1 00:00:05,910 --> 00:00:06,840 Sara Dong: Hello everyone. 2 00:00:06,900 --> 00:00:11,130 Welcome to Febrile, a cultured podcast about all things infectious disease. 3 00:00:11,610 --> 00:00:14,760 I'm Sara, your host and a Med-Peds ID fellow. 4 00:00:15,150 --> 00:00:18,570 And I have a friend here with me today, Julie, welcome to the show. 5 00:00:18,720 --> 00:00:20,270 Can you tell everyone a little bit about yourself? 6 00:00:21,000 --> 00:00:22,529 Julie Steinbrink: Hi Sara, thanks for having me. 7 00:00:22,860 --> 00:00:24,450 My name is Julie Steinbrink. 8 00:00:24,509 --> 00:00:28,680 I am an assistant professor in Infectious Diseases at Duke University. 9 00:00:29,159 --> 00:00:39,959 I specialize in adult transplant infectious diseases, so my clinical care focuses on the management of infections in immunocompromised patients, including solid organ and bone marrow transplant patients. 10 00:00:40,019 --> 00:00:42,629 You know, the, also those with hematologic malignancies. 11 00:00:42,720 --> 00:00:50,220 I also do some research focusing on noninvasive diagnostics for different types of infectious diseases in immunocompromised patients. 12 00:00:50,310 --> 00:00:52,020 Um, and so I'm very excited to be here. 13 00:00:52,170 --> 00:01:00,820 Additionally, I serve as co-chair for the American Society of Transplantation, um, our Infectious Diseases Community of Practice Education workgroup. 14 00:01:01,080 --> 00:01:05,695 And so I wanted to give a little bit of a plug for one of the initiatives that we're doing through the education work group. 15 00:01:06,115 --> 00:01:15,615 We have a survey that we've created for our ID trainees, both adult and pediatric, including both our current trainees and recent graduates in the last five years. 16 00:01:15,705 --> 00:01:21,675 And what we're really trying to do is better understand and improve upon the Transplant ID training curriculum. 17 00:01:21,735 --> 00:01:30,520 So we want to characterize what are the educational experiences and needs that our ID trainees are having, especially for those who want to further careers in Transplant ID. 18 00:01:30,610 --> 00:01:46,430 And so these data will add significantly to the existing knowledge that we have about Transplant ID training and help us to, kind of, identify gaps in training that are present and update our recommended, uh, curriculum, and really try to improve that and make it more cohesive for our trainees. 19 00:01:46,455 --> 00:01:52,005 So we hope to have this survey live within the month and it'll be open for about four weeks. 20 00:01:52,005 --> 00:01:54,795 You may see various methods of potential distribution. 21 00:01:54,795 --> 00:02:06,015 We're sending out emails through the program directors, through my IDSA say listserv, um, the AST ID COP, our online hub, and you'll see some social media blasts for it as well. 22 00:02:06,015 --> 00:02:12,379 But if you do see that present and you're a recent or current trainee, then, please feel free to engage. 23 00:02:12,379 --> 00:02:16,729 It'll really help us out and help future trainees as well to improve upon their curriculum. 24 00:02:16,729 --> 00:02:17,389 So thank you. 25 00:02:17,719 --> 00:02:18,709 Sara Dong: Yeah, that's awesome. 26 00:02:18,709 --> 00:02:29,799 So we'll, we'll send everyone a reminder once we have the link and we'll actually mentioned a couple other resources that the ID Community of Practice has put together at the end, which has helped a lot of Febrile episodes. 27 00:02:29,799 --> 00:02:30,879 And I use them all the time. 28 00:02:31,749 --> 00:02:34,539 Um, so I feel very confident plugging those. 29 00:02:35,119 --> 00:02:43,399 You know, our current case based episodes in April and May are part of , uh, what we called the Curious Congenital Conundrums, which I hope everyone's listening to. 30 00:02:43,399 --> 00:02:47,479 We have some amazing international colleagues that have been joining for that series. 31 00:02:47,539 --> 00:02:57,140 And the most recent episode, number 39 called Seal of Approval, talks through the approach and challenges in a case with congenital toxoplasmosis. 32 00:02:57,169 --> 00:03:04,204 But one of the most awesome and fun parts about ID is that we get to learn about infections in a variety of hosts. 33 00:03:04,565 --> 00:03:12,845 And so I thought today we could talk a little bit about toxo in a different setting and transplant recipients, which I think people probably could guess by our introduction. 34 00:03:12,875 --> 00:03:26,915 So as a quick refresher, toxoplasma is a protozoal infection and transmission can be foodborne, zoonotic or congenital, but there's also human to human transmission on rare occasions through blood transfusion and organ transplant. 35 00:03:26,975 --> 00:03:36,065 And it's been estimated that anywhere up to probably half or so of the world's population has probably been exposed, although it's always kind of hard to get those figures. 36 00:03:36,515 --> 00:03:45,494 Um, so Julie, can you talk a little bit about screening for toxoplasmosis before transplant and the things that we are worried about in that setting? 37 00:03:45,989 --> 00:03:46,829 Julie Steinbrink: Sure, definitely. 38 00:03:46,889 --> 00:03:53,279 So toxoplasmosis in transplant recipients can be a manifestation of donor derived infection. 39 00:03:53,279 --> 00:03:59,219 It can be reactivation of a latent infection in the recipient, or could also be a primary acute infection. 40 00:03:59,369 --> 00:04:04,289 And so in the transplant space, we can see it both in our solid organ and in our stem cell transplant patients. 41 00:04:04,289 --> 00:04:08,429 But I'm going to focus, of course, on the solid organ transplants for the purposes of this talk. 42 00:04:08,759 --> 00:04:12,389 So screening of all of our organ donors and recipients is recommend. 43 00:04:13,279 --> 00:04:19,159 The seronegative recipients of toxoplasma IgG positive donors have the highest risk of infection. 44 00:04:19,459 --> 00:04:23,000 So those are, you know, so donor positive recipient, negative mismatch. 45 00:04:23,180 --> 00:04:31,430 And the highest concern is for those who are heart transplant recipients because of the propensity of the Toxoplasma to want to encyst in that cardiac muscle. 46 00:04:31,490 --> 00:04:39,440 And they can have up to a 75% risk of early post-transplant infection unless they received the appropriate antimicrobial prophylaxis. 47 00:04:39,500 --> 00:04:48,710 And so this is particularly important in the first, you know, three months or so after transplant, when they have the highest levels of immunosuppression, so highest concern for potential transmission of infection. 48 00:04:49,294 --> 00:05:12,700 Although the risk of transmission is highest or most concerning in our heart transplant recipients, we have to also consider it in our other non-cardiac transplant patients as well, particularly if they still have that donor positive recipient negative mismatch, and so increased recognition of this donor derived infection in non-cardiac transplant patients has led to a, more of a mandated toxoplasma IgG donor screening for all organs. 49 00:05:13,030 --> 00:05:20,349 I was even part of like a multicenter study, where we looked at a couple of centers in the Southeast USA and the toxoplasma rates in our transplant patients. 50 00:05:20,409 --> 00:05:35,559 And we found that, yes, we did have it in our cardiac transplant patients, but you actually also had it in the majority were actually in our non-cardiac transplant patients as well, and more frequently in the setting of rejection and then patients who did not receive appropriate antimicrobial prophylaxis at that time. 51 00:05:35,650 --> 00:05:46,150 So I think some of that stems from the fact that as people become more aware of toxoplasma, they get appropriate prophylaxis maybe at the time of transplant, and that helps prevent in that acute setting. 52 00:05:46,179 --> 00:05:50,085 But then down the road, people tend to maybe forget about their toxoplasma status. 53 00:05:50,085 --> 00:05:59,304 And then they get augmented immunosuppression in the setting of allograft rejection and they don't get appropriate toxoplasma prophylaxis, and then that leads to downstream potential infections. 54 00:05:59,304 --> 00:06:07,054 So those would probably be like the two biggest times to consider it would be like immediately after transplant, and then also when you're treating for rejection. 55 00:06:07,505 --> 00:06:21,044 Sara Dong: And I thought maybe you could tell us a little bit about specifics about prophylaxis and how we can try to prevent infection, but also what are the things that we can counsel our patients on potentially avoiding infection. 56 00:06:21,494 --> 00:06:22,604 Julie Steinbrink: Yeah, definitely. 57 00:06:22,635 --> 00:06:26,835 So, as I mentioned, you want to have prophylaxis at times of high levels of immunosuppression. 58 00:06:27,054 --> 00:06:31,825 You want to particularly consider it in your patients where there's the highest risk of transmission, so those mismatches. 59 00:06:31,885 --> 00:06:43,075 The good news is that typically your common trimethoprim sulfa, uh, regimens that you use for Pneumocystis prophylaxis in these patients will also adequately, typically protect against toxoplasma as well. 60 00:06:43,075 --> 00:06:48,090 And that can include, you know, three times a week regimen as well as their daily regimens as well. 61 00:06:48,140 --> 00:06:51,320 Lower dose regiments are probably less likely to be effective. 62 00:06:51,530 --> 00:07:04,104 Some centers though may potentially can use lower dose regimens for other center-specific reasons, or even consider adding things like pyrimethamine to it in particularly high risk combinations, if they were to have that medication available. 63 00:07:04,315 --> 00:07:10,825 There's a little bit less data for other alternative regimens for toxoplasma prevention, like dapsone or atovaquone. 64 00:07:11,005 --> 00:07:17,305 Um, there is some concern that there have been some breakthrough infections on atovaquone and so concerns for failure there. 65 00:07:17,395 --> 00:07:22,765 Potentially some breakthrough infections on dapsone if you're using lower doses to make sure you're dosing that appropriately. 66 00:07:23,609 --> 00:07:28,020 And other Pneumocystis regimens like pentamidine are not going to be effective against toxoplasma. 67 00:07:28,049 --> 00:07:42,330 So something to take into consideration, you know, a lot of our patients get trimethoprim sulfa right after the time of transplant for their pneumocystis prophylaxis, but then they get switched off of it for various other reasons, you know, kidney injury or myelosuppression or other things. 68 00:07:42,419 --> 00:07:51,599 And so you just have to keep in mind that if you're doing that and you're transitioning them to a different pneumocystis regimen, you potentially could be sacrificing their toxoplasma coverage as well. 69 00:07:51,599 --> 00:07:52,770 So just something to consider. 70 00:07:53,760 --> 00:07:59,489 The other thing that's a bit debatable as well is the duration of prophylaxis for these type of patients. 71 00:07:59,549 --> 00:08:04,799 And again, that can be center dependent, depending on how endemic the infection is in your area. 72 00:08:04,799 --> 00:08:07,020 What particular organ groups you're working on. 73 00:08:07,140 --> 00:08:10,049 You can do between three to six months versus a year. 74 00:08:10,049 --> 00:08:14,219 Sometimes they'll do a lifetime prophylaxis if you've got really high risk or cardiac transplant patients. 75 00:08:14,309 --> 00:08:16,440 Um, and again, that can be a bit variable. 76 00:08:16,954 --> 00:08:31,114 So I think that covers the first part of your question there that you're talking about, you know, pro uh, antimicrobial prophylaxis for these patients, but certainly there are other things you can do to counsel your patients on lifestyle interventions that can help prevent against like acquisition of new infection. 77 00:08:31,174 --> 00:08:35,704 So we tell our patients about ways to try to avoid this, um, infection. 78 00:08:35,714 --> 00:08:48,359 So trying to avoid eating raw or like under cooked meats and avoiding contact with surfaces that may have been contaminated by these undercooked meats, um, unless they've been thoroughly cleaned afterwards. 79 00:08:48,480 --> 00:08:51,599 Untreated drinking water as well is something you want to avoid. 80 00:08:51,689 --> 00:08:58,704 You know, given the concern for cats for transmission, we tell transplant patients to avoid, you know, contact with stray cats or kittens. 81 00:08:58,704 --> 00:09:01,074 You know, if you don't know what their toxoplasma status is. 82 00:09:01,134 --> 00:09:13,644 Um, telling our patients as best they can to avoid changing their cat litter boxes, or if they are going to change it, that they'd try to take appropriate precautions, including gloves and washing hands and considering, you know, wearing masks and things like that. 83 00:09:13,704 --> 00:09:31,744 And they should still be changing the litter box daily or somebody in their house should be changing the litter box daily because it can take at least 24 hours for the parasite to become infectious after it shed in the cat feces, but in addition to, you know, undercooked meats and cats as potential methods of transmission, you also want to keep in mind that gardening can also be a potential risks. 84 00:09:32,844 --> 00:09:40,164 Telling our patients that if they're going to be in contact with soil or sand, for things like gardening, that they take appropriate precautions again. 85 00:09:40,584 --> 00:09:43,494 Uh, wearing gloves with appropriate hand washing after removal. 86 00:09:43,524 --> 00:09:55,344 So we don't want transplant patients to change their entire lifestyles, but we just want them to be able to take in, you know, appropriate precautions to make sure that they can do those activities safely for them and for, uh, the rest of their family. 87 00:09:56,379 --> 00:09:56,769 Sara Dong: Yeah. 88 00:09:57,459 --> 00:10:03,459 Um, and you know, I feel like sometimes toxo plasma gets a little bit forgotten on the differential. 89 00:10:03,789 --> 00:10:18,639 And I was wondering if you, you know, I know there's a variety of things we might see, but maybe you can mention some clues or clinical presentations that might make toxo come a little bit higher on your list or be considered a little bit more. 90 00:10:19,079 --> 00:10:20,289 Julie Steinbrink: Yeah, definitely. 91 00:10:20,349 --> 00:10:25,719 Um, I think the tricky thing is exactly what you said in toxoplasma for immunocompromised patients. 92 00:10:25,719 --> 00:10:33,639 You can really see a variety of clinical presentations depending on where the infection manifests in that particular patient. 93 00:10:33,699 --> 00:10:35,559 And so it can involve multiple organ systems. 94 00:10:35,559 --> 00:10:40,449 You can have pneumonitis, encephalitis, chorioretinitis, you know, a number of different things. 95 00:10:40,449 --> 00:10:42,939 And it really depends on the organ that's involved. 96 00:10:43,029 --> 00:10:51,594 Um, a couple of things that you really want to think about and some of the main organs that are involved would be, one of the primary ones that I think about is pulmonary infection. 97 00:10:51,594 --> 00:10:58,194 So patients will present with your typical respiratory symptoms, including fever, dyspnea, cough. 98 00:10:58,284 --> 00:11:03,834 And typically when you look on their imaging, they'll see bilateral, oftentimes diffuse kind of infiltrates. 99 00:11:03,924 --> 00:11:05,304 And so keeping that in mind. 100 00:11:05,954 --> 00:11:18,084 Uh, CNS or central nervous system infection is another big one that I think about, especially once I've identified toxoplasma in other organ systems and they can present with, you know, a variety of different types of neurologic symptoms. 101 00:11:18,084 --> 00:11:24,084 So if they're having an unexplained headache or encephalitis or seizures or other focal neurologic deficits. 102 00:11:24,129 --> 00:11:32,319 You want to think about it and on their imaging, you'll typically see, you know, the buzzword is the multiple ring enhancing lesions, um, that you'll notice on their imaging. 103 00:11:32,649 --> 00:11:36,729 And those are typically localized near the, to the basal ganglia area. 104 00:11:37,329 --> 00:11:41,799 And so if you see that on imaging, that definitely raises high concern for toxoplasma CNS infection. 105 00:11:43,154 --> 00:11:47,444 Um, of course, as I said, you know, the predilection for muscle, it can infect the hearts. 106 00:11:47,444 --> 00:11:51,644 And so myocarditis you know, and congestive heart failure can be a presentation of that. 107 00:11:52,064 --> 00:12:02,175 Although sometimes that can be difficult to distinguish, um, from like rejection or other things if you're looking at heart transplant patients, and so sometimes you'll need to look at biopsy in order to be able to do that. 108 00:12:03,290 --> 00:12:08,789 Um, and then visual changes is another big one too, for the patients that have chorioretinitis. 109 00:12:09,439 --> 00:12:14,119 Um, because then they might have, you know, again, vision changes, photophobia things. 110 00:12:14,149 --> 00:12:20,449 And when you look at their retinal exam, you'll often see these like yellow to yellow, white lesions on their retina as well. 111 00:12:20,449 --> 00:12:23,930 And those are kind of, that's kind of a red flag of toxoplasma infection. 112 00:12:24,199 --> 00:12:30,469 So those would be some of the main manifestations that would kind of raise a little bit of a flag in my head. 113 00:12:31,519 --> 00:12:33,559 And you should keep a vigilant eye out for toxo. 114 00:12:34,099 --> 00:12:52,969 Um, especially, you know, I do agree that sometimes it does sort of fall a little bit to the back of the differential, but if you're, if you see any of these kinds of clinical syndromes and your other diagnostic workups, thus far as becoming unrevealing, then, you know, taking into consideration that patients and, you know, donor and recipient toxoplasma status, it should definitely be something that should be. 115 00:12:54,259 --> 00:12:54,619 Sara Dong: Yeah. 116 00:12:54,799 --> 00:13:03,109 And so let's say we have one of those presentations and were a bit worried about acute toxo in a solid organ transplant patient. 117 00:13:03,529 --> 00:13:06,589 What is our diagnostic test of choice? 118 00:13:06,589 --> 00:13:07,819 What do we want to request? 119 00:13:08,359 --> 00:13:08,719 Julie Steinbrink: Definitely. 120 00:13:09,399 --> 00:13:23,949 We talked already a bit about serologic testing and, you know, while you can do IgG testing for toxoplasma for screening purposes, and you can do the IgM for some evidence of acute infection, but it has varying sensitivity and specificity. 121 00:13:23,949 --> 00:13:27,489 So it's kind of not the best choice in this kind of situation. 122 00:13:27,489 --> 00:13:31,009 If you're thinking about acute infection, particularly in immunocompromised patients. 123 00:13:31,139 --> 00:13:41,074 Really if you can you really want to try to get a PCR, polymerase chain reaction testing, in these patients because that can really expedite diagnosis in these folks. 124 00:13:41,404 --> 00:13:46,894 And what's nice is that you can do it from different bodily fluids, depending on what organ system you're concerned for infection. 125 00:13:46,924 --> 00:13:50,854 So if you're concerned about CNS infection, you can get it off the CSF. 126 00:13:51,339 --> 00:13:54,159 You can get it off of the blood, if you're concerned for disseminated infection. 127 00:13:54,159 --> 00:13:57,789 If you're worried about the lungs, you can get it from the BAL fluid, you can get it from the vitreal fluid. 128 00:13:57,789 --> 00:14:08,199 And so if you, depending on, if even if they just have a localized to an organ system, you can still get, try to get a PCR from that bodily fluid, if possible, and that can really help you make a diagnosis. 129 00:14:08,319 --> 00:14:22,444 The nice thing about PCR testing is you can also quantitatively follow that as well, in addition to their clinical progress to determine how they're responding to treatment because their parasite loads, you know, theoretically be declining and, you know, while you're treating them with their appropriate therapy. 130 00:14:22,654 --> 00:14:28,894 I think the PCR of the bodily fluids or blood would be your first choice and probably the least invasive. 131 00:14:28,984 --> 00:14:33,994 Um, additionally of course, you know, one other gold standard would be, you know, if you had a biopsy and you were able to get that. 132 00:14:34,534 --> 00:14:42,244 And then if you see, you know, the tachyzoites on a, you know, on a cardiac biopsy, when you're concerned for that, then that would also determine the presence of acute infection. 133 00:14:42,244 --> 00:14:47,644 But obviously that's much more of an invasive procedure and not necessarily always as easy to be able to get in real time. 134 00:14:48,484 --> 00:14:51,664 Sara Dong: You know, we're not going to dig too much into treatment today. 135 00:14:51,664 --> 00:15:08,805 We talked a bit about prevention, but I thought I could end by one last question about challenges and management for these infections, the medications that we use, if you have any thoughts or things that you've learned, um, when treating patients with toxoplasmosis who have a transplant in the past. 136 00:15:08,925 --> 00:15:09,255 Julie Steinbrink: Yeah. 137 00:15:09,255 --> 00:15:30,290 So, uh, typically, you know, the guideline driven recommendations for treatment would be if you're using your induction regimen with the pyrimethamine, your sulfadiazine, and your leucovorin typically for a minimum of six weeks and followed by their chronic suppressive therapy with a lower dose for a period of time, again, kind of outlined in the ID COP guidelines. 138 00:15:30,410 --> 00:15:41,089 Um, of course there can be alternative regimens if you, if the patients either can't tolerate sulfas or if they can't get access to the drugs, you know, there can be other things. 139 00:15:41,089 --> 00:15:44,029 Various kind of mix and match regimens. 140 00:15:45,030 --> 00:15:53,099 Clindamycin and pyrimethamine or, you know, trimethroprin sulfa monotherapy, or potentially atovaquone monotherapy, kind of combinations of depending on that. 141 00:15:53,130 --> 00:16:00,510 But, but those would not, those would kind of be second line, if for some reason, either they had an, a drug intolerance or they couldn't get access to the drugs that were available. 142 00:16:02,204 --> 00:16:02,655 Sara Dong: All right. 143 00:16:02,655 --> 00:16:06,675 So I did want to mention a few resources before we finish up. 144 00:16:06,704 --> 00:16:12,285 And one, I sort of mentioned as we've come along, I hope most fellows have these bookmarked or saved. 145 00:16:12,285 --> 00:16:26,145 I, I actually have them all downloaded in a folder on my computer, but the AST ID Community of Practice has a collection of guidelines for, you know, toxoplasma is one of them, but various infections in transplant recipients. 146 00:16:26,175 --> 00:16:34,005 And so I always refer to these and in fact, many of the Febrile transplant based episodes, we've tried to structure in a way that reflects those guidelines. 147 00:16:34,005 --> 00:16:43,860 And so these are really great to get caught up on topics yourself, but I also think they're a really good resource to give to learners on your team if they're starting on a transplant rotation or aren't as familiar. 148 00:16:43,949 --> 00:16:54,209 Um, so for example, I'll put a link to the tissue and blood protozoa one that has toxoplasmosis in the Consult Notes, but I'm also put the link to the collection that has the other ones. 149 00:16:55,064 --> 00:17:06,804 In addition to this, there is an AST, it's kinda like a Zotero library, and so, you can go to the website, transplantid.net as well as on Twitter they're at @transplantIDnet. 150 00:17:06,824 --> 00:17:21,259 And this is an awesome, I guess I use the word crowdsource, but basically they see ID Community of Practice members have built this and maintained it and they have it sort of grouped into various clinical questions or topics that are related to transplant. 151 00:17:21,259 --> 00:17:29,960 And so it's a really great reference to find key resources, if you're in a, in a bind or maybe you're really busy, it's a fast way to find, find resources. 152 00:17:30,020 --> 00:17:33,560 And I don't know if you have any other thoughts on this Julie or other things you wanted to mention 153 00:17:33,705 --> 00:17:34,634 Julie Steinbrink: No, that was great. 154 00:17:34,634 --> 00:17:37,304 I think those are some of the top resources, you know? 155 00:17:37,395 --> 00:17:42,134 Um, and I know that both trainees and faculty alike use both of those resources. 156 00:17:42,525 --> 00:17:48,855 So, uh, yeah, those would be two of the top ones that I would plug, you know, the guidelines and then the additional articles to transplantID.net. 157 00:17:49,065 --> 00:17:50,114 So thanks. 158 00:17:50,114 --> 00:18:01,304 And, um, I'm also of course, going to give one more plug for our little survey that's going to be coming out, um, that, you know, we really, you know, again, in the spirit of improving, you know, education and training for our transplant ID trainees. 159 00:18:01,385 --> 00:18:05,945 Please when you see that come out, um, feel free to engage and let us know. 160 00:18:06,034 --> 00:18:09,004 We can get a better idea of where the gaps are in your transplant ID training. 161 00:18:09,004 --> 00:18:12,185 So that way we can further develop a more comprehensive curriculum in the future. 162 00:18:12,185 --> 00:18:13,745 So, uh, so thanks for that. 163 00:18:13,745 --> 00:18:16,264 And thanks so much, Sara, for, for allowing me to be on here. 164 00:18:16,264 --> 00:18:17,105 I really enjoyed myself. 165 00:18:17,850 --> 00:18:18,419 Sara Dong: Yeah. 166 00:18:18,629 --> 00:18:25,830 Well, the last thing I was going to say is for those who are considering transplant or aren't sure, it's a very welcoming community. 167 00:18:25,830 --> 00:18:33,450 I've reached out to plenty of people, both, you know, where at my institution, but also elsewhere and a lot of times through AST. 168 00:18:33,450 --> 00:18:37,710 So if you're trying to learn more about transplant, just reach out really to anyone. 169 00:18:37,710 --> 00:18:41,920 I bet they would love to talk, talk your ear off about doing transplant. 170 00:18:42,245 --> 00:18:43,864 Julie Steinbrink: I 100% agree with that. 171 00:18:43,864 --> 00:18:44,254 Yeah. 172 00:18:44,554 --> 00:18:48,304 Our AST, our ID Community of Practice loves welcoming people. 173 00:18:48,304 --> 00:18:55,475 Even if you're inquiring, just kind of experimenting with transplant ID, we're welcomed to kind of, you know, bring you over to our dark side here. 174 00:18:55,475 --> 00:18:57,574 And, uh, we, uh, we'd be welcome. 175 00:18:57,665 --> 00:19:00,935 We'd love to be able to chat with you and it'd be able to talk more. 176 00:19:00,935 --> 00:19:02,104 So thanks for bringing that up. 177 00:19:03,485 --> 00:19:03,874 Sara Dong: All right. 178 00:19:03,905 --> 00:19:05,284 Well, thank you so much, Julie. 179 00:19:05,705 --> 00:19:06,124 Julie Steinbrink: Thank you. 180 00:19:07,144 --> 00:19:07,955 All right, everyone. 181 00:19:07,955 --> 00:19:09,514 Thank you so much for listening. 182 00:19:09,544 --> 00:19:14,764 Our next episodein the Curious Congenital Conundrum series will be out next week on Monday. 183 00:19:15,304 --> 00:19:23,435 Uh, you can find Febrile on Twitter or at our website, febrilepodcast.com where you'll find links to all the mentioned articles from today's episode. 184 00:19:23,764 --> 00:19:24,665 Thanks for listening. 185 00:19:24,725 --> 00:19:26,314 Stay safe and I'll see you next week.