42: Febrile Digest - A Few Papers

Sara Dong: 00:00:06

Hi everyone.

Sara Dong: 00:00:07

Welcome to Febrile, a cultured podcast about all things infectious disease.

Sara Dong: 00:00:11

I am Sara Dong, a Med-Peds ID fellow and Arthur is back with me today for another Febrile Digest.

Arthur Jackson: 00:00:18

Hey Sara!

Arthur Jackson: 00:00:19

Thanks for having me again.

Sara Dong: 00:00:20

So we're going to do another literature review, like we did not too long ago and sort of like a clinical update of a couple of things that we found interesting and just wanted to share.

Sara Dong: 00:00:29

So I think I'll start us off.

Sara Dong: 00:00:31

I wanted to try, at least to do my best, to summarize what we know about these acute hepatitis cases that have been seen in children and have sort of gotten picked up in some of the news outlets, or if folks are on Twitter.

Sara Dong: 00:00:45

I will note that we're recording this on May 4th and it's going to get released in a week and a half or so from now, so there may be newer information since we record.

Sara Dong: 00:00:54

But the first report that was published was from the UK Health Security Agency from April 8.

Sara Dong: 00:01:01

And they put out a notice saying that they're investigating potential causes of an unusually high number of acute hepatitis cases of unknown etiology in children in Scotland, England, and Wales.

Sara Dong: 00:01:13

And then that was followed up, really the next week, on April 14th by, uh, another Rapid Communication.

Sara Dong: 00:01:19

This time from Eurosurveillance, and I'll put links to all these for anyone to look at.

Sara Dong: 00:01:23

Um, but this had a little bit more detail about the initial investigation for the first Scottish cases.

Sara Dong: 00:01:30

And around the time that they published in mid April, they had 13 cases from March and April.

Sara Dong: 00:01:35

The children were a median age of a little under four years old.

Sara Dong: 00:01:39

They all had vomiting, jaundice, and ALT numbers that were over 2000 and then their other workup had had been overall unrevealing.

Sara Dong: 00:01:49

Hepatitis A B, C, and E as well as COVID testing were negative.

Sara Dong: 00:01:54

And then there was a mixture of both negative and positive testing for Adenovirus.

Sara Dong: 00:01:59

So three of these children were evaluated for transplant and one actually received a successful liver transplant.

Sara Dong: 00:02:05

Uh, so at this point they were still hypothesizing infectious pathogen versus some sort of toxic exposure, but infection was already being favored due to some of these adenovirus tests that were positive.

Sara Dong: 00:02:18

Um, and then that was followed the next week by the WHO Multi- country Disease Outbreak News, uh, that summarized these initial clusters in Europe.

Sara Dong: 00:02:27

And at that point had compiled at least 169 cases, but a much broader, uh, age range than the prior two reports.

Sara Dong: 00:02:36

So anywhere from one month to 16 years old, but 10% of the patients required liver transplant, uh, which is a really high number.

Sara Dong: 00:02:43

And then adenovirus have been identified in a least 74 of the cases, which really prompted this to be one of the leading hypotheses.

Sara Dong: 00:02:52

And then to get us back, another recent report in MMWR from the end of April explained what they had seen in pediatric patients at the University of Alabama in Birmingham.

Sara Dong: 00:03:02

Had a similar story, severe acute hepatitis, otherwise immunocompetent children, a median age of two years old, and they had vomiting and diarrhea and ultimately signs of hepatic dysfunction.

Sara Dong: 00:03:14

It looked like the ALT, AST ranges were anywhere from 600 up to the 4000s, and they did find adenovirus viraemia based on PCR numbers without a clear alternate explanation for what was going on, such as other like Hepatitis A, B, and C or auto-immune causes, Wilson's, things like that.

Sara Dong: 00:03:35

And so it's interesting.

Sara Dong: 00:03:36

They did have information about the quantity of the viral load being anywhere from 1000 to 70,000 [copies/mL].

Sara Dong: 00:03:43

And this ended up being about nine children that were identified.

Sara Dong: 00:03:47

I think what was interesting though, is the liver biopsies don't actually show any specific viral inclusions, it sounds like, or clear immunohistochemical evidence of adenovirus, but again, children with acute liver failure and high high amounts of, I guess I should say, percentages of kids getting evaluated or ultimately transplanted.

Sara Dong: 00:04:10

So that was a whirlwind, but hopefully summarize, summarizes is kind of what we know so far and, and what the concern is, but I suspect we'll hopefully get more information in these coming weeks and months.

Arthur Jackson: 00:04:23

Yeah.

Arthur Jackson: 00:04:23

You did a great job there, putting all that together.

Arthur Jackson: 00:04:26

That's a lot of information.

Sara Dong: 00:04:27

I did talk really fast!.

Arthur Jackson: 00:04:29

Um, it's, I, I, I don't have a, kind of a, a real feeling as to where this is leading to, do you?

Sara Dong: 00:04:37

No and I think it's interesting because I mean, we know the adenovirus can make people quite sick and, or I guess I should say children and sort of immunocompromised hosts sick in certain circumstances, but it's unusual for them to have this profound liver failure.

Sara Dong: 00:04:54

And it's hard to know.

Sara Dong: 00:04:55

Maybe it's not adenovirus at all?

Arthur Jackson: 00:04:57

Exactly.

Arthur Jackson: 00:04:57

I've, I've, I've heard, I've heard arguments on all sides, Twitter, as you know, tells you one thing, then tells you the exact opposite in another thread.

Arthur Jackson: 00:05:06

And they, um, so as in I think anyone who claims to know for sure what's going to be the true outcome is ,eh, isn't to be taken too seriously.

Sara Dong: 00:05:16

Yeah, and I think it's just important for people to be aware so that if they have a case that doesn't quite have an explanation, that you figure out who's the right person to report it to like for us, you know, mechanisms of reporting it back to the CDC or whatever similar mechanism folks have local to them.

Arthur Jackson: 00:05:34

Yeah, it's great that the, um, this is one where COVID vaccine is not being highlighted as a, as a putative cause.

Arthur Jackson: 00:05:42

So I'm very glad to hear that.

Arthur Jackson: 00:05:44

Um, so will I go onto my next study?

Arthur Jackson: 00:05:46

So we were going to talk about the Landman, et al.

Arthur Jackson: 00:05:49

study.

Arthur Jackson: 00:05:49

It's a French multi-center trial that was published in Lancet HIV recently.

Arthur Jackson: 00:05:54

So they call it the QUATUOR trial, 59 sites in France.

Arthur Jackson: 00:05:58

They looked at four days on, three days off for HIV therapy.

Arthur Jackson: 00:06:03

This was really interesting.

Arthur Jackson: 00:06:05

They, um, they enrolled about 336 adults.

Arthur Jackson: 00:06:08

They, they had multiple baseline regimens.

Arthur Jackson: 00:06:12

They included protease inhibitor based regimens, and NNRTI, as well as integrase inhibitor regimens.

Arthur Jackson: 00:06:17

They looked at, um, a non-inferiority and they found non-inferiority, which was really interesting.

Arthur Jackson: 00:06:24

Um, obviously people when there is going to be a, this break in the mantra of "you must take your, your medicine every day", um, the concern then is, is it going to be in any concern for virological resistance?

Arthur Jackson: 00:06:37

They, they found that there was no signal of major virological resistance coming through in the intermittent arm compared to the, the, the arm that stayed on their therapy, um, 7 days, um, although they did find a numerically slightly higher amount in the intermittent arm.

Arthur Jackson: 00:06:57

So a larger study probably is needed to see whether that is something that, that comes through.

Arthur Jackson: 00:07:02

And this was a study that went on for 48 weeks, so like the equivalent of a year.

Arthur Jackson: 00:07:07

They followed their patients pretty much every three months.

Arthur Jackson: 00:07:10

And, um, and they, and they did a number of interesting kind of analyses including patient satisfaction, which has extremely high, um, acceptability extremely high.

Arthur Jackson: 00:07:21

Of course, the reason for doing this is to see whether or not you're, you're just wasting additional resources by giving it seven days in the week if you don't need to give it seven days of the week.

Arthur Jackson: 00:07:31

So the, they found there was an actual cost saving of 43%, which is huge if you're looking at that as a budgetary component.

Arthur Jackson: 00:07:40

They also looked at some of the other, um, potentially you might call them secondary markers, such as inflammatory markers.

Arthur Jackson: 00:07:47

The, they did not find any rise in things like ultra-sensitive CRP or the like.

Arthur Jackson: 00:07:53

And so that's reassuring to think that there isn't background inflammation that isn't being picked up at the, at the time of virological load measurement.

Arthur Jackson: 00:08:03

So it's a really interesting study.

Arthur Jackson: 00:08:05

And, um, it makes you think, is this going to change the way we practice in the future?

Arthur Jackson: 00:08:12

Obviously a lot of people are already switching to dual therapy rather than, um, triple therapy.

Arthur Jackson: 00:08:16

So this is a study looking at triple therapy in this intermittent regimen.

Arthur Jackson: 00:08:21

So could it be applied to dual therapy in the future?

Arthur Jackson: 00:08:24

And, uh, I suppose it's the question of how low can you go or or something along those lines?

Arthur Jackson: 00:08:28

It's it's not enough yet to change my practice.

Arthur Jackson: 00:08:31

But it is very interesting.

Arthur Jackson: 00:08:34

And, um, I, I think it looks like something that might end up changing practice as time goes on.

Sara Dong: 00:08:41

Yeah.

Sara Dong: 00:08:41

And it feels like a hard to remember schedule, but I think, even before us changing our practice, maybe it's just a good example or a way to sort of, for ourselves and to counsel our patients, that I don't know for those patients who are suppressed and they probably are missing doses here and there more than perhaps they tell us in clinic that maybe we can relax a little bit.

Sara Dong: 00:09:04

I, you know, I don't know if that's another way to think about it, particularly for patients who difficulty with adherence to the medication.

Arthur Jackson: 00:09:12

Yeah.

Arthur Jackson: 00:09:12

That's certainly another benefit of any rate.

Arthur Jackson: 00:09:14

Anyway, no question about it.

Arthur Jackson: 00:09:15

You can, you can lean on the data a little bit from that point of view.

Sara Dong: 00:09:19

Yeah.

Sara Dong: 00:09:19

So my next article is what I thought was a really cool study, uh, from Justesen and others in CID from earlier in April.

Sara Dong: 00:09:28

They combined population-based data about bacteremia and colorectal cancer and found a couple of bacterial species, primarily anaerobic gut bacteria, that were associated with an up to 20% colorectal cancer, or I'll probably say CRC, diagnosis risk within one year following their bacteremia.

Sara Dong: 00:09:48

So for context, I suspect many who are listening to Febrile know about the often tested link between colorectal cancer and Strep Bovis group bacteria, um particularly gallolyticus.

Sara Dong: 00:09:59

The relationship between cancer and Clostridium septicum bacteremia is also known, but the associations of other anaerobic bugs is, is a little less well known.

Sara Dong: 00:10:09

And so this was a population-based cohort study in about 2 million people where they had 45,000 bacteremia episodes with also 231,000 blood culture negative cases in Denmark.

Sara Dong: 00:10:21

And, uh, they folded this up against a Danish Colorectal Cancer registry and found a couple different organisms, in addition to the Strep Bovis or Clostridium, uh, the ones that I was going to pull out are primarily Bacteroides species.

Sara Dong: 00:10:36

So Bacteroides ovatus and B.uniformis as well as some Fusobacterium.

Sara Dong: 00:10:42

And these patients were actually at similar risk for cancer as items like Strep bovis.

Sara Dong: 00:10:47

So this leads to that question of what risk level should really prompt a colorectal cancer workup?

Sara Dong: 00:10:55

Is there a time or a threshold when you would ask for that evaluation and cases of bloodstream infections with certain anaerobic gut bugs.

Sara Dong: 00:11:04

And then, you know, I think the followup question to that as whether it actually translates into improvement in their morbidity.

Sara Dong: 00:11:10

Uh, so the registry didn't have data on pre-malignant or adenoma lesions.

Sara Dong: 00:11:14

It's a little bit harder to translate in to thinking about timing for the benefit of their workup, but you do wonder if we'll be able to use information like this, or even more details like the subspecies, to help us decide whether that workup would be indicated.

Sara Dong: 00:11:29

But then, you know, I think the sort of flip side of this, as you do wonder a little bit, if you perhaps have lost that window of opportunity by the time they have bacteremia, and that's a, it's hard to tell from this type of study, but I think just a cool perspective on something that's ID related that you can think about if you were to see patients with, um, something like these Bacteroides bloodstream infections.

Sara Dong: 00:11:52

And so I suspect a lot of these patients probably were already in a range where it would be indicated to have their colorectal cancer screening, but just something to think about to potentially push for appropriate screening and, or perhaps earlier screening, if they have some sort of unique risk factors or the story doesn't quite add up.

Arthur Jackson: 00:12:11

It's interesting to see just the once again, the integration of big data with medicine.

Arthur Jackson: 00:12:17

So there is an obviously being able to study 2 million people that are get data in that, in that scenario.

Arthur Jackson: 00:12:23

So, so my next study is a New England Journal paper, and it's really just kind of referring or talking about the, the tebipenem, which is the new oral carbapenem.

Arthur Jackson: 00:12:34

So it's from Ekberg et al, New England Journal recently.

Arthur Jackson: 00:12:38

And, um, they looked at, they were doing a non-inferiority study looking at complicated UTIs or pyelonephritis in admitted patients.

Arthur Jackson: 00:12:47

And they randomized them to either ertapenem or this new drug, which is an oral drug called, uh, tebipenem pivoxil hydrobromide.

Arthur Jackson: 00:12:58

No surprise that it was proven to be non-inferior.

Arthur Jackson: 00:13:01

So I'm, I'm not, I'm not going to go to huge details about the methods and the likes.

Arthur Jackson: 00:13:07

So it was a study looking at this oral regimen of 600 milligrams, three times a day, versus ertapenem one gram once a day.

Arthur Jackson: 00:13:16

And they found that there was similar cure rates, no difference.

Arthur Jackson: 00:13:19

And it's just really interesting that there is now a new oral carbapenem, which is, uh, certainly the first time we've seen this.

Arthur Jackson: 00:13:29

Um, the question is, is this something that can be moved into other clinical areas, such as pneumonia, such as other, um, extended or highly resistant organisms?

Arthur Jackson: 00:13:42

I was interested to see them talking that in the U S, of all of the admitted patients with complicated UTI or pyelonephritis, they find the 20% of them were ESBL and 33% were fluoroquinolone resistance.

Arthur Jackson: 00:13:55

So, um, there really is a huge issue with, with antimicrobial resistance, which we all know about.

Arthur Jackson: 00:14:02

And obviously the solution might lie, I won't say obviously, the solution may lie in developing new antibiotics and it's good to see new antibiotics coming.

Arthur Jackson: 00:14:13

Obviously the concern is whether or not there will be, if you have greater ease of access to antibiotics, are you going to lead in time to, um, increased resistance rates?

Arthur Jackson: 00:14:24

Unless that's a concern.

Sara Dong: 00:14:25

Yeah.

Sara Dong: 00:14:26

And I saw that the company Spero Therapeutics, it sounds like maybe they're deferring working on tebipenem further and restructuring reportedly because the FDA was potentially not going to approve tebipenem.

Sara Dong: 00:14:40

Um, so it's interesting, like wherever you are on the spectrum of being terrified of oral carbapenems or being excited to have another option, that I think in many ways, it's always a little bit disappointing to see things that antibiotic wise get sort of worked up and, and brought forward.

Sara Dong: 00:14:57

But, um, the company's losing interest and not pursuing them, uh, which I think regardless of where you are on that spectrum can probably be a little bit disappointing for us in ID.

Arthur Jackson: 00:15:08

Yeah.

Arthur Jackson: 00:15:09

And then ID, it's important to note that when a new antibiotic comes on, we're the first people to say, please don't prescribe this unless it's really needed.

Arthur Jackson: 00:15:18

So, um, we definitely.

Arthur Jackson: 00:15:20

The idea.

Arthur Jackson: 00:15:21

It is somewhat terrifying.

Arthur Jackson: 00:15:22

The idea of a, an oral carbapenem that is licensed and, um, and available to anyone to prescribe.

Sara Dong: 00:15:33

Yeah, well, speaking of stewardship, that was a great transition.

Sara Dong: 00:15:36

My next article it's a little bit of a combo of transplant ID and antimicrobial stewardship.

Sara Dong: 00:15:43

And I think many of us an ID are very acutely aware of the challenges that come with trying to balance our broad approach to transplant, or you could even say immunocompromised hosts in general and wanting to be good stewards or "stewies".

Sara Dong: 00:15:59

And so there was a paper by, uh, Dr.

Sara Dong: 00:16:02

So and others called Bring It On-- Top Five Anti-microbial Stewardship Challenges in Transplant ID and Practical Strategies to Address Them.

Sara Dong: 00:16:10

And this was in Anti-microbial Stewardship and Health Epi.

Sara Dong: 00:16:12

And so I thought this was a really cool, sort of like a summary paper.

Sara Dong: 00:16:17

And they took five examples of challenges that we see a lot and provided some strategies on how to approach the question and your multidisciplinary team.

Sara Dong: 00:16:27

And so the five that they selected were -- asymptomatic bacteriuria in renal transplant recipients, febrile neutropenia in hematopoietic stem cell transplant, antifungal prophylaxis in liver and lung transplant recipients, LVAD infections, and then C diff infection.

Sara Dong: 00:16:44

So I'm not gonna read those, but, uh, if it's a pretty quick read and there's a really great table one that actually summarizes everything altogether.

Sara Dong: 00:16:51

Um, so I'd recommend people check it out.

Arthur Jackson: 00:16:53

Yeah, I think it sounds really, really important and really difficult to, uh, to properly get a handle on.

Arthur Jackson: 00:17:01

So another one I was going to talk about is the OFID publication by Hillenbrand et al, about Candida and the eyes.

Arthur Jackson: 00:17:11

So I thought this is quite interesting for a few reasons.

Arthur Jackson: 00:17:14

There's always been the arguments raging between infectious diseases and ophthalmology as to whether or not it is indicated to get a, an ocular exam on every patient who has a candidemia.

Arthur Jackson: 00:17:27

As an ID doctor, I've always gone with the, with the line that yes, it is important and it is needed.

Arthur Jackson: 00:17:34

Um, I liked in their discussion, they kind of brought up the two questions saying, well, the, what you need is these two questions to be answered.

Arthur Jackson: 00:17:41

Is the incidence high enough of ocular complications of candidemia and then a really important one, will a change in management happen if there are ocular complications of candidemia.

Arthur Jackson: 00:17:52

And this is the second point is the one that has really been called into focus recently because the, um, since 2014, um, or sorry since 2016, the IDSA has been saying, um, that the primary treatment for candidemia should be echinocandins.

Arthur Jackson: 00:18:11

Echinocandins don't have ocular penetration.

Arthur Jackson: 00:18:15

So you can imagine that, um, that you can intuitively imagine that the, the, eye will be more vulnerable if you're treating with a non azole non-amphotericin regimen, um, in a, in a systemic candidal infection.

Arthur Jackson: 00:18:31

So this was a study.

Arthur Jackson: 00:18:32

It was a large retrospective review where they looked at 2014 until 2020, they identified 226 cases of candidemia and, um, and they found about a 23% overall ocular complications associated with the candidemia, of which 25% they felt were truly due to the candidemia or were candida specific.

Arthur Jackson: 00:18:55

What they found, which is more interesting, was that as time progressed, so pre 2016, it was around about 18%, and 2019, it was about 40%, 2020 of small numbers, it was about 60%.

Arthur Jackson: 00:19:09

So, so really and truly, they were feeling that they were seeing a, a greater increase in ocular complications with time.

Arthur Jackson: 00:19:18

So basically, it is suggesting that with the advent of echinocandins, um, you really do need to be more concerned about getting an ophthalmological review, the reason being that if you identify, um, an ocular problem associated with candidemia, you will need to change your regimen to either an azole based regimen or an amphotericin-based regimen to, to treat out the course.

Sara Dong: 00:19:46

I feel like this is a great summary of the questions really come up when, when you're faced with this in patients that are in the hospital and ever since the change in the ophthalmology guidelines suggesting against routine exams, I think it's a good, good excuse for all of us to take a look at what we, what we know and understand about endophthalmitis and thinking about this.

Arthur Jackson: 00:20:09

The, uh, one of the other points that they made was they were saying, well, if only a minority of them were Candida specific where these just background eye changes and they said they didn't really feel they were because those background eye changes worsened with times that they felt that they were Candida associated or worsened by the candidemia or something, but they, they, they, they really did feel it was clinically significant.

Sara Dong: 00:20:32

Yeah.

Sara Dong: 00:20:32

Yeah.

Sara Dong: 00:20:33

Well, my next one is another tie in back to actually a, a Febrile episode.

Sara Dong: 00:20:39

So I selected a paper from Dr.

Sara Dong: 00:20:42

Fitzpatrick and a couple others also from CID that looked at the information that we understand about the impact of maternal hyper immune globulin and valacyclovir on outcomes of CMV infection and pregnancy.

Sara Dong: 00:20:55

And so this is a review from some authors in Australia who basically summarize what we know about using these two therapies to prevent vertical transmission or to potentially reduce a sequelae of neonatal CMV infection.

Sara Dong: 00:21:10

You know, this is an area that we're still trying to understand.

Sara Dong: 00:21:13

There's definitely various observational studies that support the use of valacyclovir, if you can time it right in pregnancy, which is a challenge in and of itself.

Sara Dong: 00:21:23

And it's interesting because what we know about the use of CMV hyper immunoglobulin, uh, it wasn't supported as a preventative strategy in the two available randomized controlled trials that we have.

Sara Dong: 00:21:33

But, uh, there are several observational studies that were in contrast to that.

Sara Dong: 00:21:37

I actually posted this previously from the Febrile account when I saw it because it timed really well with our ongoing case-based episodes.

Sara Dong: 00:21:44

So hopefully folks are listening to those.

Sara Dong: 00:21:46

We're doing this Curious Congenital Conundrum series.

Sara Dong: 00:21:49

The episode for CMV from Drs.

Sara Dong: 00:21:52

Hermione Lyall and Nuria Sanchez Clemente.

Sara Dong: 00:21:54

It's number 37.

Sara Dong: 00:21:56

Dr.

Sara Dong: 00:21:56

Lyall does a really nice job summarizing these tools and thinking about the evidence for them in the context of this example case that we did, uh, for the episode.

Sara Dong: 00:22:05

So I think if people listened to the episode to think about CMV in pregnancy and newborns, and then also read this paper, it's a really great synergy and they'd work, work together.

Sara Dong: 00:22:15

And hopefully the Consult Notes and the website as well.

Sara Dong: 00:22:17

I think I've linked to all the majority of the papers that would be relevant, but it was just had good timing.

Arthur Jackson: 00:22:24

Yeah it sounds really good.

Arthur Jackson: 00:22:27

Uh, my last paper is the, um, is an editorial.

Arthur Jackson: 00:22:30

I just thought it was interesting and topical and, um, it was written by a written in the BMJ.

Arthur Jackson: 00:22:36

They don't give a name of an author.

Arthur Jackson: 00:22:38

So I wonder, is that the editor in chief or is it the, the board of editors have written as a group, but the it's talking about infectious diseases and war and their, their interrelatedness.

Arthur Jackson: 00:22:49

And, um, it's, it's specifically mentioning the Ukrainian war.

Arthur Jackson: 00:22:52

So, um, just to highlight some of the points that they make, they talk about the destroyed infrastructure from a health infrastructure, also from a transport infrastructure in terms of being able to get to and from hospitals, um, in terms of resource redirection to the war effort, rather than to, to healthcare.

Arthur Jackson: 00:23:10

They of course look at vaccine preventable diseases, especially measles outbreaks and polio outbreaks, they mentioned.

Arthur Jackson: 00:23:17

They talk about people on antiretrovirals and the insurance and disruption to their supply chain, TB, overcrowding, COVID and, uh, and the overcrowding happening both in the sights of the war, but also in, in refugee camps, um, where the displaced people have had to move.

Arthur Jackson: 00:23:36

They do reference wars in Afghanistan, Yemen, uh, Burma, but they, they do focus a lot on this Ukraine war.

Arthur Jackson: 00:23:43

And they're very brave in their final paragraph where they talk about how yes, it will be great if Ukraine can, can get out of this without the same destruction we're seeing everywhere else in the same association.

Arthur Jackson: 00:23:56

But in one way, they said, if that does happen, it will probably be an indictment of the West's approach to white wars versus non-white wars and wars in places where, where this color of people's skin is not, uh, Caucasian or white skin.

Arthur Jackson: 00:24:11

I thought it was very brave and very appropriate that they would, that they would call out and bring it into the, into the mainstream.

Sara Dong: 00:24:18

Yeah.

Sara Dong: 00:24:19

This piece made me think of how a lot of the, uh, Febrile guests who've come on the show, you know, we ask about, can you share a piece of culture or something that you think you'd recommend for the listeners and multiple people have brought suggestions for books or, or items that emphasize this connection between ID and history or world events or war.

Sara Dong: 00:24:39

And I think a lot of these are brought up in the context of reflecting on our journey with COVID, but I, I think the idea of creating an awareness of our past to learn, um, to learn from is important in various scenarios, and that includes conflict and war.

Sara Dong: 00:24:58

You know, I think the main message.

Sara Dong: 00:25:00

I totally agree with that our response to and decisions about both these world events, as well as our patients and infections, they don't exist in some sort of isolation from one another that they are fundamentally tied to one another.

Arthur Jackson: 00:25:15

Yeah.

Arthur Jackson: 00:25:15

And it's would say, um, it's amazing to see the same awful outcomes happening again and again and again and again.

Arthur Jackson: 00:25:22

So, um, it's, it's really important.

Arthur Jackson: 00:25:25

To be aware of it, but not just to be aware of it, but to try to use that knowledge, to change the outcome, hopefully.

Sara Dong: 00:25:32

Yeah.

Sara Dong: 00:25:32

Well, we did it, Arthur!

Sara Dong: 00:25:34

We got in right under 30 minutes.

Sara Dong: 00:25:36

We have like a minute left.

Sara Dong: 00:25:38

I so nice to have you back.

Sara Dong: 00:25:39

And uh, we'll keep, keep bringing these episodes and hopefully, you know, folks have suggestions for things that we should talk about.

Sara Dong: 00:25:47

They can always send it to us.

Arthur Jackson: 00:25:48

Absolutely!

Arthur Jackson: 00:25:49

Thank you so much for having me on again.

Arthur Jackson: 00:25:51

It's a real honor.

Arthur Jackson: 00:25:52

Thank you.

Sara Dong: 00:25:53

Thank you all for listening.

Sara Dong: 00:25:55

Like our other episodes, I'll put links to all the articles in our consult notes.