05:46:01
I like that term.

00:05:46:01 - 00:05:47:21
Yeah. Yes.

00:05:47:21 - 00:05:50:19
So it reaches some sort of tipping point

00:05:50:19 - 00:05:52:00
where it's become,

00:05:52:00 - 00:05:53:25
especially with multiple exposures

00:05:53:25 - 00:05:55:17
of different kinds of antibiotics,

00:05:55:17 - 00:05:56:16
we can kind of burn

00:05:56:16 - 00:05:58:12
through all the available

00:05:58:12 - 00:06:01:00
armamentarium that we may have,

00:06:01:00 - 00:06:03:23
quickly, actually, such that

00:06:03:23 - 00:06:04:23
we don't… we’re left

00:06:04:23 - 00:06:07:15
without an antibiotic to treat a person.

00:06:07:15 - 00:06:09:09
So are we constantly...

00:06:09:09 - 00:06:09:24
And by we,

00:06:09:24 - 00:06:10:24
I mean like the smart people,

00:06:10:24 - 00:06:11:17
like you guys.

00:06:11:17 - 00:06:14:10
Are you constantly

00:06:14:10 - 00:06:16:16
are antibiotics being updated

00:06:16:16 - 00:06:20:01
constantly to get ahead of.

00:06:20:04 - 00:06:20:17
Right.

00:06:20:17 - 00:06:22:03
That's one of the, one of the key points.

00:06:22:03 - 00:06:22:24
Yes. Of course.

00:06:22:24 - 00:06:23:29
You know,

00:06:23:29 - 00:06:24:25
pharmaceutical companies

00:06:24:25 - 00:06:26:22
are always working on

00:06:26:22 - 00:06:28:21
making sure that pipeline is good, right?

00:06:28:21 - 00:06:30:07
There are new antibiotics coming in

00:06:30:07 - 00:06:31:09
so that we can deal

00:06:31:09 - 00:06:32:18
with some of these multidrug

00:06:32:18 - 00:06:35:18
resistant organisms - MDROs we call them.

00:06:35:29 - 00:06:37:23
So that's one for sure.

00:06:37:23 - 00:06:39:21
But what we have understood over

00:06:39:21 - 00:06:41:29
the decades is that bacteria are so smart

00:06:41:29 - 00:06:43:21
that they will eventually learn

00:06:43:21 - 00:06:45:13
when an antibiotic hits the market.

00:06:45:13 - 00:06:46:09
It isn't long

00:06:46:09 - 00:06:47:22
after that time

00:06:47:22 - 00:06:48:25
that we start

00:06:48:25 - 00:06:50:16
to see a rise in resistance.

00:06:50:16 - 00:06:51:16
So I think there's a

00:06:51:16 - 00:06:52:10
two pronged response.

00:06:52:10 - 00:06:54:07
Yes, we need more more

00:06:54:07 - 00:06:56:19
drugs to help us out in a in a tight spot

00:06:56:19 - 00:06:57:29
when we get into this multidrug

00:06:57:29 - 00:06:59:29
resistant organism level.

00:06:59:29 - 00:07:03:00
But the bigger bang for our buck,

00:07:03:01 - 00:07:05:07
honestly, is to use antibiotics

00:07:05:07 - 00:07:06:16
wisely. Okay.

00:07:06:16 - 00:07:08:04
And use as narrow

00:07:08:04 - 00:07:09:27
spectrum of an antibiotic as possible.

00:07:09:27 - 00:07:10:15
You know,

00:07:10:15 - 00:07:13:07
like the analogy I like to think of is,

00:07:13:07 - 00:07:13:13
you know,

00:07:13:13 - 00:07:14:27
killing an ant with a sledgehammer.

00:07:14:27 - 00:07:16:25
You know, you get you

00:07:16:25 - 00:07:18:25
you're going to in trying to kill that

00:07:18:25 - 00:07:20:09
ant with such a large item,

00:07:20:09 - 00:07:20:29
you'll end up,

00:07:20:29 - 00:07:23:00
you know, getting your entire table

00:07:23:00 - 00:07:23:29
injured as well. Yes, totally.

00:07:23:29 - 00:07:26:04
You want to target your antibiotic

00:07:26:04 - 00:07:27:22
as much as possible

00:07:27:22 - 00:07:29:16
towards the effect you need.

00:07:29:16 - 00:07:30:16
So thinking of it like that way,

00:07:30:16 - 00:07:31:25
it's almost like you guys are constantly

00:07:31:25 - 00:07:32:21
in a state of war

00:07:32:21 - 00:07:34:11
with the thing you're treating, right?

00:07:34:11 - 00:07:35:03
It's like the art of war

00:07:35:03 - 00:07:36:10
you have to stay ahead of.

00:07:36:10 - 00:07:37:19
Yes, you got to think ahead.

00:07:37:19 - 00:07:38:15
Think ahead.

00:07:38:15 - 00:07:40:00
Don't give the enemy the chance

00:07:40:00 - 00:07:41:05
to figure out what we're up

00:07:41:05 - 00:07:42:11
to, because it's gonna figure it out.

00:07:42:11 - 00:07:43:13
You just have to be ahead of it

00:07:43:13 - 00:07:44:16
when it figures it out.

00:07:44:16 - 00:07:45:10
I love this.

00:07:45:10 - 00:07:47:22
What kind of conditions are do you,

00:07:47:22 - 00:07:48:18
would you say.

00:07:48:18 - 00:07:49:03
And this might be

00:07:49:03 - 00:07:50:11
a really stupid question. I'm sorry.

00:07:50:11 - 00:07:51:10
What kind of conditions

00:07:51:10 - 00:07:52:18
best lend themselves

00:07:52:18 - 00:07:55:06
to antibiotic treatment?

00:07:55:06 - 00:07:57:17
Infections that are caused by bacteria.

00:07:57:17 - 00:07:58:04
Okay.

00:07:58:04 - 00:07:59:23
We we as opposed to viruses,

00:07:59:23 - 00:08:00:28
I think that's an important question.

00:08:00:28 - 00:08:02:12
Just because a lot of people,

00:08:02:12 - 00:08:03:28
one of the reasons why we have such a

00:08:05:03 - 00:08:06:07
rising tide

00:08:06:07 - 00:08:08:04
of antibiotic resistant organisms

00:08:08:04 - 00:08:10:07
is because we end up as patients.

00:08:10:07 - 00:08:12:06
Many people think that you have a cold

00:08:12:06 - 00:08:14:04
or a typical flu.

00:08:14:04 - 00:08:16:07
You think that you need,

00:08:16:07 - 00:08:17:12
antibiotics,

00:08:17:12 - 00:08:19:22
antibacterial antibiotics, and

00:08:19:22 - 00:08:20:23
and actually that's not the case

00:08:20:23 - 00:08:21:29
because antibiotics

00:08:21:29 - 00:08:23:27
that when we talk about antibacterials

00:08:23:27 - 00:08:25:18
really only work against bacteria.

00:08:25:18 - 00:08:27:15
They don't work against viruses.

00:08:27:15 - 00:08:28:21
And so you want to... And cold’s a virus.

00:08:28:21 - 00:08:30:22
Cold’s a virus. Covid for example.

00:08:30:22 - 00:08:31:16
Classic example.

00:08:31:16 - 00:08:33:08
You know you don't need antibiotics

00:08:33:08 - 00:08:34:07
for that, right?

00:08:34:07 - 00:08:36:25
You just need to... supportive care.

00:08:36:25 - 00:08:37:10
Yeah.

00:08:37:10 - 00:08:38:06
You just talked about

00:08:38:06 - 00:08:39:21
not using the sledgehammer to

00:08:39:21 - 00:08:40:17
kill an ant.

00:08:40:17 - 00:08:43:22
So why then when if I'm taking

00:08:43:22 - 00:08:45:12
if you put me on some antibiotics

00:08:45:12 - 00:08:46:12
and then I already feel

00:08:46:12 - 00:08:47:12
better and everything.

00:08:47:12 - 00:08:49:03
Why do you say just keep.

00:08:49:03 - 00:08:50:03
Take it. Finish this. Ah, finish the course.

00:08:50:03 - 00:08:51:19
Doesn't that seem like a sledgehammer?

00:08:51:19 - 00:08:53:13
Like, if it's already gone, done.

00:08:53:13 - 00:08:55:08
Or do I not know that it's done?

00:08:55:08 - 00:08:55:27
Right, right.

00:08:55:27 - 00:08:56:03
Okay,

00:08:56:03 - 00:08:57:21
so that's a whole different concept.

00:08:57:21 - 00:08:58:23
When the sledgehammer

00:08:58:23 - 00:09:00:03
analogy is best for...

00:09:00:03 - 00:09:00:25
Okay, listen,

00:09:00:25 - 00:09:02:11
my antibiotic can't tell the difference

00:09:02:11 - 00:09:03:08
between a good bacteria and

00:09:03:08 - 00:09:05:04
bad bacteria and is going to kill everything.

00:09:05:04 - 00:09:06:16
Why don't we target

00:09:06:16 - 00:09:08:03
and choose the right antibiotics?

00:09:08:03 - 00:09:10:22
But suppose I have already targeted that

00:09:10:22 - 00:09:11:08
or I didn't.

00:09:11:08 - 00:09:13:16
I use a broader spectrum antibiotic

00:09:13:16 - 00:09:14:16
because I didn't know

00:09:15:16 - 00:09:16:11
what best

00:09:16:11 - 00:09:17:07
antibiotic to

00:09:17:07 - 00:09:18:13
use for for a patient,

00:09:18:13 - 00:09:19:26
and I wanted to cover all my bases. Okay, got it.

00:09:19:26 - 00:09:21:05
Suppose. Right, right.

00:09:21:05 - 00:09:21:19
It's important

00:09:21:19 - 00:09:23:05
to complete that treatment

00:09:23:05 - 00:09:26:05
because patients,

00:09:26:05 - 00:09:27:07
even though you might feel better

00:09:27:07 - 00:09:28:27
because your immune system is so noble,

00:09:28:27 - 00:09:30:12
you're going to start feeling better.

00:09:30:12 - 00:09:32:16
But the population of bacteria

00:09:32:16 - 00:09:34:05
that might be hiding, say, in your lung

00:09:34:05 - 00:09:35:07
because you had a pneumonia.

00:09:35:07 - 00:09:37:19
Say in your urinary tract infection,

00:09:37:19 - 00:09:38:12
urinary tract

00:09:38:12 - 00:09:40:23
because you had a urine infection.

00:09:40:23 - 00:09:41:12
Yeah.

00:09:41:12 - 00:09:42:24
The bacteria

00:09:42:24 - 00:09:44:05
can hide in the nooks and crannies.

00:09:44:05 - 00:09:44:28
And we need

00:09:44:28 - 00:09:46:16
to get that antibiotic

00:09:46:16 - 00:09:47:04
to penetrate

00:09:47:04 - 00:09:49:21
the whole nidus of infection

00:09:49:21 - 00:09:52:19
in order to, you know, fully treat...

00:09:52:19 - 00:09:53:13
I see. The person.

00:09:53:13 - 00:09:54:12
And actually,

00:09:54:12 - 00:09:55:22
it's important to complete the course

00:09:55:22 - 00:09:58:17
because then you want to make sure that,

00:09:58:17 - 00:09:59:24
there's no lingering bacteria

00:09:59:24 - 00:10:01:11
that can learn our antibiotics

00:10:01:11 - 00:10:02:22
and cause resistance.

00:10:02:22 - 00:10:04:01
So it's like some spies in there

00:10:04:01 - 00:10:05:18
that could just be hanging out.

00:10:05:18 - 00:10:06:19
Okay. I don't like them.

00:10:06:19 - 00:10:07:24
Yeah, no, we got rid of them.

00:10:07:24 - 00:10:09:06
That's not good. See, because I think.

00:10:09:06 - 00:10:09:24
And I bet you

00:10:09:24 - 00:10:10:03
no one's

00:10:10:03 - 00:10:11:05
going to be honest with you about this.

00:10:11:05 - 00:10:12:03
None of your patients.

00:10:12:03 - 00:10:13:25
But I think a pressing thing

00:10:13:25 - 00:10:15:21
for us as as patients,

00:10:15:21 - 00:10:17:00
we don't want to be on this antibiotics.

00:10:17:00 - 00:10:19:05
What we do is we'll we'll save it.

00:10:19:05 - 00:10:19:13
We'll go.

00:10:19:13 - 00:10:21:05
Oh, if I ever have this again.

00:10:21:05 - 00:10:21:19
Now I've got,

00:10:21:19 - 00:10:22:12
I got a jump start

00:10:22:12 - 00:10:23:25
with some amoxicillin or whatever.

00:10:23:25 - 00:10:24:10
I don't even know

00:10:24:10 - 00:10:26:06
if that's an antibiotic, but yeah. Oh.

00:10:26:06 - 00:10:28:10
It absolutely is. You're welcome.

00:10:28:10 - 00:10:29:27
So that's how I, that's how I view this.

00:10:29:27 - 00:10:30:27
But I'm doing it wrong.

00:10:30:27 - 00:10:31:29
Yeah. That's exactly right.

00:10:31:29 - 00:10:32:05
You know,

00:10:32:05 - 00:10:33:09
you don't want to save antibiotics

00:10:33:09 - 00:10:35:01
for later for a couple of reasons.

00:10:35:01 - 00:10:36:09
Unless the doctor told you, you know,

00:10:36:09 - 00:10:37:13
there are some people who

00:10:37:13 - 00:10:39:09
do need antibiotics in reserve, right?

00:10:39:09 - 00:10:40:00
Because they get, keep

00:10:40:00 - 00:10:41:27
getting repeated infections or some such.

00:10:41:27 - 00:10:43:03
That's rare.

00:10:43:03 - 00:10:43:19
But generally

00:10:43:19 - 00:10:44:27
you don't want to save antibiotics

00:10:44:27 - 00:10:45:18
because A,

00:10:45:18 - 00:10:46:04
you don't know

00:10:46:04 - 00:10:49:04
if your next infection is caused

00:10:49:04 - 00:10:50:15
because you

00:10:50:15 - 00:10:51:09
that prior

00:10:51:09 - 00:10:53:05
antibiotic didn't work correctly,

00:10:53:05 - 00:10:55:10
or if now you've bred resistance

00:10:55:10 - 00:10:57:13
because it was incomplete treatment

00:10:57:13 - 00:10:59:09
of the prior infection. Wow.

00:10:59:09 - 00:11:01:23
And then and so just complete the course.

00:11:01:24 - 00:11:02:25
Yeah. All right.

00:11:02:25 - 00:11:03:29
What are the problems

00:11:03:29 - 00:11:05:06
you mentioned this broad

00:11:05:06 - 00:11:06:27
this broad spectrum thing. Right.

00:11:06:27 - 00:11:08:07
So you'll throw this thing at it

00:11:08:07 - 00:11:10:16
because you're not exactly entirely sure

00:11:10:16 - 00:11:11:22
which one is going to pinpoint.

00:11:11:22 - 00:11:12:24
So what are the problems

00:11:12:24 - 00:11:13:19
with the broad spectrum.

00:11:13:19 - 00:11:14:04
Because to me,

00:11:14:04 - 00:11:14:15
if I,

00:11:14:15 - 00:11:15:28
if I, you know, as my brain,

00:11:15:28 - 00:11:16:23
I'm thinking just use

00:11:16:23 - 00:11:17:27
broad spectrum all the time.

00:11:17:27 - 00:11:18:16
Yeah.

00:11:18:16 - 00:11:19:17
I mean,

00:11:19:17 - 00:11:21:22
definitely, it seems to make sense.

00:11:21:22 - 00:11:22:27
And that's how the, how

00:11:22:27 - 00:11:25:01
the industry had been behaving before.

00:11:25:01 - 00:11:25:07
Right.

00:11:25:07 - 00:11:27:24
We also we don't like as physicians,

00:11:27:24 - 00:11:28:25
we don't like uncertainty.

00:11:28:25 - 00:11:31:22
And patients don't like uncertainty.

00:11:31:22 - 00:11:33:15
And so we tend to pick broad spectrum

00:11:33:15 - 00:11:34:25
until we really, really know.

00:11:34:25 - 00:11:35:05
Right?

00:11:35:05 - 00:11:37:07
That's been the general consensus

00:11:37:07 - 00:11:38:23
in the way that we approach patients.

00:11:38:23 - 00:11:40:04
But what we're learning now

00:11:40:04 - 00:11:42:28
is that these antibiotics have untoward

00:11:42:28 - 00:11:46:05
side effects on the kidneys, the liver,

00:11:46:29 - 00:11:49:18
and can cause actually more infections,

00:11:49:18 - 00:11:51:21
more... different types of infection.

00:11:51:21 - 00:11:52:15
One, for example,

00:11:52:15 - 00:11:54:03
is C difficile colitis,

00:11:54:03 - 00:11:55:24
a different type of infection

00:11:55:24 - 00:11:57:11
that is caused by an imbalance

00:11:57:11 - 00:12:00:11
in our gut microbiome.

00:12:00:23 - 00:12:03:09
And then on that last point, again, as I

00:12:03:09 - 00:12:04:19
as I mentioned,

00:12:04:19 - 00:12:06:11
because the broad spectrum kills

00:12:06:11 - 00:12:07:25
both healthy and

00:12:07:25 - 00:12:11:00
and the unhealthy bacteria, that healthy

00:12:11:04 - 00:12:12:22
component of bacteria,

00:12:12:22 - 00:12:14:04
really we're just scratching

00:12:14:04 - 00:12:16:23
that surface on understanding how

00:12:18:01 - 00:12:20:13
good bacteria really help us out there.

00:12:20:13 - 00:12:23:13
There are data suggesting that,

00:12:23:15 - 00:12:26:18
that you need these gut microbiome

00:12:27:04 - 00:12:30:04
microbes to process

00:12:30:04 - 00:12:31:16
vitamins. For example,

00:12:31:16 - 00:12:34:05
risk for diabetes has been correlated.

00:12:34:05 - 00:12:35:04
Risk for auto immune

00:12:35:04 - 00:12:36:19
diseases have been correlated

00:12:36:19 - 00:12:38:00
with having an unhealthy

00:12:38:00 - 00:12:40:18
bacterial population. Obviously for cancer

00:12:40:18 - 00:12:42:23
even. These data are preliminary

00:12:42:23 - 00:12:45:05
and more work is needed.

00:12:45:05 - 00:12:46:28
But all to say,

00:12:46:28 - 00:12:49:06
use only as many antibiotics

00:12:49:06 - 00:12:51:22
and as as targeted antibiotic as you can

00:12:51:22 - 00:12:53:21
to minimize the untoward impact.

00:12:53:21 - 00:12:54:28
So you kind of touched on this

00:12:54:28 - 00:12:55:13
in the beginning

00:12:55:13 - 00:12:56:03
with like this,

00:12:56:03 - 00:12:57:16
this look into the future.

00:12:57:16 - 00:13:00:09
I think you said by 2050 or... Yes.

00:13:00:09 - 00:13:01:27
So what ultimately happens

00:13:01:27 - 00:13:03:21
if we don't get this under control,

00:13:03:21 - 00:13:05:29
the use of antibiotics? Yes.

00:13:05:29 - 00:13:07:06
Where, where do we go?

00:13:07:06 - 00:13:08:22
When you have antibiotic

00:13:08:22 - 00:13:09:24
resistant bacteria.

00:13:09:24 - 00:13:10:24
it's been shown

00:13:10:24 - 00:13:13:03
that your risk for hospitalization,

00:13:13:03 - 00:13:13:15
your risk

00:13:13:15 - 00:13:16:15
for sepsis and life threatening infection

00:13:17:07 - 00:13:19:01
and even death is higher.

00:13:19:01 - 00:13:19:23
We know that.

00:13:19:23 - 00:13:21:09
So if you are a carrier

00:13:21:09 - 00:13:21:19
of these

00:13:21:19 - 00:13:23:01
antibiotic resistant organisms,

00:13:23:01 - 00:13:24:07
you're more likely to get infected

00:13:24:07 - 00:13:25:23
and infected more severely.

00:13:25:23 - 00:13:27:03
That's really important.

00:13:27:03 - 00:13:29:12
So if you see a rising population

00:13:29:12 - 00:13:30:05
of antibiotic

00:13:30:05 - 00:13:31:10
resistant antibiotics

00:13:31:10 - 00:13:34:03
and/or we run out of drugs to treat you,

00:13:34:03 - 00:13:35:01
you can see that you're

00:13:35:01 - 00:13:36:17
dealing with an epidemiologically

00:13:36:17 - 00:13:37:28
high risk situation.

00:13:37:28 - 00:13:39:11
So so that puts you then

00:13:39:11 - 00:13:39:19
I mean

00:13:39:19 - 00:13:41:13
because this is what you prescribe.

00:13:41:13 - 00:13:42:07
This is what you do.

00:13:42:07 - 00:13:43:07
You look into this, that

00:13:43:07 - 00:13:43:24
puts you in a bit

00:13:43:24 - 00:13:44:28
of a precarious situation

00:13:44:28 - 00:13:46:12
because you don't want to. Yeah.

00:13:46:12 - 00:13:47:17
You don't want to create the problem

00:13:47:17 - 00:13:48:12
you're trying to fix.

00:13:48:12 - 00:13:49:27
Correct. Is that. So circular.

00:13:49:27 - 00:13:51:24
It's absolutely correct. Yeah, yeah.

00:13:51:24 - 00:13:54:07
That's, that's the conundrum.

00:13:54:07 - 00:13:54:25
Okay.

00:13:54:25 - 00:13:55:19
How do then

00:13:55:19 - 00:13:56:18
what is the research

00:13:56:18 - 00:13:58:06
doing to kind of address this?

00:13:58:06 - 00:13:59:12
Like are you part of this research

00:13:59:12 - 00:13:59:25
and such?

00:13:59:25 - 00:14:00:19
Yes, absolutely.

00:14:00:19 - 00:14:02:15
You know, we just finished a

00:14:03:15 - 00:14:06:15
over seven years four big

00:14:06:17 - 00:14:08:09
randomized controlled trials

00:14:08:09 - 00:14:09:10
looking at the top

00:14:09:10 - 00:14:10:21
four reasons why

00:14:10:21 - 00:14:13:10
physicians prescribe antibiotics

00:14:13:10 - 00:14:15:05
and why patients need

00:14:15:05 - 00:14:16:25
spectrum antibiotics in the hospital:

00:14:16:25 - 00:14:18:22
pneumonia, urinary tract infection,

00:14:18:22 - 00:14:19:18
skin soft tissue

00:14:19:18 - 00:14:21:01
infection, and abdominal affection.

00:14:21:01 - 00:14:21:18
Those are the

00:14:21:18 - 00:14:22:21
top four reasons

00:14:22:21 - 00:14:24:04
for which we prescribe

00:14:24:04 - 00:14:25:09
broad spectrum antibiotics.

00:14:25:09 - 00:14:29:29
We used some modeling to identify high

00:14:30:03 - 00:14:31:19
versus low risk patients,

00:14:31:19 - 00:14:34:05
and intercalated that type of information

00:14:34:05 - 00:14:36:24
into clinical decision support tools.

00:14:36:24 - 00:14:38:03
Basically prompts

00:14:38:03 - 00:14:39:19
that when physicians order

00:14:39:19 - 00:14:41:00
a broad spectrum antibiotic,

00:14:41:00 - 00:14:43:18
we present them with the risk

00:14:43:18 - 00:14:46:15
that a patient has,

00:14:46:15 - 00:14:49:05
is low risk versus high risk

00:14:49:05 - 00:14:51:03
for antibiotic resistance

00:14:51:03 - 00:14:53:28
to help guide their selection towards

00:14:53:28 - 00:14:54:29
standard spectrum

00:14:54:29 - 00:14:56:01
rather than broad spectrum

00:14:56:01 - 00:14:57:12
whenever possible. Yes.

00:14:57:12 - 00:14:59:06
What we found across

00:14:59:06 - 00:15:02:13
four trials, more than 150 hospitals,

00:15:03:00 - 00:15:04:12
almost a million patients,

00:15:04:12 - 00:15:06:13
about 900,000 patients

00:15:06:13 - 00:15:08:13
across multiple states

00:15:08:13 - 00:15:09:18
in the United States.

00:15:09:18 - 00:15:12:07
We've got a nice pool. Nice pool,

00:15:12:07 - 00:15:14:22
and we were able to show

00:15:14:22 - 00:15:16:23
that physicians could select

00:15:16:23 - 00:15:19:27
a standard spectrum antibiotic 17%

00:15:19:27 - 00:15:23:11
to 35% reductions in extended

00:15:23:11 - 00:15:24:11
spectrum antibiotic

00:15:24:11 - 00:15:28:01
use across all of those, those trials.

00:15:28:19 - 00:15:30:15
And they could do this safely

00:15:30:15 - 00:15:32:29
without an untoward safety impact

00:15:32:29 - 00:15:34:07
on patients,

00:15:34:07 - 00:15:35:27
which is the first set of trials

00:15:35:27 - 00:15:38:16
to really... You know, as I mentioned,

00:15:38:16 - 00:15:39:04
uncertainty

00:15:39:04 - 00:15:42:04
is a big part of our decision making.

00:15:42:17 - 00:15:44:01
And what by,

00:15:44:01 - 00:15:45:15
by producing a risk

00:15:45:15 - 00:15:47:09
estimate for physicians

00:15:47:09 - 00:15:50:11
and giving them a supportive guidance

00:15:50:11 - 00:15:51:04
in the moment

00:15:51:04 - 00:15:54:18
that they're ordering, this lowers their

00:15:55:04 - 00:15:55:19
sort of,

00:15:57:05 - 00:15:58:06
tendency

00:15:58:06 - 00:15:59:04
to reach for the

00:15:59:04 - 00:16:00:07
broad spectrum antibiotics

00:16:00:07 - 00:16:02:00
and gives them something useful.

00:16:02:00 - 00:16:03:18
And so, yeah,

00:16:03:18 - 00:16:04:29
we're really excited about this.

00:16:04:29 - 00:16:05:18
The first time...

00:16:05:18 - 00:16:05:24
You know,

00:16:05:24 - 00:16:06:25
as I mentioned, for decades

00:16:06:25 - 00:16:08:05
we've been using broad spectrum

00:16:08:05 - 00:16:09:06
and then narrowing later.

00:16:09:06 - 00:16:11:22
Now what we're saying is,

00:16:11:22 - 00:16:13:27
this set of studies basically

00:16:13:27 - 00:16:14:27
says, actually,

00:16:14:27 - 00:16:16:21
maybe we can, in a subset of low

00:16:16:21 - 00:16:17:25
risk patients,

00:16:17:25 - 00:16:20:04
choose wisely upfront

00:16:20:04 - 00:16:21:23
a more standard spectrum antibiotics,

00:16:21:23 - 00:16:24:28
and then if needed, go ahead and escalate

00:16:24:28 - 00:16:27:09
if you need it. Wow, fascinating stuff.

00:16:27:09 - 00:16:29:11
So like your average person, what do

00:16:29:11 - 00:16:30:13
what do we need to know

00:16:30:13 - 00:16:31:07
that maybe we haven't

00:16:31:07 - 00:16:34:07
touched on in terms of of knowing,

00:16:35:05 - 00:16:36:19
if we're taking our antibiotics,

00:16:36:19 - 00:16:39:19
like safely and wisely as best we can?

00:16:39:23 - 00:16:40:28
First and foremost,

00:16:40:28 - 00:16:42:10
use them only if you need them.

00:16:42:10 - 00:16:43:07
Make sure you have a nice,

00:16:43:07 - 00:16:45:17
healthy conversation with your physician.

00:16:45:17 - 00:16:46:29
You know, is this a virus?

00:16:46:29 - 00:16:48:04
Is this is a bacteria?

00:16:48:04 - 00:16:49:18
And why do I need this treatment?

00:16:49:18 - 00:16:51:21
So that's a that's the first box.

00:16:51:21 - 00:16:52:29
Use them when you need them

00:16:52:29 - 00:16:53:22
and make sure that there's

00:16:53:22 - 00:16:54:23
a good reason why you need them.

00:16:55:28 - 00:16:57:13
And then when you're prescribed an

00:16:57:13 - 00:16:58:18
antibiotic just,

00:16:58:18 - 00:17:00:17
you know, take it as prescribed

00:17:00:17 - 00:17:03:01
and don't, don't save them for later.

00:17:03:01 - 00:17:05:01
Yeah I know I should not, see?

00:17:05:01 - 00:17:06:05
Don't do that.

00:17:06:05 - 00:17:08:25
And complete the course.

00:17:08:25 - 00:17:11:13
And I think those are the top few things. Okay.

00:17:11:13 - 00:17:12:04
So what about like

00:17:12:04 - 00:17:12:25
because I've always heard

00:17:12:25 - 00:17:14:02
and this could be complete nonsense,

00:17:14:02 - 00:17:15:16
but like, if you're taking an antibiotic,

00:17:15:16 - 00:17:17:05
you should also take a probiotic.

00:17:17:05 - 00:17:17:28
Is that true?

00:17:17:28 - 00:17:18:06
Ooh.

00:17:18:06 - 00:17:19:00
I, you know,

00:17:19:00 - 00:17:19:19
there are believers

00:17:19:19 - 00:17:20:16
and there are nonbelievers.

00:17:20:16 - 00:17:21:06
There's data

00:17:21:06 - 00:17:23:25
that just isn't totally clear.

00:17:23:25 - 00:17:24:05
You know,

00:17:24:05 - 00:17:25:06
the way that we like

00:17:25:06 - 00:17:27:09
to see our data, study design.

00:17:27:09 - 00:17:30:09
So, so, so there are small studies, but,

00:17:30:22 - 00:17:32:22
the jury's out in terms

00:17:32:22 - 00:17:35:22
of how helpful probiotics are

00:17:36:01 - 00:17:36:25
in...

00:17:36:25 - 00:17:39:10
But it stands to common sense...

00:17:39:10 - 00:17:42:10
It does. That having healthy bacteria

00:17:42:17 - 00:17:45:16
obliterated by by antibiotics

00:17:45:16 - 00:17:47:02
that you ought to repopulate them.

00:17:47:02 - 00:17:48:24
So I always do recommend

00:17:48:24 - 00:17:51:28
healthful sources of diverse bacteria,

00:17:51:29 - 00:17:53:14
you know, yogurts and

00:17:53:14 - 00:17:55:11
and maybe it doesn't have to be

00:17:55:11 - 00:17:56:17
probiotic pills

00:17:56:17 - 00:17:58:22
if in an immunocompromised host

00:17:58:22 - 00:18:02:16
where maybe even a big dose of probiotics

00:18:02:16 - 00:18:03:11
could be harmful,

00:18:03:11 - 00:18:04:28
you want to talk that over with your

00:18:04:28 - 00:18:07:21
with your primary physician, with your

00:18:07:21 - 00:18:08:13
with your doctor.

00:18:08:13 - 00:18:11:13
But in general, using,

00:18:11:15 - 00:18:14:06
you know, probiotics or healthful foods,

00:18:15:05 - 00:18:15:18
that help

00:18:15:18 - 00:18:16:28
diversify your gut

00:18:16:28 - 00:18:19:17
health is absolutely recommended.

00:18:19:17 - 00:18:20:10
Now, obviously,

00:18:20:10 - 00:18:21:23
I just made the comment

00:18:21:23 - 00:18:23:06
about saving antibiotics for later,

00:18:23:06 - 00:18:24:06
which we don't do anymore.

00:18:24:06 - 00:18:25:18
We don't do that.

00:18:25:18 - 00:18:26:21
Do you find

00:18:26:21 - 00:18:27:21
before we let you go here,

00:18:27:21 - 00:18:30:17
do you find that a lot of people,

00:18:30:17 - 00:18:31:17
kind of think they know

00:18:31:17 - 00:18:32:25
what's best for them

00:18:32:25 - 00:18:34:06
when it comes to this stuff?

00:18:34:06 - 00:18:34:27
Yeah.

00:18:34:27 - 00:18:35:19
You know.

00:18:35:19 - 00:18:37:01
Like, do people just take, like,

00:18:37:01 - 00:18:37:19
they're like, oh,

00:18:37:19 - 00:18:39:03
I feel like I'm getting sick.

00:18:39:03 - 00:18:40:07
I'll just take an antibiotic.

00:18:40:07 - 00:18:41:18
And it's like, hold on. Don't do that.

00:18:41:18 - 00:18:42:27
Yeah, yeah. That's right, that's right.

00:18:42:27 - 00:18:44:03
I think that I think people do

00:18:44:03 - 00:18:44:19
feel that way.

00:18:44:19 - 00:18:45:07
And you know,

00:18:45:07 - 00:18:46:15
there's there's a little bit of work

00:18:46:15 - 00:18:47:12
that we need to do

00:18:47:12 - 00:18:50:11
in terms of as a medical community

00:18:50:11 - 00:18:53:23
and in communicating with our patients.

00:18:53:23 - 00:18:54:17
This is why this

00:18:54:17 - 00:18:56:05
this type of work is so important.

00:18:56:05 - 00:18:56:22
For sure.

00:18:56:22 - 00:18:57:00
Yeah.

00:18:57:00 - 00:19:00:00
And communicating with our patients that,

00:19:00:00 - 00:19:00:09
you know,

00:19:00:09 - 00:19:01:17
they are

00:19:01:17 - 00:19:03:03
the CEOs of their bodies,

00:19:03:03 - 00:19:03:25
so to speak, right? Of course.

00:19:03:25 - 00:19:05:05
They, they know

00:19:05:05 - 00:19:06:21
exactly what their symptoms are.

00:19:06:21 - 00:19:08:27
And and so we need to enable

00:19:08:27 - 00:19:10:17
and empower that on the one hand,

00:19:10:17 - 00:19:12:01
on the other hand,

00:19:12:01 - 00:19:13:18
you know, feed the right information.

00:19:13:18 - 00:19:15:07
And so yeah, you're absolutely right.

00:19:15:07 - 00:19:16:05
They should

00:19:16:05 - 00:19:16:25
I think

00:19:16:25 - 00:19:18:00
knowing your limits

00:19:18:00 - 00:19:19:16
about what your symptoms are

00:19:19:16 - 00:19:20:11
and reporting them

00:19:20:11 - 00:19:21:21
properly to your clinician,

00:19:21:21 - 00:19:22:09
you know, your

00:19:22:09 - 00:19:24:13
your primary doctor can help you

00:19:24:13 - 00:19:25:00
just make sure

00:19:25:00 - 00:19:26:10
that you get the right treatment

00:19:26:10 - 00:19:27:25
because it may be

00:19:27:25 - 00:19:29:15
that you have the right feeling.

00:19:29:15 - 00:19:30:15
You feel better,

00:19:30:15 - 00:19:31:19
but it may not be that

00:19:31:19 - 00:19:34:01
your conclusions about that are correct.

00:19:34:01 - 00:19:34:27
So when you say, let me,

00:19:34:27 - 00:19:36:05
let me challenge something here

00:19:36:05 - 00:19:36:29
and shoot me down.

00:19:36:29 - 00:19:38:28
When you say that, you know,

00:19:38:28 - 00:19:40:17
people are the CEOs of their own bodies.

00:19:40:17 - 00:19:41:10
I would say,

00:19:41:10 - 00:19:42:25
based on what I've learned from you,

00:19:42:25 - 00:19:44:05
that the things going on inside

00:19:44:05 - 00:19:45:23
our bodies are the actual CEO.

00:19:45:23 - 00:19:46:27
We're just the acting... Yes.

00:19:46:27 - 00:19:48:13
We're just pretending to be the CEO.

00:19:48:13 - 00:19:49:29
Yeah, yeah, yeah. Or.

00:19:49:29 - 00:19:51:06
Yeah, that's exactly right.

00:19:51:06 - 00:19:53:15
The CEO should listen. Yeah.

00:19:53:15 - 00:19:54:15
We're like a mascot.

00:19:54:15 - 00:19:55:28
We're not making decisions.

00:19:55:28 - 00:19:57:06
The inside’s making

00:19:57:06 - 00:19:58:19
the choices. The inside is making choices. Really

00:19:58:19 - 00:19:59:06
well said.

00:19:59:06 - 00:20:00:23
Yeah, absolutely. Yeah.

00:20:00:23 - 00:20:02:28
Wonderful. Fascinating. Informative.

00:20:02:28 - 00:20:04:04
Really appreciate your time, Dr. Gohil.

00:20:04:04 - 00:20:05:24
Thank you so much for your time. Yeah.

00:20:05:24 - 00:20:07:07
And thanks for watching and listening.