1 00:00:06,660 --> 00:00:07,440 Sara Dong: Hi everyone. 2 00:00:07,500 --> 00:00:11,400 Welcome to Febrile, a cultured podcast about all things infectious disease. 3 00:00:11,520 --> 00:00:18,240 I am Sara Dong, a Med-Peds ID fellow and Arthur is back with me today for another Febrile Digest. 4 00:00:18,549 --> 00:00:19,299 Arthur Jackson: Hey Sara! 5 00:00:19,320 --> 00:00:20,580 Thanks for having me again. 6 00:00:20,799 --> 00:00:29,390 Sara Dong: 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. 7 00:00:29,450 --> 00:00:31,070 So I think I'll start us off. 8 00:00:31,130 --> 00:00:44,754 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. 9 00:00:45,025 --> 00:00:54,775 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. 10 00:00:54,805 --> 00:01:01,055 But the first report that was published was from the UK Health Security Agency from April 8. 11 00:01:01,055 --> 00:01:13,039 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. 12 00:01:13,130 --> 00:01:19,400 And then that was followed up, really the next week, on April 14th by, uh, another Rapid Communication. 13 00:01:19,400 --> 00:01:23,870 This time from Eurosurveillance, and I'll put links to all these for anyone to look at. 14 00:01:23,900 --> 00:01:30,020 Um, but this had a little bit more detail about the initial investigation for the first Scottish cases. 15 00:01:30,080 --> 00:01:35,030 And around the time that they published in mid April, they had 13 cases from March and April. 16 00:01:35,060 --> 00:01:38,660 The children were a median age of a little under four years old. 17 00:01:39,050 --> 00:01:49,470 They all had vomiting, jaundice, and ALT numbers that were over 2000 and then their other workup had had been overall unrevealing. 18 00:01:49,500 --> 00:01:54,420 Hepatitis A B, C, and E as well as COVID testing were negative. 19 00:01:54,690 --> 00:01:58,810 And then there was a mixture of both negative and positive testing for Adenovirus. 20 00:01:59,100 --> 00:02:04,800 So three of these children were evaluated for transplant and one actually received a successful liver transplant. 21 00:02:05,100 --> 00:02:18,115 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. 22 00:02:18,594 --> 00:02:27,774 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. 23 00:02:27,834 --> 00:02:36,820 And at that point had compiled at least 169 cases, but a much broader, uh, age range than the prior two reports. 24 00:02:36,820 --> 00:02:43,660 So anywhere from one month to 16 years old, but 10% of the patients required liver transplant, uh, which is a really high number. 25 00:02:43,660 --> 00:02:52,049 And then adenovirus have been identified in a least 74 of the cases, which really prompted this to be one of the leading hypotheses. 26 00:02:52,069 --> 00:03:02,299 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. 27 00:03:02,369 --> 00:03:14,569 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. 28 00:03:14,659 --> 00:03:35,674 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. 29 00:03:35,734 --> 00:03:36,364 And so it's interesting. 30 00:03:36,364 --> 00:03:43,170 They did have information about the quantity of the viral load being anywhere from 1000 to 70,000 [copies/mL]. 31 00:03:43,170 --> 00:03:46,679 And this ended up being about nine children that were identified. 32 00:03:47,179 --> 00:04:08,754 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. 33 00:04:10,194 --> 00:04:23,274 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. 34 00:04:23,394 --> 00:04:23,514 Arthur Jackson: Yeah. 35 00:04:23,744 --> 00:04:26,214 You did a great job there, putting all that together. 36 00:04:26,464 --> 00:04:27,474 That's a lot of information. 37 00:04:27,544 --> 00:04:29,314 Sara Dong: I did talk really fast!. 38 00:04:29,904 --> 00:04:36,534 Arthur Jackson: 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? 39 00:04:37,704 --> 00:04:54,074 Sara Dong: 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. 40 00:04:54,074 --> 00:04:55,244 And it's hard to know. 41 00:04:55,244 --> 00:04:56,984 Maybe it's not adenovirus at all? 42 00:04:57,164 --> 00:04:57,884 Arthur Jackson: Exactly. 43 00:04:57,884 --> 00:05:06,134 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. 44 00:05:06,134 --> 00:05:15,414 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. 45 00:05:16,289 --> 00:05:34,149 Sara Dong: 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. 46 00:05:34,429 --> 00:05:41,729 Arthur Jackson: Yeah, it's great that the, um, this is one where COVID vaccine is not being highlighted as a, as a putative cause. 47 00:05:42,159 --> 00:05:44,079 So I'm very glad to hear that. 48 00:05:44,229 --> 00:05:46,179 Um, so will I go onto my next study? 49 00:05:46,229 --> 00:05:49,149 So we were going to talk about the Landman, et al. 50 00:05:49,169 --> 00:05:49,739 study. 51 00:05:49,769 --> 00:05:54,459 It's a French multi-center trial that was published in Lancet HIV recently. 52 00:05:54,459 --> 00:05:58,749 So they call it the QUATUOR trial, 59 sites in France. 53 00:05:58,999 --> 00:06:03,309 They looked at four days on, three days off for HIV therapy. 54 00:06:03,759 --> 00:06:05,349 This was really interesting. 55 00:06:05,349 --> 00:06:08,609 They, um, they enrolled about 336 adults. 56 00:06:08,959 --> 00:06:12,025 They, they had multiple baseline regimens. 57 00:06:12,054 --> 00:06:17,754 They included protease inhibitor based regimens, and NNRTI, as well as integrase inhibitor regimens. 58 00:06:17,814 --> 00:06:23,754 They looked at, um, a non-inferiority and they found non-inferiority, which was really interesting. 59 00:06:24,554 --> 00:06:37,754 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? 60 00:06:37,784 --> 00:06:56,989 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. 61 00:06:57,449 --> 00:07:02,159 So a larger study probably is needed to see whether that is something that, that comes through. 62 00:07:02,339 --> 00:07:07,149 And this was a study that went on for 48 weeks, so like the equivalent of a year. 63 00:07:07,629 --> 00:07:10,319 They followed their patients pretty much every three months. 64 00:07:10,709 --> 00:07:20,999 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. 65 00:07:21,719 --> 00:07:31,239 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. 66 00:07:31,759 --> 00:07:39,959 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. 67 00:07:40,139 --> 00:07:47,309 They also looked at some of the other, um, potentially you might call them secondary markers, such as inflammatory markers. 68 00:07:47,359 --> 00:07:52,999 The, they did not find any rise in things like ultra-sensitive CRP or the like. 69 00:07:53,489 --> 00:08:02,449 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. 70 00:08:03,349 --> 00:08:05,559 So it's a really interesting study. 71 00:08:05,559 --> 00:08:10,959 And, um, it makes you think, is this going to change the way we practice in the future? 72 00:08:12,039 --> 00:08:16,689 Obviously a lot of people are already switching to dual therapy rather than, um, triple therapy. 73 00:08:16,689 --> 00:08:21,039 So this is a study looking at triple therapy in this intermittent regimen. 74 00:08:21,039 --> 00:08:24,129 So could it be applied to dual therapy in the future? 75 00:08:24,549 --> 00:08:28,719 And, uh, I suppose it's the question of how low can you go or or something along those lines? 76 00:08:28,719 --> 00:08:30,909 It's it's not enough yet to change my practice. 77 00:08:31,780 --> 00:08:34,449 But it is very interesting. 78 00:08:34,539 --> 00:08:41,319 And, um, I, I think it looks like something that might end up changing practice as time goes on. 79 00:08:41,559 --> 00:08:41,889 Sara Dong: Yeah. 80 00:08:41,889 --> 00:09:04,704 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. 81 00:09:04,704 --> 00:09:12,454 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. 82 00:09:12,544 --> 00:09:12,754 Arthur Jackson: Yeah. 83 00:09:12,754 --> 00:09:14,494 That's certainly another benefit of any rate. 84 00:09:14,584 --> 00:09:15,994 Anyway, no question about it. 85 00:09:15,994 --> 00:09:18,934 You can, you can lean on the data a little bit from that point of view. 86 00:09:19,294 --> 00:09:19,714 Sara Dong: Yeah. 87 00:09:19,804 --> 00:09:28,594 So my next article is what I thought was a really cool study, uh, from Justesen and others in CID from earlier in April. 88 00:09:28,654 --> 00:09:48,004 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. 89 00:09:48,064 --> 00:09:59,649 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. 90 00:09:59,739 --> 00:10:09,459 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. 91 00:10:09,519 --> 00:10:21,889 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. 92 00:10:21,920 --> 00:10:36,074 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. 93 00:10:36,074 --> 00:10:42,094 So Bacteroides ovatus and B.uniformis as well as some Fusobacterium. 94 00:10:42,285 --> 00:10:47,354 And these patients were actually at similar risk for cancer as items like Strep bovis. 95 00:10:47,444 --> 00:10:53,925 So this leads to that question of what risk level should really prompt a colorectal cancer workup? 96 00:10:55,254 --> 00:11:04,044 Is there a time or a threshold when you would ask for that evaluation and cases of bloodstream infections with certain anaerobic gut bugs. 97 00:11:04,194 --> 00:11:09,444 And then, you know, I think the followup question to that as whether it actually translates into improvement in their morbidity. 98 00:11:10,074 --> 00:11:14,484 Uh, so the registry didn't have data on pre-malignant or adenoma lesions. 99 00:11:14,484 --> 00:11:29,664 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. 100 00:11:29,874 --> 00:11:52,964 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. 101 00:11:52,964 --> 00:12:11,444 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. 102 00:12:11,714 --> 00:12:17,154 Arthur Jackson: It's interesting to see just the once again, the integration of big data with medicine. 103 00:12:17,739 --> 00:12:23,229 So there is an obviously being able to study 2 million people that are get data in that, in that scenario. 104 00:12:23,540 --> 00:12:34,914 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. 105 00:12:34,944 --> 00:12:38,364 So it's from Ekberg et al, New England Journal recently. 106 00:12:38,454 --> 00:12:46,804 And, um, they looked at, they were doing a non-inferiority study looking at complicated UTIs or pyelonephritis in admitted patients. 107 00:12:47,164 --> 00:12:57,784 And they randomized them to either ertapenem or this new drug, which is an oral drug called, uh, tebipenem pivoxil hydrobromide. 108 00:12:58,324 --> 00:13:01,924 No surprise that it was proven to be non-inferior. 109 00:13:01,924 --> 00:13:07,404 So I'm, I'm not, I'm not going to go to huge details about the methods and the likes. 110 00:13:07,404 --> 00:13:15,864 So it was a study looking at this oral regimen of 600 milligrams, three times a day, versus ertapenem one gram once a day. 111 00:13:16,134 --> 00:13:19,674 And they found that there was similar cure rates, no difference. 112 00:13:19,974 --> 00:13:29,489 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. 113 00:13:29,849 --> 00:13:41,729 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? 114 00:13:42,059 --> 00:13:55,764 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. 115 00:13:55,764 --> 00:14:02,244 So, um, there really is a huge issue with, with antimicrobial resistance, which we all know about. 116 00:14:02,694 --> 00:14:12,414 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. 117 00:14:13,254 --> 00:14:24,414 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? 118 00:14:24,414 --> 00:14:25,584 Unless that's a concern. 119 00:14:25,824 --> 00:14:25,974 Sara Dong: Yeah. 120 00:14:26,454 --> 00:14:40,324 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. 121 00:14:40,424 --> 00:14:57,134 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. 122 00:14:57,134 --> 00:15:08,379 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. 123 00:15:08,649 --> 00:15:09,039 Arthur Jackson: Yeah. 124 00:15:09,039 --> 00:15:17,709 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. 125 00:15:18,309 --> 00:15:19,779 So, um, we definitely. 126 00:15:20,454 --> 00:15:21,204 The idea. 127 00:15:21,204 --> 00:15:22,554 It is somewhat terrifying. 128 00:15:22,554 --> 00:15:32,034 The idea of a, an oral carbapenem that is licensed and, um, and available to anyone to prescribe. 129 00:15:33,069 --> 00:15:36,789 Sara Dong: Yeah, well, speaking of stewardship, that was a great transition. 130 00:15:36,789 --> 00:15:43,119 My next article it's a little bit of a combo of transplant ID and antimicrobial stewardship. 131 00:15:43,149 --> 00:15:59,534 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". 132 00:15:59,564 --> 00:16:02,454 And so there was a paper by, uh, Dr. 133 00:16:02,454 --> 00:16:09,984 So and others called Bring It On-- Top Five Anti-microbial Stewardship Challenges in Transplant ID and Practical Strategies to Address Them. 134 00:16:10,044 --> 00:16:12,924 And this was in Anti-microbial Stewardship and Health Epi. 135 00:16:12,984 --> 00:16:17,514 And so I thought this was a really cool, sort of like a summary paper. 136 00:16:17,544 --> 00:16:27,654 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. 137 00:16:27,684 --> 00:16:44,659 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. 138 00:16:44,689 --> 00:16:51,919 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. 139 00:16:51,949 --> 00:16:53,869 Um, so I'd recommend people check it out. 140 00:16:53,959 --> 00:17:01,024 Arthur Jackson: Yeah, I think it sounds really, really important and really difficult to, uh, to properly get a handle on. 141 00:17:01,684 --> 00:17:10,744 So another one I was going to talk about is the OFID publication by Hillenbrand et al, about Candida and the eyes. 142 00:17:11,194 --> 00:17:14,164 So I thought this is quite interesting for a few reasons. 143 00:17:14,214 --> 00:17:26,634 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. 144 00:17:27,569 --> 00:17:33,570 As an ID doctor, I've always gone with the, with the line that yes, it is important and it is needed. 145 00:17:34,110 --> 00:17:41,489 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. 146 00:17:41,580 --> 00:17:52,289 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. 147 00:17:52,799 --> 00:18:11,059 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. 148 00:18:11,539 --> 00:18:15,299 Echinocandins don't have ocular penetration. 149 00:18:15,299 --> 00:18:30,829 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. 150 00:18:31,110 --> 00:18:32,310 So this was a study. 151 00:18:32,610 --> 00:18:55,494 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. 152 00:18:55,544 --> 00:19:09,784 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%. 153 00:19:09,784 --> 00:19:17,914 So, so really and truly, they were feeling that they were seeing a, a greater increase in ocular complications with time. 154 00:19:18,454 --> 00:19:46,529 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. 155 00:19:46,739 --> 00:20:09,344 Sara Dong: 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. 156 00:20:09,584 --> 00:20:32,399 Arthur Jackson: 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. 157 00:20:32,639 --> 00:20:32,729 Sara Dong: Yeah. 158 00:20:32,759 --> 00:20:32,909 Yeah. 159 00:20:33,059 --> 00:20:39,119 Well, my next one is another tie in back to actually a, a Febrile episode. 160 00:20:39,119 --> 00:20:42,179 So I selected a paper from Dr. 161 00:20:42,179 --> 00:20:55,719 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. 162 00:20:55,749 --> 00:21:10,384 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. 163 00:21:10,414 --> 00:21:13,444 You know, this is an area that we're still trying to understand. 164 00:21:13,474 --> 00:21:23,334 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. 165 00:21:23,354 --> 00:21:33,074 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. 166 00:21:33,074 --> 00:21:37,154 But, uh, there are several observational studies that were in contrast to that. 167 00:21:37,334 --> 00:21:44,644 I actually posted this previously from the Febrile account when I saw it because it timed really well with our ongoing case-based episodes. 168 00:21:44,644 --> 00:21:46,714 So hopefully folks are listening to those. 169 00:21:46,714 --> 00:21:49,234 We're doing this Curious Congenital Conundrum series. 170 00:21:49,284 --> 00:21:52,094 The episode for CMV from Drs. 171 00:21:52,124 --> 00:21:54,644 Hermione Lyall and Nuria Sanchez Clemente. 172 00:21:54,674 --> 00:21:55,884 It's number 37. 173 00:21:56,004 --> 00:21:56,294 Dr. 174 00:21:56,294 --> 00:22:05,374 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. 175 00:22:05,374 --> 00:22:15,154 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. 176 00:22:15,154 --> 00:22:17,764 And hopefully the Consult Notes and the website as well. 177 00:22:17,794 --> 00:22:24,084 I think I've linked to all the majority of the papers that would be relevant, but it was just had good timing. 178 00:22:24,464 --> 00:22:26,664 Arthur Jackson: Yeah it sounds really good. 179 00:22:27,134 --> 00:22:30,564 Uh, my last paper is the, um, is an editorial. 180 00:22:30,564 --> 00:22:36,444 I just thought it was interesting and topical and, um, it was written by a written in the BMJ. 181 00:22:36,594 --> 00:22:38,274 They don't give a name of an author. 182 00:22:38,274 --> 00:22:49,164 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. 183 00:22:49,614 --> 00:22:52,784 And, um, it's, it's specifically mentioning the Ukrainian war. 184 00:22:52,924 --> 00:23:10,449 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. 185 00:23:10,794 --> 00:23:17,004 They of course look at vaccine preventable diseases, especially measles outbreaks and polio outbreaks, they mentioned. 186 00:23:17,454 --> 00:23:35,844 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. 187 00:23:36,769 --> 00:23:43,429 They do reference wars in Afghanistan, Yemen, uh, Burma, but they, they do focus a lot on this Ukraine war. 188 00:23:43,759 --> 00:23:55,759 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. 189 00:23:56,509 --> 00:24:11,779 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. 190 00:24:11,829 --> 00:24:17,349 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. 191 00:24:18,594 --> 00:24:19,044 Sara Dong: Yeah. 192 00:24:19,094 --> 00:24:39,584 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. 193 00:24:39,584 --> 00:24:57,809 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. 194 00:24:58,469 --> 00:24:59,999 You know, I think the main message. 195 00:25:00,029 --> 00:25:15,019 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. 196 00:25:15,559 --> 00:25:15,949 Arthur Jackson: Yeah. 197 00:25:15,949 --> 00:25:22,759 And it's would say, um, it's amazing to see the same awful outcomes happening again and again and again and again. 198 00:25:22,759 --> 00:25:24,619 So, um, it's, it's really important. 199 00:25:25,469 --> 00:25:32,069 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. 200 00:25:32,309 --> 00:25:32,489 Sara Dong: Yeah. 201 00:25:32,639 --> 00:25:34,079 Well, we did it, Arthur! 202 00:25:34,669 --> 00:25:36,389 We got in right under 30 minutes. 203 00:25:36,389 --> 00:25:37,739 We have like a minute left. 204 00:25:38,059 --> 00:25:39,989 I so nice to have you back. 205 00:25:39,989 --> 00:25:47,009 And uh, we'll keep, keep bringing these episodes and hopefully, you know, folks have suggestions for things that we should talk about. 206 00:25:47,009 --> 00:25:48,569 They can always send it to us. 207 00:25:48,729 --> 00:25:49,509 Arthur Jackson: Absolutely! 208 00:25:49,509 --> 00:25:51,089 Thank you so much for having me on again. 209 00:25:51,089 --> 00:25:51,899 It's a real honor. 210 00:25:52,049 --> 00:25:52,289 Thank you. 211 00:25:53,924 --> 00:25:55,094 Sara Dong: Thank you all for listening. 212 00:25:55,124 --> 00:25:58,824 Like our other episodes, I'll put links to all the articles in our consult notes. 213 00:25:59,094 --> 00:26:02,664 Stay safe and, I'll see you next week..