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Updates on Allergy Prevention, Immunotherapy and Immune Deficiency · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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Welcome to Pediatrics Now, cases, updates, and discussions for the busy practitioner.
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I'm your host, Holly Wayment. I work for UT Health San Antonio's Department of Pediatrics.
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In this podcast, we explore how we can provide the best, most cutting-edge,
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compassionate care for children.
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We hope to give you a unique and behind-the-scenes edge from our expert guests.
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After listening, click on the link on this podcast for free credit that may
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include CME, MOC, or ethics credit, depending on the topic.
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Joining me back on the show today is Dr. Ed Brooks.
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He's Division Chief of Allergy, Immunology, and Infectious Disease at the University
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of Texas Health Science Center at San Antonio.
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He also has 30 years of experience in this field. And Dr.
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Brooks, Brooks, you were on a national panel that set these type of guidelines.
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That's correct. Thank you so much for being back here on the show.
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In the New York Times, it says spring allergy season is getting worse.
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Experts explain how if you have allergies and how to find relief if you do, spring is here.
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And if you're among the estimated one in four adults in the United States who
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suffer from seasonal allergies, your sneezing and scratching may have already
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started. And with climate change affecting temperatures and plant growth,
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you may need to be on the lookout earlier than ever before.
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And they do mention that allergy season is lasting longer, and they do talk about Texas there.
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What do you want to say about these pollen allergies right now?
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Well, unfortunately, you know, San Antonio has been like this for some time.
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So, grass pollens are pretty much year-round.
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We have winter grasses through the
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winter and because we have such mild winters other
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than when we get a really not mild week a very cold week the rest of the time
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you know the weeds and grasses are growing but we mainly get grass pollens and
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of course san antonio unique with the mountain cedar that pollinates in the
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winter that's normal for it
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but there's a lot of research Research showing with increased CO2 levels,
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some plants respond to that by producing more pollen.
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And the warmer, longer growing periods, you know, you're going to get more pollen.
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That's just sort of nature's way, if you will.
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And so it's slow, though. It's not that dramatic, but over decades,
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it may have an effect on the amount of pollens, et cetera.
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The other thing, you know, why do we have so many people with allergies?
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That seems to be a bigger problem with no easy solution in the sense that what
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we call the hygiene hypothesis and the microbiome research that's been done
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as to why we have more allergic disease in general.
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It's because the allergy is not anything
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about the environment change it's about our internal
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environment if you will it's the immune system and
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if we we're too clean that's the bottom
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line you know humans if you
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think about it over the last few hundred years have evolved out of throwing
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the chamber pot out the window you know we lived in a cesspool but that had
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one of those she was was telling us about that she was because of her age and
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the family it was her job on certain days to take out the chamber pot.
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So our avoidance of the outdoors being exposed to the natural environment and
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you know it's not changing you know there's more and more people living in cities
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but and there eventually will be You know, people take probiotics and all of this stuff,
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and there may be some advantages to that and how the diet that we eat.
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But in general, as humans, our immune systems evolved throughout,
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you know, the eons to fight off a lot of microorganisms in the environment.
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And if we're not exposed to those, you know, there's good bugs and bad bugs,
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but we're not exposed to those, our immune system doesn't develop properly.
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And the result is it tends to bias towards this allergic response.
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And so that's not going to change, probably. But, you know, I tell people,
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go to the park and roll the kid in the dirt.
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We ate mud pies when I was little, and it turns out that may not be such a terrible thing.
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My favorite study that I quote, and really,
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you know, people have studied the effect of animals and it's,
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I mean, dogs and even cats in some studies early in life has a protective effect
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on children having allergies.
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And the reason for that is they're dirty. You know, as one scientist said, they don't wipe.
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So those microorganisms turn out to be beneficial.
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And they did a study with, dogs and frequent colds in children and,
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The basis is the same. If the immune system doesn't develop properly,
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you may have more colds and develop allergy.
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And that's why when the babies constantly have a runny nose,
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people say, oh, it's their allergies. No, it's an infection, but it's the same basis.
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The immune system is biased.
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But the children that, you know, raised with dogs have less of those colds.
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And they went one step further.
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They said, is it indoor dogs, outdoor dogs or the dogs that go in and out?
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And the answer is the dogs that go in and out.
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Exactly. Yeah. And so the theory is that they're bringing in the natural environment
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that people can develop, you know, a better immune system. So,
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on the one hand, these microorganisms, some of them are bad and kill us.
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Most of them are pretty good. And it's a delicate balance between you don't
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want your child outside eating dog poop that has worms,
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but at the same time, you do want them exposed to the natural environment and
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those dirt bugs, if you will, and helping to develop their immune system.
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Them so my daughters and i go ride horses
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about once a week in wolverde and there's got
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to be some dirt involved there yeah yeah well
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i mean humans have evolved with their farm animals for god knows how many thousands
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of years and so we've co-evolved and so our museums are very well adapted to
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that and and we sort of removed a lot of that natural environment or you know
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farm environment from our exposures.
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And so, unfortunately, the adjustment is we have more, all of a sudden,
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our immune system seem to recognize anal dander or pollens as enemies and try to fight it.
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And so, it's just an abnormal immune response.
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And the same goes for certain viruses. We don't seem to fight off certain viruses
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as aggressively or as efficiently sufficiently,
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as we would if we were living in a dirtier environment, if you will.
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So are you talking about like cold viruses or? Yeah, common colds.
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Yeah, so when a child has an exacerbation, ends up in the hospital,
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I guarantee it's a virus.
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It's not because of allergies. Allergies can cause anaphylaxis,
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you know, a true allergic reaction like a food anaphylaxis
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or a pet anaphylaxis less common
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but and in the most common virus is called rhinovirus and the younger children
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get something called RSV the respiratory and sexual virus and there's other
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so do it parent influenza virus and metanuma virus but not the corona viruses,
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You know, the common cold coronaviruses that everybody knows about now,
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we know about coronavirus, actually play a role in exacerbations of childhood arthritis.
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A little bit different disease, but similar pathway.
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The coronavirus does? Mm-hmm. I did not know that.
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And isn't childhood arthritis, while still rare, it's on the rise?
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It is on the rise, and probably from some early studies, similar findings that
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their intestinal microbiome is less diverse.
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So the more diversity you have, diversity is a good thing.
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The more diverse you are, the less likely you are to develop allergic disease.
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And that same theory is starting to come out in juvenile arthritis as well.
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Well, and you see your immune dysregulation, both of them are diseases of immune dysregulation.
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And I know you see patients for that condition as well.
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Is this also another case for, say, getting that hamster or guinea pig that
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your child is begging for?
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Yeah, I would say yes.
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Obviously, once you're sensitized, like you have an allergy to mice,
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Obviously, you're better not having a guinea pig in the house or playing with the mice.
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But prior to that, so the vulnerable period appears to be early life.
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Early life exposure seemed to predict these things.
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So in the first three years of life,
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being exposed to pets and the natural environment seems to be beneficial.
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And you think about it, what's the most sterile period of a baby's life that first year?
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Right. And of my three children, my son is the only one where we didn't have
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a dog when he was a baby, and he's the only one who has allergies.
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And I'm one. Yeah. But do you recommend in general, though, for all of us,
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for our health, pets are good for us?
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If you like animals, they are good for us. Yeah, absolutely.
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I'm a good pet lover. I think so.
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So our immune systems, you know, again, I think in evolution,
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we evolved with our dogs and our pets and our farm animals.
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And I think our immune systems are somehow in sync with those animals.
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And you also recommend using the least amount of soap as possible,
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only as necessary, right?
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Right. Yeah. I mean, the mom running around with the sterile wipes and wiping
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everything the baby touches is probably overdoing it.
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And there's a series of nice studies that the first child born is the one most
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likely to develop allergies.
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But the more children in a sib ship, they tend to have less and less allergy.
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And think about it, you know, after you've got a house full of kids, it ain't clean. Right.
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The first kid, you know, new parents are really anxious and,
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you know, washing the binky off every time it hits the floor.
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And then after a while, you're like, let's stick it back in their mouth and don't worry about it.
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So, I think we're a little. Now, I've also done a lot of toxicology research
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and I worry about the chemicals we bring into our homes. And so I tell parents,
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don't use all the strong Mr.
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Clean and all that stuff on your floor because where's that baby?
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Down on the floor. Kids are down where our feet are. And some cultures,
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you know, take their shoes off when they come in the house.
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Americans don't. So whatever poisons and toxins people have sprayed all over
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your work, we just walk right in the house and spread it around.
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So I think there's some potential risk there. They're not good studies to point
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to that directly, but use of pesticides and herbicides in some studies have
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shown to increase the risk for development of allergic disease.
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So in your home, do you recommend taking off your shoes before entering and
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a certain type of floor cleaner? Yeah, water.
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Yeah, just keep it plain water if possible. Yeah, plain water is fine,
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but if you'd have to use a cleaner, then, you know, if you're If you're cutting
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up raw chicken, you do want to use some disinfectants on the surfaces.
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You don't want to spread salmonella around.
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But in a lot of other situations, you know, I have yet to see a child that got sick from a dirty dish.
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But, you know, if you ask my wife, you know, she rewashes dishes because she
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can see it. See, I didn't do a good job.
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But I think in general, there's very low risk issues.
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Dirt so to speak in our environments and
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what we consider dirty is actually
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somewhat beneficial right if you take
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and i tell them don't use pesticides and herbicides in
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the house because guess what that's going to make it inside the house and children
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get exposed to that children are more vulnerable you know at a certain age they
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stick everything in their mouth right right and you know we're always reprimanding
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them but in a way And there hasn't been any good research on this,
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but a child sampling the world with their mouth may be an evolutionary way of
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getting used to the natural environment because the immune system has to learn
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what's normal so they can distinguish between that and a real threat,
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an infection that's going to kill them.
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Most of the bacteria and fungi
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things that are in our gut and they're in the
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environment and they're harmless and actually help shape
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the immune system it's just a delicate balance now because we've got lead in
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the soil from old lead-based paint we've got all kinds of junk we spray in our
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yards and then out there in the world you know there's no controls on the chemicals
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people use for cleaning.
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I've had several patients have severe asthma exacerbations after going into
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a restroom where they just cleaned.
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So toilet bowl cleaners and things like that. A lot of these chemicals can trigger
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a severe asthma exacerbation.
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And so do you recommend though, if people feel comfortable doing so,
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take off shoes before you enter a house?
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I think that's a reasonable, but it's cultural. It's hard to tell people that, right?
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Right. Yeah. It's a cultural thing. And I just think the shoes you've worn all over the street and,
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you know, where cars are and all the oils and chemicals that people are using
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to heal weeds in the sidewalks and spraying pesticides everywhere,
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you bring traces of that into your home.
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So I think it's reasonable not to wear your street shoes all around your home,
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but it's a cultural thing.
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That's great advice though. And Dr. Brooks, do you, for our pediatric practitioner
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listeners, do you have any advice about the pollen allergies in particular now?
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Is there anything new or the top three things to be saying to patients to help them?
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Once you develop sensitization, it's hard to manage it.
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You know, parents ask me, well, asthma in general gets better in teen years
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and naturally it comes back when you're older but in childhood you know teenagers
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have fewer problems in general.
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Eczema tends to get better, you know, start off in early childhood and then
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tends to improve after a few years, naturally.
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Allergies tend to come and stay. They don't tend to go. And the more you get,
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the more you're going to get.
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So what I mean by that is children may start out with typically indoor allergens
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like dust mite. That's the most common.
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Over time, they start to develop pollen sensitivities.
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So there are some, you know, I wish it was FDA approved therapy,
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but the sublingual, you know, the allergy drops have been, you know,
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allergies been doing hundreds of years are effective and, you know, shots work very well.
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But how many babies you want to put on shots?
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It's pretty harsh. so there's these
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new sublingual tablets that one
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is a grass tablet and one's a ragweed and those are approved down
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to five and the dust mite
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tablet is now approved well it's just approved at 12 they say they're going
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to go down lower but i think those are really good therapies and if you treat
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with immunotherapy early on the likelihood of them continuing to advance their
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allergies is much lower.
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So it helps the asthma. It helps their allergies. It reduces the progression of allergy.
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You know, you heard a lot of people who say, oh, yeah, they test me.
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I'm allergic to everything.
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Well, children can only be allergic to a few things.
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And if you treat that early on, it's less likely to progress to I'm allergic to everything.
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Early intervention. So ideally, we'd be giving very young infants sublingual
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therapy. It's just not insurance won't pay for it.
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And that's sort of the allergy drops. It's the same thing we give in shots.
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And I've used them in patients effective.
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And but it's not FDA approved. Insurance won't pay for it. And so it's all out
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of pocket. And these allergy extracts are quite expensive.
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And as one CEO of an allergy company said, we're just providing what people
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didn't get when they were children.
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In other words, exposure to the natural environment, natural desensitization,
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teaching the immune system that pollens are okay and dog dander is okay.
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Something to be said for that. So treating it early with immunotherapy is very effective.
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It's just pragmatically difficult. Either you go in frequently for allergy shots,
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or if you have the money, you pay for the drops,
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and hopefully they'll develop more of these sublingual tablets where we can
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treat young children early on and nip it in the bud, so to speak.
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So, for example, and before we wrap up, so for my son who has pollen,
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the oak pollen allergies, and it's pretty specific, but are the shots more effective
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than the sublingual drops?
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We have less experience with the sublingual, and that's just the nature of the
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industry and the fact that it's not FDA approved, so we don't get big studies.
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I treated my son with the drop, and he had severe cat allergy and mountain cedar,
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and now he doesn't have either. He's got a cat, in fact.
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Nice. And some people ask me, well, once you have cat allergies,
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is it better or worse to have cats?
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And so I quote a study in which they studied people who had lots of cats.
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I call them weird cat people, you know, with too many cats.
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And they studied their blood.
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And we do testing. It's the IgE.
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And that's all we have available really commercially. There's no other good tests available.
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Research-wise, we can measure a lot of different factors that point towards
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benefit or what we call the protective immune response.
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In other words, when I put someone on allergy shots, it may take several years
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before that allergy test, that skin test, goes away. way.
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But if I could take their blood to the laboratory, I could show a lot of other immune factors.
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And one of them we call blocking antibodies.
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So after exposure to these things, the immune system develops blocking antibodies,
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and those block the immune response to allergies.
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And they studied these weird cat people, and they hadn't been on shots,
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but their blood Blood factors look as if they've been on allergy shots.
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The same with beekeepers who get stung all the time.
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They have these protective factors, so they don't develop allergy because they
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get stung all the time. It's like getting allergy shots.
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Wow. But so far in the case of my son, Liam, though, so he could take the sublingual
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drops because he's been asking me about, do I really need shots for the oak pollen?
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Right, right. Every kid has the same response. and yes he could and ut is a
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little cumbersome and private practice a lot easier but i have to get approval
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for each patient that wants to go on sublingual drops and we basically charge,
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the cost of the extract in other words you know whatever we buy the extracts
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for it's not inexpensive now oak is not bad cat's very expensive so people with
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cat allergy you know Now,
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it's hard to do because I'd be paying like 200 bucks a month just for their drops.
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Because with sublingual, you have to go much higher on the dose,
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much higher before you get the benefit.
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The shots are cheaper in that context because you use much less of the extract.
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But the drops, you've got to use a lot of it.
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It's also sort of a, it's not standardized. The studies that have been done, which are not that many,
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use standardized, they measure like the major proteins in there and then they
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equate the dosing with that. Well, I don't know what that is in most extracts.
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I don't have that. They don't provide that information.
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They're what we call non-standardized. It's just take a bunch of pollen and
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extract it and it's a ballpark.
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You know so we have to be very careful with shots because it could vary in potency,
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but the drops are safer you do
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have to do them every day but uh
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but they work and the shots can vary in potency or the drops or both oh okay
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yeah that's why we have to be very careful with giving shots because when we're
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desensitizing people can we're giving what you're allergic to and they can have
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a full-blown anaphylactic reaction to the injection.
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So we have to be very careful and slowly build it up.
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Immune deficiency, that's a whole other topic. Immune deficiency are those like
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the bubble boy, you know, that have too many infections, too many pneumonias,
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have an immune defect in there.
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And so they're the kids that catch everything, end up on antibiotics constantly,
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and may need to go on gamma globulin replacement therapy.
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You know, the treatments are pretty straightforward, but how to recognize those
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patients and get them to us so we can evaluate them is important, I think. it.
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And that's a big thing I get, you know, so many pediatricians,
23:48
pediatric practitioners, so much is coming at them.
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And the worry is, of course, not to miss anything.
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So how would you know if a child would need to see you for this?
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What would be the top warning signs? I would say.
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Need for antibiotics more than like five or six times a year.
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You know, that's a real red flag.
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Pneumonias in children. And then there's an old saying that any child with a
24:16
severe infection ends up in the hospital with some terrible infection,
24:21
deserves an immune evaluation.
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But usually it's the kid with, you know, constant runny nose, et cetera.
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And I think pediatricians are pretty good at this. They recognize,
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okay, the first time they go to daycare or first year of school,
24:40
let's say they've kept it home and they really don't have any exposure,
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haven't caught anything.
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And then all of a sudden they go to school and they're sick as dogs.
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That's probably normal. You know, they go through a period and how sick are they?
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They have a constant running. I was, well, that's natural for kids.
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They're going to catch all those colds. They're going to be sick all the time.
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And so I'll give you an example. After the shutdown, you know,
25:08
during the shutdown, nobody caught anything.
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Right. They're all at home. Very few other colds and viruses going around.
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We're all afraid of COVID.
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And then after when the schools forced everyone back to school after a year
25:22
and a half, that fall was a bad fall. all, there was headlines about rhinovirus
25:28
and RSV and all these terrible viruses.
25:31
Well, these are the same virus that had been around. They hadn't changed.
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What had changed is exposure.
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Nobody had been exposed to these viruses for a year and a half,
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and their immunity probably had waned.
25:44
And all of a sudden, they're getting sick again.
25:46
And a lot of people sent their kids, a lot of pediatricians sent their kids to me and Dr.
25:52
Infante, and we studied their immune system, another fine.
25:56
And this was just a phenomenon of exposure. So it's a combination,
26:00
you know, in diagnosing these diseases. It's a combination of exposure.
26:05
I've had kids who are very immune deficient and never got sick.
26:08
Why? Because they kept them in a bubble.
26:11
You know, they weren't exposed to the common cold. They weren't in general school.
26:15
There's a lot of more online school and homeschooling going on.
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So all that becomes very important in understanding whether this is normal.
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And they got a lot of colds and they're getting over them on their own. So that's important.
26:27
You know, you get a cold and you recover after a week or you get a cold and
26:32
every single time you get a cold,
26:34
you end up on antibiotics because you got a bad sinus infection or ears or,
26:39
you know, ear infections and particularly pneumonias.
26:42
Those more severe infections really catch our attention because it's not normal.
26:50
And then if a child is found to be immune deficient, what do you do then?
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And what's the treatment?
26:56
Well, it depends on the types of infections. And the more common immune deficiencies
27:02
are antibody deficiencies.
27:04
So, you know, we're not making enough good antibodies.
27:08
So the easy thing that we do is we put them on preventive antibiotics.
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It's sort of a weaker antibiotic, and we give it at a lower dose a few times a week.
27:19
And it works really well at preventing those viruses from turning into a bacterial infection.
27:25
I tell all my quote allergy patients to stop their antihistamines.
27:31
Because why? Well, because you want that stuff to drain out if you have an infection.
27:38
Again, I think there's a bias in our community. Every time their nose runs, it's allergy.
27:44
Right. They're treated with allergy. And the doctors are sort of,
27:47
well, they take over the counter medications, or the doctors put them on an
27:51
antihistamate, even the very young children.
27:55
And I'm sort of against regular antihistamates. It's okay to take one here and
27:59
there for itchy, sneezy. That's what they're good for.
28:01
And even if you have a bad cold, a Benadryl at night will help you sleep.
28:07
But taking them regularly every day or
28:11
even for colds i think is
28:14
counterproductive it makes it look good on the outside but
28:17
it doesn't really it doesn't really help you get over it is dr
28:21
is immunodeficiency on the
28:24
rise or are you saying it we just need to
28:26
be more conscious of it so we can identify these children
28:30
and they can get the care they need right i
28:33
think because of the genetic revolution we're
28:38
able to identify so there was there's a condition called common variable immune
28:43
deficiency it's very common quite variable it's sort of that waste basket we
28:50
we don't know what they have so we call it common variable but it really involves antibody deficiency,
28:56
by definition but when i was in training you know i was trained oh these don't
29:02
show up until until they're adults.
29:04
You get a young adult with two or three pneumonias in a year,
29:07
then they've got probably an antibody deficiency.
29:12
But we always knew that there was sort of variability in children.
29:18
It's like you have the kid that gets sick with every virus, right?
29:24
And I remember an old publication that said, oh, it's normal to have up to 13
29:29
infections a year. Well, they're constantly infected.
29:33
I think we're recognizing now that some of those children do have an immune deficiency.
29:38
It's not a dramatic one. And some of those kids go on in later life and develop
29:43
a full-blown immune deficiency.
29:45
Then we genetically test them, and we can identify some of these immune deficiencies
29:50
that are sort of not obvious.
29:53
It's not like the bubble boy where they have severe infections,
29:55
have to get a bone marrow transplant. That's the most dramatic, right?
29:58
They have no immune system. system, but these more subtle immune deficiencies,
30:05
I think we're recognizing more frequently and putting a name on it instead of
30:10
like, yeah, your kid has too many infections. I don't know what to do about it.
30:13
And most of them don't need to go on gamma globulin replacement or anything dramatic.
30:20
We may use a preventive antibiotic and that gets them through these vulnerable years.
30:25
And then they tend to go through a period where they're healthy,
30:28
but I see adults anywhere from from their 20s up until their 70s having immune
30:34
deficiency and then I do the genetics and like yeah you've got a gene marker
30:39
that probably and some other testing we can do more sophisticated testing in
30:43
the immune system we're recognizing that there are some sort of.
30:48
Abnormalities and they don't they have always been there it just didn't manifest
30:52
as an obvious immune deficiency so i don't think it's necessarily on the rise
30:57
this concept of remember i told you the story about the children had fewer colds
31:03
if they had dogs i think it's coupled with,
31:06
environmental influences that can
31:09
predispose to an immune system that's not is not is not well-developed and most
31:17
of the kids kind of grow out of it you know i studied was like well it's a little
31:20
off but it's not too bad let's just see what happens and then eventually they
31:25
get better and they stop having the frequent colds and i don't know if that's a developmental issue,
31:30
with again for the same reason that hygiene hypothesis we're not exposed to enough,
31:35
microorganisms to help build the immune system or whether there's something
31:39
underneath it that It really predisposes them to having infections.
31:43
I think you can have some of these genetic factors that may not ever manifest
31:49
depending on environmental factors.
31:52
And then, of course, back in the day, people died of smallpox, for instance.
32:02
And I remember studying a family. family, the kid that we identified initially
32:07
had a really severe chicken pox, and in Texas, these people said, this is unusual.
32:14
Anyway, we ended up studying the family that had an immune deficiency.
32:20
Back in the day, you know, a bunch of the kids died from smallpox,
32:24
you know, so bad infections can reveal, you know, where some people survive and others don't.
32:30
And you think about it evolutionarily, when the Europeans came to the U.S.,
32:35
a lot of the Native Americans died from smallpox.
32:38
Well, they had never seen that infection before. Did they have an immune deficiency?
32:42
Well, yeah. I mean, everyone who died from COVID, did they have immune deficiency?
32:47
No. No, but, you know, so there's just some bad infections out there.
32:52
And part of that could be, you know, exposure. You know, our evolution, we've never seen that.
32:58
Or there's new emerging bad bugs that are coming out that can kill even normal people.
33:04
And then there's differences in our immune system that might predispose to having
33:09
a bad infection from a certain type of bugs.
33:12
Drugs so i think our recognition of immune
33:15
variability probably a better
33:18
way to say it in individuals is has
33:21
gotten better so i wouldn't say it's necessarily on the rise
33:24
but we certainly recognize the
33:28
kid that has 13 infections a year
33:31
in that old study i would think i would study him i would do genetics on that
33:36
patient and find out what it is that gives him 13 infections and after that
33:40
first year of school or daycare if they continue to have their current infections
33:44
that's a red flag that's a flag that okay there's something going on you,
33:50
and that child should see an an allergist or immunologist yeah all allergists
33:55
have immunology training so they you know all allergists in town should be able to uh,
33:59
evaluate them if they turn out to have something really bad they usually send them to me and tony.
34:05
But they're not as sophisticated doing the genetic studies and some of these more advanced studies.
34:11
And, of course, getting them on the right medications, the gamma globular replacement
34:16
is sometimes difficult, given the insurance issues.
34:21
And sometimes I think they refer them to us because they don't want to deal
34:24
with the insurance company.
34:28
Well, and, of course, we're talking about Anthony Infante. Yes. Dr. Infante.
34:31
Music.
34:39
Well, Dr. Ed Brooks with the University of Texas Health Science Center,
34:43
thank you so much for being here back on the show on Pediatrics Now. Thank you so much.
34:49
Let's talk about pediatric arthritis down the road. Sure. I'd love to do an interview on that.
34:58
Yeah, I'd be happy to. That'd be fun. Okay. Well, thank you,
35:02
Dr. Ed Brooks. books. I appreciate you being here on Pediatrics Now.
35:06
All right. You take care. Okay. Bye-bye.
35:09
Music.
35:15
We hope you've enjoyed this episode of Pediatrics Now. Click on the link for
35:19
free credit if you're a practitioner.
35:22
I'm Holly Wayment. I hope you can join us for our next episode.