Posts for category: Gastroenterology
We’re right in the middle of the holiday season, and while that has some celebrating “the most wonderful time of the year”, it’s leaving others suffering in silence due to a digestive disease called GERD. So, before you attend that next holiday party or family gathering filled with delicious appetizers, drinks, and full course meals, make sure you understand this disease and how to keep it from impacting and even ruining the rest of your holiday season.
What is GERD?
GERD, or Gastroesophageal Reflux Disease, is a common problem in America, impacting around 20% of the population. To put that into perspective, 60 million Americans report 2 or more incidents of GERD each month. GERD is characterized by symptoms and/or tissue damage that results from repeated or prolonged exposure of the lining of the esophagus to acidic contents coming back up from the stomach. This occurs when the lower esophageal sphincter (the circular muscle at the bottom of the esophagus that allows food and drink to enter into the stomach) becomes weakened or relaxes too much, allowing the contents to leak backward and into the esophagus. The contents from the stomach begin eating away at the tissue in the esophagus, ultimately leading to severe chest pain (heartburn), throat ulcers, scar tissue accumulation, or in severe and more rare cases cancer.
What are the Symptoms of GERD?
There are many symptoms of GERD, but the two most frequent are heartburn and acid regurgitation. Statistics show that 60 million Americans suffer from heartburn at least once a month. Other symptoms of GERD include:
- Chronic Cough
- Chest pain
- Difficulty swallowing
- Bad breath or a bitter acidic taste in the mouth
- Dental Erosion
When Should I Consult My Doctor?
Unfortunately, too many people who are suffering from GERD don’t seek the medical attention they need. In reality, anyone who is experiencing any of the symptoms of GERD regularly or for a prolonged period of time needs to schedule an appointment and consult a physician. They will be able to diagnose your condition - whether it is GERD or not - and help you get the treatment you need. If you are experiencing severe chest pains and aren’t sure if heartburn is the issue, you need to seek medical attention immediately - as heartburn and heart attacks can be difficult to tell apart. With heart attacks, severe chest pains are usually accompanied with shortness of breath and even pain in the jaw or arm. However, symptoms can vary for each individual, and emergency help should be sought when experiencing chest pains to any degree.
How Do I Treat GERD?
Thankfully, GERD is a treatable disease, as there are certain things people struggling with GERD can do to help mitigate or stop the suffering. Certain lifestyle changes can provide relief for GERD sufferers. Losing weight, ceasing smoking and limiting alcohol consumption are key changes.
Steering clear or minimizing certain foods that trigger increase acid production like peppermints, chocolates, spicy foods, citrus , or caffeinated beverages can provide the relief many seek.
Some experience discomfort when they eat too much or when they lie down after eating. In fact, some have reported cases of waking up randomly in the middle of the night and gagging, believing they are about to vomit. This sensation occurs because the acid is leaking and creeping back up into the throat in a significant enough way that it causes one to awaken rapidly. After eating, try to stay upright and allow the food to settle in the stomach. In addition, adjusting and increasing the time between dinner and bedtime gives the stomach more time to digest the food before lying down. Shoot for at least a couple hours between eating and laying down if you can.
Unfortunately, changing aspects of one’s lifestyle doesn’t always do the trick when it comes to finding relief from GERD. In more severe cases, over the counter and/or prescription medications can be extremely helpful. These medications include proton pump inhibitors, H2 receptor blockers, and antacids. There are other medications your doctor may prescribe to counteract stomach acid or help the stomach empty faster. If diet changes and medicine don’t prove effective, your doctor may recommend further testing. If medications and lifestyle changes are not effective, surgical options may be considered.
If you have questions about GERD or are experiencing some of the symptoms, please schedule a visit with us quickly so we can help you find the relief you deserve!
Everyone gets sick or feels run down once in a while. Maybe you’re feeling fatigued with no real explanation for a week, or you’ve had a couple of bouts of indigestion, diarrhea, or constipation. Those things alone may be signs that you’re a little stressed, or maybe you have a viral infection that needs to run its course. Or, these may be signs of digestive problems that could be indicative of a deeper digestive issue. Read on to learn a little bit more about different types of digestive symptoms, what you should look out for, and when it warrants a call to a GI specialist for evaluation.
Signs and Symptoms of Digestive Issues
Most insurance companies have a certain protocol that they follow, and most often, the first appointment patients will make is with their primary care physician, unless they are already under the care of a gastroenterologist and are experiencing new or changing symptoms. If you experience one instance of gas, constipation, or diarrhea, most likely, you aren’t going to give your PCP a call. But if these conditions persist you should give your primary healthcare provider a call. Be on the lookout for new digestive symptoms such as:
- Persistent gas
- Trouble swallowing
- Persistent fatigue or lethargy
If you’re experiencing one or more of these symptoms persist, it may be indicative of some type of digestive problem. Some GI and digestive problems are more “quality of life” issues, where symptoms affect comfort more than anything else, while others can be more serious.
If you notice blood in your stool or wonder about hemorrhoids, you discuss it with your primary physician. Rectal bleeding can be a byproduct of hemorrhoids, or it can be a symptom of other GI disturbances, but it certainly warrants a thorough workup. Similarly, hemorrhoids should also be evaluated and treated. They are not a life-threatening or severe condition, but they can certainly affect the quality of life and can be painful. Some hemorrhoids are internal and are located on the inside of the rectum. These can be removed via colonoscopy or through other methods. Others may need surgical intervention.
Signs and Symptoms You Notice Over Time
Of course, everyone notices a bout of diarrhea or heartburn that lasts a few days, but there are other, more benign signs and symptoms of GI problems that you may not notice over a week’s - or even a month’s - time.
One sign to look for is that your jeans are suddenly too tight. It’s not like you’ve suddenly put on weight, or you’ve gone off your diet. However, jeans that maybe fit three weeks ago are now a little bit snug, and it’s noticeable. This can be because you’re bloated. Bloating can be the result of many different things - from overeating at a few sittings to lactose intolerance, but it can also be from gastroesophageal reflux disease (GERD), irritable bowel syndrome (IBS), constipation, gallstones, or other GI problems. If you find that your jeans are too tight, and you’re also experiencing heartburn and other GI disturbances, let your doctor know.
On the flip side, if your pants are suddenly too loose and you’re not trying to diet or lose weight, there may also be a problem. Unexplained weight loss could be a sign of an underlying GI problem. If you notice that you’re shedding pounds unexpectedly, it’s time to see your physician.
If your stools are black, tarry stools. It can be a sign of one or more GI problems, so see your doc f you notice these.
Everyone passes gas, but if you notice that your gas is particularly smelly and persistent, this may be a sign of an intestinal issue. Also, unusual amounts of gas paired with other symptoms, such as abdominal pain, changes in bowel habits, or unexplained weight loss are all reasons to see a GI specialist or your PCP.
If you experience trouble swallowing beyond something of a cold or viral infection (such as swollen lymph nodes), let your doctor know. If it feels like there is a “lump” in your throat and it’s painful to swallow food and liquid, this may be a sign of trouble with your esophagus. If trouble swallowing is also paired with coughing and hiccupping, see your PCP or GI specialist as soon as possible.
Common GI Problems
A GI specialist treats a wide array of disorders and problems. Patients may worry that by going to see a specialist that there may be something seriously wrong with them, but that is often not the case. Very often, a GI specialist will want to treat the motility of the GI tract (its ability to keep moving), and the treatment will be changing diet or exercise habits. This may include excluding dairy, adding more fiber to the diet, exercising more, or avoiding certain medications.
GI doctors also treat common, everyday conditions such as diarrhea, constipation, and heartburn.
Irritable bowel syndrome (IBS) is a common problem treated by GI specialists. The primary treatment for IBS includes avoiding certain foods or practices that trigger the irritation of the colon (such as caffeine). IBS, while not a life-threatening disorder, can be a significant condition quality of life issue.
GI specialists also treat inflammatory bowel diseases (IBD), such as ulcerative colitis and Crohn’s disease. Inflammatory bowel disease involves inflammation and damage to the tissue and lining of the colon. Left untreated IBD can result in significant and lasting damage.
Gastroenterologists also treat diseases of the liver, pancreas, and esophagus, treat anal disorders such as anal fissures and hemorrhoids, treat cancer such as colon cancer, and manage any disease or disorder that is part of the digestive system.
If you need more information about digestive disorders or need to be seen by a GI specialist, request an appointment with GI Associates today. We have five separate office locations in north and central Wisconsin.
This is the perfect time to reevaluate what you’re doing for your own health.
The holiday season is upon us and this usually means spending time with family and friends over generous helpings of foods. Of course, not all those foods are the best for your health. As we come up to the New Year, many patients make a resolution to be healthier. From the office of our Wausau, WI, gastroenterologists, here are some tips to keep your GI tract healthy in the New Year.
Eat Healthier for a Healthier You
The holiday season is a time for delicious foods and yet a lot of the foods we love can also lead to heartburn, indigestion and constipation. It’s important to know what triggers these symptoms so that you can avoid these foods whenever possible. Aim to include fruits and vegetables, lean meats, low-fat dairy and whole grains into your diet while avoiding processed foods. Incorporate fiber into your diet and limit both caffeine and alcohol, which can cause digestive issues.
Manage Overeating and Bad Habits
We know how tempting it can be to reach for another helping of mashed potatoes or to grab another slice of pumpkin pie; however, if you find yourself feeling guilty about how much you’re eating this holiday season then here are some quick tips to allow you to enjoy delicious holiday foods without the guilt.
- Pace yourself and set your fork down between bites. By slowing down you can control just how much you eat and allow your body time to let you know that it’s done. You can still enjoy the foods you love, just in moderation.
- If you’re still hungry after a meal, drink a glass of water and wait 10-15 minute to see if the pangs go away.
- Stress can also wreak havoc on our ability to manage bad eating habits, so make sure to carve out some time in between carving that turkey to unwind and relax.
- Practice mindful eating, which means turning off distractions and focusing on eating. Eating while working or multitasking can lead to consuming hundreds of extra calories.
Decide to Lose that Weight
Getting fit is a resolution for many and adding regular physical activity to your week is important for a healthy digestive system. In fact, something as simple as a 30-minute walk each day can prevent bloating and constipation. Getting regular exercise can also reduce your risk for colon cancer. Those who are overweight or obese are at a greater risk for developing with diabetes, fatty liver disease and other GI problems.
Schedule a Colonoscopy
Okay, so perhaps this isn’t something you’ve put on your wish list this holiday season but a colonoscopy is the best way to detect polyps and colorectal cancer, and both men and women should start getting screened by the time they reach 50 years old. If you are turning 50 this year then it’s time to schedule a colonoscopy with our Wausau, WI, GI doctor.
If you want to start out the New Year with good digestive health then the team at GI Associates in Wausau, WI, can provide you with the advice and treatment you need to handle any issues you might be having. Call us today to schedule an appointment.
Are you experiencing periodic pain, itching or have blood when you wipe after a bowel movement? If so, you could have hemorrhoids. Hemorrhoids are a condition resulting from swelling and distention in the veins of the anus and rectum. Hemorrhoids are one of the most common causes of rectal bleeding, and the condition isn’t considered serious or life-threatening. In fact, some cases of hemorrhoid may clear up on their own within a few weeks. Of course, if you are noticing any blood in your stool it’s important that you contact your physician to evaluate the cause of your bleeding.
Hemorrhoids may be either internal or external. Internal hemorrhoids are inside the rectum. Often times the only symptom of internal hemorrhoids is bright red blood when wiping after a bowel movement. Itching and mild discomfort are also frequent. External hemorrhoids are usually more painful because they are found around the anus rather than inside the rectum. Besides pain, these hemorrhoids can also cause bleeding.
What causes hemorrhoids?
Straining during a bowel movement, standing or sitting for long periods of time, or having constipation or diarrhea can also bring on hemorrhoids.
Excess pressure placed on the rectum can increase your chances for hemorrhoids. This might be the case if you are overweight, or are pregnant.
Genetics can play in role in whether or not you develop hemorrhoids; therefore, if a family member deals with them then you are more likely to deal with them, too.
Can you prevent hemorrhoids?
There are certain habits you can adopt to reduce your chances of getting hemorrhoids. This includes:
- Getting enough fiber every day
- Drinking water
- Getting regular exercise
If you are prone to hemorrhoids, then talk to your doctor about ways to change your diet or lifestyle to reduce your risk.
How are hemorrhoids treated?
Most of the time you can alleviate your symptoms and treat hemorrhoids with simple at-home measures such as:
- Incorporating more fiber into your diet
- Using a short course of over-the-counter hemorrhoid cream (topical steroids)
- Soaking in warm water (sitz bath)
- Avoiding dry toilet paper
- Applying a cold compress to the area
- Taking over-the-counter pain relievers
Most people will see hemorrhoid symptoms disappear in about a week. If you are still experiencing symptoms after a week or if you are experiencing severe symptoms, then you need to contact your care provider to discuss options. For internal hemorrhoids, a team of GI Associates gastroenterologists offers the CHR O’Regan treatment system. Performed in the office, this minimally invasive procedure requires no prep and no sedation and patients return to work the same day.
Symptomatic external hemorrhoids may require surgery to remove the veins causing the symptoms. If you have been diagnosed or are suspicious of underlying internal hemorrhoids give GI Associates in Wausau, WI, a call. We would be happy to schedule an evaluation for you.
Have you or someone you know been diagnosed with Colitis? If so, you may be trying to get answers about this inflammatory gastrointestinal condition, what causes it, its symptoms and how it's best treated. Our Wausau, WI, gastroenterologists have you covered. Here’s what you should know about this intestinal disorder:
What is Colitis?
This condition causes inflammation and sometimes ulcers within the colon and rectum. There are several different kinds of colitis such as infectious, ischemic, ulcerative, microscopic and medication-induced.
What are the symptoms of colitis?
The most common symptoms of colitis are chronic diarrhea and a persistent urge to have a bowel movement. It’s common for there to be blood in the stool when you have ulcerative colitis. Along with diarrhea, you may also experience weight loss, abdominal pain, fatigue, and fever.
Some patients even experience spasms of the rectum. If you’ve been noticing persistent or bloody diarrhea or abdominal pain, it’s a good idea to give your GI doctor in Wausau a call to schedule an evaluation.
What causes this intestinal disorder?
Research is still being done to discover the causes of ulcerative colitis; however, it is believed that family history does play a role in who develops this condition and who doesn’t. If a family member has had colitis there is a chance you could have it too. Of course, environmental factors may also be to blame, as higher rates of colitis have been found within urban settings.
How is colitis treated?
The treatment options that are best for you will depend on the cause of your colitis. Once we figure out what’s causing it we can recommend the proper treatment options. For example, if colitis is due to an infection, you may need a round of antibiotics.
If your colitis is due to an autoimmune disease, called ulcerative colitis, you may need any one of several kinds of medications. Common options include anti-inflammatory medications such as corticosteroids, immunomodulators and immunosuppressant’s (to reduce inflammation). We will discuss the best options for you.
GI Associates of Wausau, WI, is here to help you feel better. No matter if you are dealing with unexplained abdominal pain, persistent diarrhea, blood in the stool or other symptoms, it’s important that you have a team of GI specialists who can help. Call us today to schedule an appointment with us.
Learn more about your options for treating nonalcoholic fatty liver disease.
Did you know that nonalcoholic fatty liver disease is actually the most common type of chronic liver disorder in the US? In fact, as many as 80 to 100 million Americans have it. Have you or a loved one just been diagnosed with non-alcoholic fatty liver disease? If so, our Wausau, WI, gastroenterologists are here to tell you more about this condition and what our team of specialist can do to help.
What is non-alcoholic fatty liver disease?
As you may be able to guess from the name alone, this disorder refers to a condition of the liver that causes too much fat to be stored in the cells of the liver. While many liver disorders are associated with heavy drinking or alcoholism, this condition affects those who do not drink alcohol or who drink very little.
What causes non-alcoholic fatty liver disease?
Unfortunately, medical experts have not been able to pinpoint the exact reason why some people accumulate more fat on their livers than others; however, there are certain conditions and factors that have been linked to non-alcoholic fatty liver disease such as:
- Obesity or being overweight
- High blood sugar
- High-fat levels within the blood
- Insulin resistance
There are also some conditions and factors that can increase your chances of developing non-alcoholic fatty liver disease such as:
- High cholesterol
- Metabolic syndrome
- Sleep apnea
- Type 2 diabetes
- Polycystic ovary syndrome (PCOS)
What are the symptoms?
In most cases, people don’t experience symptoms of non-alcoholic fatty liver disease. Some people with non-alcoholic fatty liver disease may notice:
- Abdominal pain in the upper right region
- Weight loss or loss of appetite
How is this condition treated?
While there is no specific treatment for this condition, we may ask you to change your diet and current lifestyle.
If you are overweight or obese, this means helping you to lose that weight safely but effectively through creating a healthier diet and regular exercise plan.
In many cases, losing the excess weight will greatly improve the health of your liver. This may also include reducing or stopping how much alcohol you drink.
Periodic measurement of liver elasticity and liver function blood tests may be recommended to monitor the health of your liver over time.
Whether you have already been diagnosed with non-alcoholic fatty liver disease or you are experiencing symptoms, the team at GI Associates in Wausau, WI, are here to provide you with the support and care you need. You don’t have to handle these issues alone. Call us today.
Find out more about this potentially serious gastrointestinal infection and its symptoms.
While most people will deal with bouts of gastroenteritis (colloquially referred to as the “stomach bug”), diarrhea, and even food-borne illnesses such as e. coli, there is another infectious strain that doesn’t get as much recognition but does infect close to half a million Americans each year. This infection is known as C. diff, and our Wausau, WI, gastroenterologists are here to tell you more about it.
What is C. diff?
C. diff, or Clostridium difficile, is a bacterial infection of the large intestine that can cause everything from mild diarrhea to more severe diarrhea and abdominal pain with dehydration. Severe cases can be life-threatening.
What are the symptoms?
C. diff can cause a variety of symptoms that mimic that of other conditions. Common symptoms include:
- Abdominal pain and tenderness
If you are dealing with a mild case, you may experience diarrhea and other symptoms for anywhere from five to 10 days. Those with more severe cases may experience symptoms that last well over 10 days.
Since the most classic symptom of C. diff is diarrhea, it’s common for patients to become dehydrated. If you are experiencing diarrhea for more than two days, if there is blood in your stool or if your diarrhea is accompanied by a fever, you should call our Wausau GI doctors right away.
How do you contract C. diff?
Most cases of C.diff infection occur in people who have recently taken an antibiotic for an infection elsewhere in the body. The antibiotic has killed most of the healthy bacteria in the colon. This allows the C.diff to grow and cause the infection in the large intestine. The C.diff can spread from one infectious person to another or through contaminated utensils or clothes. C.diff is more likely to spread in places like hospitals where more patients are on antibiotics and can come in contact with the bacterium.
How is C. diff treated?
Even though there are certain antibiotics that can increase your chances of developing C. diff, if you do develop this infection the best way to treat it is with a round of antibiotics that kill the C.diff bacteria. Metronidazole (Flagyl) and oral Vancomycin are common antibiotics used for treating C. diff.
Sometimes the infection is resistant to treatment. A longer course of these antibiotics or a different antibiotic may be required. A small number of patients may require “Fecal Material Transplantation”. This is a procedure in which healthy bacteria are placed in the colon to combat the C.diff infection.
The team at GI Associates is dedicated to providing comprehensive and gentle digestive treatment and care whenever you need it most. We have locations in Wausau, Stevens Point, Woodruff, Eagle River, Rhinelander, and Antigo, WI. Whether you are dealing with symptoms of C. diff or you are experiencing other issues, don’t hesitate to reach out to us right away to get your GI system back on track.
Find out more about this inflammatory bowel disease and what a diagnosis might mean for you.
Have you or a loved one just been diagnosed with ulcerative colitis? Approximately 907,000 Americans have ulcerative colitis, a type of inflammatory bowel disease (IBD) that causes inflammation and ulcers within the lining of the colon (large intestines) and rectum. Our Wausau, WI, gastroenterologists are here to answer all of your most common questions regarding this intestinal condition.
What are the symptoms of ulcerative colitis?
Symptoms will vary from person to person, but many people with this condition experience mild to moderate symptoms during flare-ups; however, some people with experience severe inflammation and other symptoms. Common symptoms of ulcerative colitis include:
- Abdominal pain
- Bloody diarrhea
- Rectal bleeding and/or pain
- Changes in bowel movement frequency
- Unexpected or sudden weight loss
Keep in mind that if you haven’t been diagnosed with ulcerative colitis and you are experiencing some of these symptoms that it doesn’t necessarily mean that you have this type of IBD. In fact, many gastrointestinal issues have similar symptoms, which is why it’s important to visit one of our Wausau GI specialists for a proper diagnosis.
Is ulcerative colitis the same as Crohn’s disease?
While both of these conditions are considered an inflammatory bowel disease and some symptoms may be the same, there are some differences. Ulcerative colitis causes inflammation in the lining of the colon and rectum while Crohn’s disease can produce inflammation anywhere in the digestive tract from the mouth to the rectum. Crohn’s disease may include symptoms such as mouth sores and anal fissures that do not typically occur for people with ulcerative colitis.
How is ulcerative colitis treated?
There are different medications that can effectively manage your ulcerative colitis symptoms. The two most common medications are prescription-strength anti-inflammatories and immunosuppressants. Depending on the symptoms you experience, you may also take over-the-counter pain relievers, anti-diarrheal medications, or even certain supplements.
The only way to get rid of ulcerative colitis is by removing the colon and rectum. This surgical procedure should only be considered if inflammation or ulcers are severe and cannot be controlled through medication.
GI Associates is ready to provide you with the comprehensive gastrointestinal care you need. We have offices in Wausau, Stevens Point, Woodruff, Eagle River, Rhinelander, and Antigo, WI, to serve you better. Regardless of whether you are looking for ulcerative colitis treatment or you are dealing with symptoms, call one of our offices today for an appointment.
Find out what could be causing this rather embarrassing problem and how you can treat it.
Diarrhea happens to almost everyone at some point in their lives. Most of the time it will run its course in a day or two. Of course, there are some situations when symptom may stick around longer than you had hoped.
Some of the most common causes of diarrhea include:
- Viral gastroenteritis
- Bacterial infection (e.g. food poisoning)
- Hyperthyroidism (overactive thyroid)
- Food Sensitivities
- Inflammatory bowel syndrome (e.g. ulcerative colitis; Crohn’s disease)
- Alcohol abuse
- Radiation therapy
Your primary care provider can help you manage the majority of diarrheal causes. If your diarrhea continues, or additional symptoms like abdominal pain occur, a gastroenterology consultation may be needed.
How is diarrhea treated?
Mild symptoms are usually well managed with over-the-counter medications. Your primary care provider may also consider additional medications, lab or radiology testing in certain circumstances.
Remember to continue to drink liquids throughout the day to stay hydrated.
If your symptoms continue your primary care provider may refer you to GI Associates. Prior to your appointment, we will gather information from your primary care provider’s office about treatments and testing have already been performed. We will ask you questions about your symptoms and, from there, decide what additional diagnostic tests may be needed.
If underlying conditions such as Celiac or Crohn’s disease are suspected, we may recommend an endoscopy procedure be performed.
From there we can work with you to manage your symptoms through daily lifestyle changes and certain medications.
GI Associates in Wausau, WI, is committed to providing the very best in gastrointestinal care. If you are experiencing any changes or digestive health concerns, please call our office to make an appointment. Our board certified gastroenterologists are here to help.
For your convenience, we offer services in a Wausau, Stevens Point, Antigo, Rhinelander, Woodruff and Eagle River.
Colonoscopy: An Important Colon Cancer Screening Procedure
A colonoscopy allows your doctor to examine the lining of your large intestine or colon for any abnormalities. During a colon cancer screening in Wausau, WI, a thin flexible tube is inserted and slowly advances through the GI tract into the rectum and colon. Known as the colonoscope, your doctor can view images on a video monitor with ease. Polyps or abnormal growths in the colon lining may be found that can be removed during this important cancer screening procedure.
Colorectal cancer is the third leading cause of cancer deaths in the United States. Known as the silent killer, there are usually no warning signs. At age 50 all adults are urged to get screened.
More about Colon Cancer Screenings in Wausau, WI
For most patients, there is no pain during this procedure. Patients may feel cramping, bloating or pressure after the colonoscopy. If your doctor thinks something needs further evaluation, they may obtain a biopsy and take a sample to be analyzed. After a colon cancer screening in Wausau, WI, one of our board certified gastroenterologists professionals from GI Associates & GI Associates Endoscopy Center will explain the results of your procedure with you. Further information about diet and activities will be given to you too. You will need a ride since you are given a sedative during the procedure, which makes it unsafe for you to drive for the rest of the day. In general, there are few complications associated with a colonoscopy, but bleeding at the site of a polyp or biopsy sample removal is the most common. To schedule this important screening procedure with one of our professionals, call 877-442-7762 today.