The Draft Returns: Love/Hates in Infectious Diseases

Paul Sax: [00:00:14] Hi, this is Paul Sax. I'm the editor in chief of Clinical Infectious Diseases. And welcome to the Let's Talk ID podcast. And today I'm joined by Dr. Rebeca Plank, a long-term ID colleague and friend. Rebeca, welcome. 

Rebeca Plank: [00:00:27] Thanks, Paul. Thanks for inviting me. 

Paul Sax: [00:00:29] Well, spring has come finally to cold Boston, and I thought that this would be a good time for Rebeca and I to get together and do another one of our antibiotic related drafts, although this one's much broader than that. So let me tell you what we're going to draft today. We are going to draft "love/hates" in infectious diseases. These are things that we both love and things that we hate. You got the general idea, Rebeca? 

Rebeca Plank: [00:00:52] Yeah. We have deep mixed feelings about. 

Paul Sax: [00:00:54] Exactly. In fact, my father, who was a psychiatrist, would call that ambivalence. I know your father wasn't a psychiatrist- 

Rebeca Plank: [00:01:01] No, he was not. 

Paul Sax: [00:01:01] Yeah, but you do know the word. These are things about which we have plenty of ambivalence. Because life, after all, isn't simple. It's not always black and white. It can be some grays. And we're going to share with you some grays today. So here are the rules. Each person will get three things that they choose to draft. It can be a medication, a diagnostic test, something related to infectious diseases. You have to explain why you love it and why you hate it. And you have to give the other person a chance to respond. If the other person takes one, it's off the books. You can't choose that one anymore. And then we'll talk about a love hate that's not an infectious disease, because life does exist outside of this great field of ours. 

Rebeca Plank: [00:01:44] 100%. 

Paul Sax: [00:01:46] Rebeca, since you've taken time out of your extremely busy schedule, you can go first. 

Rebeca Plank: [00:01:52] Thanks, Paul. Very kind. My number one draft pick for this is doxy PEP. 

Paul Sax: [00:01:59] Ah, doxy PEP. So explain now what doxy PEP is and give me your love/hate. 

Rebeca Plank: [00:02:06] Doxy PEP is a strategy that can be used for people who have had a diagnosis of a sexually transmitted infection within the last 12 months. They can be given doxycycline to take, essentially on-demand after sexual exposure, ideally within 24 hours, but up to 72. This has been shown to reduce the incidence very specifically of chlamydia and syphilis to a smaller degree, gonorrhea, in people who have been randomised to this strategy. And I will like to add that it is limited to men who have sex with men and transgender women who have sex with men. The same robust results were not seen in cisgender women in East Africa anyway. 

Paul Sax: [00:02:49] Okay, sounds all good so far. 

Rebeca Plank: [00:02:51] And additionally, the other reason I love it, right? Because that's something to love, is that it has reduced STIs in these populations, even though it has not been strongly demonstrated in women. However, it's also been shown to reduce population level in STIs. 

Paul Sax: [00:03:05] Yeah. 

Rebeca Plank: [00:03:06] Yeah. In certain populations. Right. Where you reach a certain level of saturation, I think. 

Paul Sax: [00:03:11] Okay. 

Rebeca Plank: [00:03:11] Now, the reason I hate it is because I'm going to harken back to our first podcast, which was the antibiotic draft, where you and I both chose doxycycline as our number one draft pick antibiotic. And soso, my concern, and as much as I love doxy PEP and the idea of it, I also am hesitant to embrace it is because I worry about the development of antimicrobial resistance. 

Paul Sax: [00:03:34] A very appropriate concern. And in fact, a fine journal that I'm aware of has already shown that there's an increase in the carriage of certain doxycycline resistant staph isolates in people who are using doxy PEP and in that fine journal, and guess what it is? 

Rebeca Plank: [00:03:50] Is it Clinical Infectious Disease? 

Paul Sax: [00:03:51] It sure is. Good guess. Okay. So, is there any other reason you hate it? 

Rebeca Plank: [00:03:55] I mean, I think from an individual perspective and a population perspective, I think it's a good thing. I think that we have to see what's going to happen with resistance over time. And as you say, this is mostly a concern for things like staph aureus. Also certain gram negative rods that occasionally, like if for a UTI, you could maybe use doxycycline. However, I don't think that people are walking around with, say, tularemia. That's going to be a commensal that will inadvertently, you know, have growing resistance to doxycycline. 

Paul Sax: [00:04:22] I was wondering when tularemia would come up in this podcast. Usually it takes a little longer. 

Rebeca Plank: [00:04:26] Earlier than that often. 

Paul Sax: [00:04:27] I like your first choice very much. That wasn't my first choice. 

Rebeca Plank: [00:04:29] Oh it wasn't? 

Paul Sax: [00:04:30] No, no. My first choice is trimethoprim sulfamethoxazole. 

Rebeca Plank: [00:04:34] Wow. 

Paul Sax: [00:04:34] Yes. All of those syllables at once. So, as you know, it is kind of like the Swiss Army knife of antimicrobials. It has all of these applications, not just with bacteria. I think it's still so remarkable that the treatment of choice for a fungal infection, pneumocystis pneumonia, and a parasitic infection, toxoplasma gondii, is the same antibacterial antibiotic we use for things like MRSA or E coli. I mean, it's pretty remarkable. So that gives me a lot of respect for trimethoprim sulfamethoxazole. It's incredibly well absorbed orally. So, you don't need to give it intravenously. And I would say, you know, the other thing about it is that you can give it up and down the age spectrum. You can give it to toddlers, you can give it to oldsters. It's just basically a terrific antibiotic. 

Rebeca Plank: [00:05:28] That is a lot to love. 

Paul Sax: [00:05:30] Yes, yes. And you'd share with me some of that love, yes? 

Rebeca Plank: [00:05:33] I agree, yes, I agree with that. 

Paul Sax: [00:05:36] But first of all, let me just talk about the pills. The pills are ginormous. They're absolutely huge. I mean, that's 960mg. I did the math of medicine in a single double strength tablet and a single double strength tablet is actually not an oxymoron in this case because it is one double strength tablet. It's kind of as big as, think about a Lego piece. It's kind of- 

Rebeca Plank: [00:06:00] You don't want to swallow those. 

Paul Sax: [00:06:01] No, you don't want to swallow those. Or step on them. And then, more importantly, the side effects. So, you know, hepatitis, bone marrow suppression, hyperkalemia, and then of course, rashes. And if you have never seen a trim sulfa rash, you haven't been in practice very long. And when they happen, they can be really bad. They can be life threatening. In fact, I used to ask when I used to talk to experienced primary care doctors, I used to say, raise your hand if you've had a patient who had to go to the hospital, the emergency room, or be hospitalized with a trim sulfa related hypersensitivity reaction. And it was incredible how many of these primary care doctors actually had experienced just that. Certainly, I have I remember seeing someone who had high fevers, terrible total body rash, and actually aseptic meningitis at the same time. It was really bad. He was in the hospital for several days, and I remember one of the great founding figures of transplant, infectious disease Dr. Bob Rubin. Remember him? 

Rebeca Plank: [00:06:56] Very well. 

Paul Sax: [00:06:57] Yeah, he once told me, he said, if this antibiotic went before the FDA now, it would never get approved. It's just too many severe side effects. I don't know if that's true or not, but a good way of expressing his opinion. So, it's definitely a love/ hate. And then the last thing I'm going to say about trimsulf is that, you know, I have this pet peeve about generic names, about using generics over brand names. And it's so hard to say trimethoprim sulfamethoxazole, that lots of people default to the brand name, even though brand name is like terribly outdated. 

Rebeca Plank: [00:07:30] And it's not the same everywhere. 

Paul Sax: [00:07:31] No it's not. It's some places it's bactrim, some places it's septra, some places, it's cotrim. So those are my reasons. That's my number one choice. 

Rebeca Plank: [00:07:39] Well, I agree with you that is, I frequently find myself wringing my hands when we are given essentially a clinical situation where we're choosing between trim sulfa and a quinolone. I think that they both have their benefits and they both have their risks. I think that recently the pendulum has swung in favor of trim sulfa over quinolones, but I think that that's a tough choice. 

Paul Sax: [00:08:05] It is a tough choice. 

Rebeca Plank: [00:08:06] Can you say more about how you make that choice, given because I think that the same love/ hate relationship exists with quinolones. 

Paul Sax: [00:08:13] Yeah. The quinolones, you know, the pendulum on quinolones has really swung way too far now in people avoiding them because they're really important antibiotics. But, you know, we've gotten so much publicity about their side effects that a lot of clinicians are scared to use them. But, you know, most people do fine on quinolones. So, I would say I'm probably most of the time choosing trim sulfa over the fluoroquinolone, but fluoroquinolone but sometimes choosing the other anyway. We're each going to choose our top three. So you've chosen your first one, which is doxy PEP. I've chosen my first one, which is trim sulfa, trimethoprim sulfamethoxazole, and now love hate number two for Dr. Rebeca Plank. 

Rebeca Plank: [00:08:51] Serum Beta-d-glucan testing. 

Paul Sax: [00:08:54] Ah, excellent choice. I didn't put that on my list, but I should have, I should have. I'm jealous. 

Rebeca Plank: [00:09:00] Okay. The thing that's appealing about this test is that it can pick up so many infections even before you are able to get the antigen back, the antibody back, the culture back. It picks up pneumocystis, which is incredibly important. Many fungal infections. I think that we use it hopefully every single time we recommend it, every time we send it, we're like, this is going to give us a definitive answer. And a lot of times it comes back in like a non-helpful range, which is a low positive. That's when I hate it. And the other reason I hate it is because it's sent sometimes in a clinical situation where it's not perfectly indicated. And in this hospital, there's so much focus on oncology and patients who have immunosuppression, that a lot of them have appropriate use of fungal markers. But I think that then everybody who comes in gets a fungal marker. And then that's really confusing. And there are other reasons for the test to be a false positive. Complicate the issue even more, especially in the ICU. 

Paul Sax: [00:09:59] Yes. I think this is a great choice. And I agree with your love and your hate. I mean, it was so transformative the first time I saw a patient with suspected Pneumocystis and could make the diagnosis with a blood test, and the person didn't even have to submit a sputum sample because he was at high risk for Pneumocystis. He had classic presentation. His blood test was positive. Unfortunately, when it's sent in like a person who's been, you know, smoldering in the ICU for weeks, you know, with surgical drains, it's often positive at a low level. We have no idea what to make of that. So excellent choice. I actually wrote a piece for a journal with one of our former fellows, Dr. Jed Pilkington, taking the con side of use of beta glucan. There was a group who took the pro side, but I could easily have taken the pro side. 

Rebeca Plank: [00:10:46] Because it's love/hate. 

Paul Sax: [00:10:47] Excellent choice. 

Rebeca Plank: [00:10:48] How about your number two? 

Paul Sax: [00:10:50] Number two for me is kind of going to be a little controversial. It's the mRNA Covid vaccines. So, these vaccines were life changing. They took this brand new virus, this brand new disease, and turned what was a life-threatening disease before into something that was much more manageable. It really did the trick. So, we basically had the sequence, we downloaded it. We created these vaccines with lightning speed. And suddenly in 2021, if you had had your Covid vaccines, the chances of you dying from this scary disease drop dramatically, dramatically. I remember I was doing inpatient medicine in the summer of 2021, and the people admitted with Covid that summer, you could easily tell the ones that had been vaccinated versus those who hadn't, because the ones who hadn't had so much more severe disease. It was like it was completely two different diseases. I've already mentioned the technology is amazing. It's being adapted in other ways. I just read about this baby where they used mRNA technology to combine with Crispr to completely transform a genetic disease from previously fatal to something that was basically manageable. So that's what I love about it. But we may have oversold them. We went from people hearing about these miraculous vaccines to basically saying, wait a minute, I got this vaccine and I still got Covid. You know what's going on? 

Paul Sax: [00:12:14] We had policies that probably lasted too long mandating the vaccine, even for people who'd been vaccinated before. You're required to have your third one to work here, or who had had Covid previously, which also induced immunity. So, we just kind of pushed a little too far. And all of this has created this unbelievable polarization in the public, not just about Covid vaccines, but about all vaccines. And we're still trying to get over it. And I think the one other thing I want to mention is that these are reactogenic vaccines. And we downplayed the side effects at first. Most people have minor side effects or minimal, but some people got severe side effects. And I think that was something we were slow to recognize. I'm just going to finally say this. I don't think we know anymore which healthy adults should get this vaccine every year. I know it was broadly recommended for pretty much the whole U.S. population as an annual vaccine, but, you know, a healthy 30-year-old, you know, the research kind of stopped. 

Rebeca Plank: [00:13:14] Do you think that we know who should get treated for Covid? 

Paul Sax: [00:13:17] You're talking about the use of nirmatrelvir ritonavir? 

Rebeca Plank: [00:13:21] No, I'm talking just in general. 

Paul Sax: [00:13:23] Okay. I'm a fan of antiinfectiveanti-infective treatment for infections. So I do feel that if we had the right antiviral that we should actually treat people with Covid if they're symptomatic. But the right antiviral we don't have, what we have is a tool that we're talking about Paxlovid now, a tool that was and molnupiravir tools that were developed when the disease was different. And so, we need something that's a little better now. I just want to say, parenthetically, there's going to be a post-exposure prophylaxis for Covid released soon called Ensitrelvir. And Ensitrelvir will be given for people with household exposures. And it'll act like giving oseltamivir or baloxavir post-influenza. So anyway, that's my number two love/ hate, the mRNA Covid vaccines. 

Rebeca Plank: [00:14:10] I like the points that you brought up. Okay. Yeah. Number three, for me, this may be controversial, also coming from an infectious disease doctor. It's the social history. 

Paul Sax: [00:14:19] The social history? [laughs] But I love the social history. 

Rebeca Plank: [00:14:23] Right! I know, I love it.  

Paul Sax: [00:14:25] Sometimes the most interesting part of the whole case. 

Rebeca Plank: [00:14:28] I completely agree, I completely agree. It's a little bit like that diagnostic test, though, that you're like, oh, what are we going to do with this? I'm just thinking that it's like a boards question, right? Like this person works as a butcher. Unless they're traveling in the Amazon, there's some social histories that we love to present, right? Because they're so over the top. And a lot of times they end up being red herrings. 

Paul Sax: [00:14:52] Ok, wait, so you like them? 

Rebeca Plank: [00:14:54] I love them- 

Paul Sax: [00:14:54] But? 

Rebeca Plank: [00:14:55] But I also hate them. Because they can be distracting. 

Paul Sax: [00:14:57] Okay. They're distracting. 

Rebeca Plank: [00:14:58] Because they can be distracting. They're always fun to hear about. 

Paul Sax: [00:15:02] Any particular social histories you want to share with me? Because I have a couple I want to share with you. 

Rebeca Plank: [00:15:07] Two cases in particular, where this was a real case where somebody came back with a fever after traveling in the Amazon. And this person went to do like an ayahuasca. I think that's the right name. It's some hallucinogenic experience in the Amazon. 

Paul Sax: [00:15:22] Yes, I would never heard of it. 

Rebeca Plank: [00:15:23] So, they went down and they hadn't gotten a single vaccine. Because one thing I love unequivocally is travel clinics. So, this person had not gone to travel clinic. They had not gotten any vaccines. They didn't take any prophylaxis. And while they were there, they drank the water. They swam in the river.  

Paul Sax: [00:15:37] High- risk behavior. 

Rebeca Plank: [00:15:38] Oh yeah. So, then they come back and they have a fever. We're like, oh, this is amazing. Like, it's such a rich social history. Go down this whole long path. And then like, at the end of the day, we look at the now this person has developed a rash and it's a target lesion. And this person is an artist who lives in Western Massachusetts and just had Lyme. But I feel like people get distracted. In fact, there was another case where this guy came back from hiking in Nepal with like chest pain and cough. And it turned out that what he had was ischemic heart disease. 

Paul Sax: [00:16:08] Oh, no. 

Rebeca Plank: [00:16:09] But people were going down this road of like, what's causing shortness of breath and cough when somebody would just come back from Nepal. 

Paul Sax: [00:16:13] My favorite example of this for foreign travel is a guy who actually was doing primate research in Southeast Asia, and his job involved going into the jungle and collecting the urine of the primates. He came back to the United States and he had fever. And I thought, oh my God, this is going to be some exotic Burmese jungle fever. And it turns out he had strep throat. All right, one more social history.  

Paul Sax: [00:16:44] I always mention this. I was working with a fellow who did very complete social histories, and we were seeing the patient together. The patient had been in a motorcycle accident, and he was in the room with his parents there. And the fellow was taking the history. And the fellow asked, does he have any pets? The patient was kind of sedated because of pain control, and the mother says, yes, he has a parakeet. The fellow said, what's the parakeet's name? And she said, Froot Loop. And I was thinking, this is not going to be relevant at all to this motorcycle accident. Anyway, just a small digression. 

Rebeca Plank: [00:17:19] I'll also add another point here about the social history. It's fun to ask about because you know what? People are always happy to talk about their pets. And when you ask them, have you had any, you know, do you have pets or animal exposures? They love to tell you about it. 

Paul Sax: [00:17:30] Their eyes light up. 

Rebeca Plank: [00:17:31] They light up. And then the other social history question that I love to ask is, what's the most exotic place you've ever traveled? Because people love to talk about that too. 

Paul Sax: [00:17:38] That's a good one. 

Rebeca Plank: [00:17:38] So in a way, like those are the reasons why I love the social history, but I just think that sometimes we get too attached to it. 

Paul Sax: [00:17:44] Okay, I'll grant you that one. 

Rebeca Plank: [00:17:45] How about yours? 

Paul Sax: [00:17:46] My number three is metagenomic sequencing. This is the, of course, most commonly done now with the carious type testing. Wow. It feels like magic. In fact, I'm going to say that you were one of the first people ever to mention this test to me. So, thank you for teaching me about it. This is way back in the Dark Ages. It's basically a blood test that detects non-human DNA and in the blood. So that's a way of figuring out whether someone has an infection when everything else is negative. Cultures are negative, imaging is unrevealing. The whole workup is just negative, negative, negative. And you're struggling with someone with fevers. And lo and behold. Or pulmonary- 

Rebeca Plank: [00:18:25] Cephalitis. 

Paul Sax: [00:18:26] Encephalitis. Pneumonia. Immunocompromised. Shazam! The next day, you get your result back. It's just a miraculous thing. The other thing I love about it, and I get to use the cliche, it's completely agnostic. You know, you don't actually need- 

Rebeca Plank: [00:18:39] The social history. 

Paul Sax: [00:18:40] You don't even need to tell the lab what you're looking for. It looks for you, which is pretty amazing. And then the other incredible thing is they've incorporated now detection of resistance genes when you have certain bacteria. So you get the result back. It's a staph aureus. And in your metagenomic test and they tell you whether it's MRSA or not, it's MecA testing comes back as well. So, it's pretty remarkable. 

Paul Sax: [00:19:01] So why do I hate it? Well, the first thing I want to mention is the cost. The high estimate for the cost of the test is about what I spent on my first car. Now of course, adjusting for inflation, it's so expensive that it's now extensively stewarded in most institutions. You try to order it as an outpatient, it's virtually impossible because insurance plans basically rarely ever cover it. And then the other thing about it is the test performance is weird. I mean, it picks up all of this other stuff that you probably don't even think is relevant. And learning when to interpret that correctly can be challenging. You've recently had a case here in the hospital where it was like the aha moment was the carrier was positive for Enterococcus species. But you know what probably wasn't related to the actual case? So, in that way, you're creating a new problem rather than solving one. The other thing that bothers me about this test is that we're using it now often as the last test. But I think the much more interesting question is when should it be used earlier on as one of the first tests? Let's say you have fever in the ICU, an early part of that assessment or a person who's showing up with endocarditis, you know, you get this result back in 24 hours. 

Rebeca Plank: [00:20:18] Who got antibiotics maybe before they came. 

Paul Sax: [00:20:20] Yeah, exactly. Exactly. Especially the people who got antibiotics rather than this long saga of culture negative endocarditis. And then I'm going to just mention outpatients again, outpatients with FUO. This is a powerful test. I was able to order this on someone, an older woman with weeks of fever. The fact that her Karius test was negative was incredibly powerful and ended up having a giant cell arteritis, which of course is a much more common cause of FOU. After all those negative cultures in the elderly. So, I love the test. I hate the test. 

Rebeca Plank: [00:20:53] So if it were less expensive, do you think that it would fall out of the love hate? 

Paul Sax: [00:20:57] If it were less expensive, we'd have a much better sense of how to interpret the results and use it much more broadly. I mean, I am not- this test will go the way of cross-sectional imaging. Cross-sectional imaging, once upon a time was very expensive and hard to get. And then over time, it's in every emergency room. People can get the tests really easily. It's so much more accurate than chest X-rays or plain films of the abdomen. So of course we're going to order that test much more often. The metagenomic blood test for infections is heading in that direction, but it's just going to take some time. 

Rebeca Plank: [00:21:29] Goodness. 

Paul Sax: [00:21:29] Yeah. So anyway we've done our top three. We did not overlap. 

Rebeca Plank: [00:21:33] Amazing. 

Paul Sax: [00:21:33] Can I mention a few others or do you want to mention any few others? 

Rebeca Plank: [00:21:36] Please go ahead. 

Paul Sax: [00:21:36] Okay. I had to put rifampin on here because rifampin almost made it to my list because it's such an incredible TB drug and it's got for non-tb infections for Ntms. It's also important and it's really important for bacterial infections because of its biofilm properties. But oh my goodness, those drug interactions. It is a problem child like none other. And so, rifampin and all the side effects, the hypersensitivity and the hepatitis and the leukopenia and the rifampin, it's hard. Sometimes you're thinking, I'm not really managing this infectious disease problem. I'm managing rifampin. 

Rebeca Plank: [00:22:13] That reminds me of the way that ritonavir used to be. 

Paul Sax: [00:22:15] Yes. 

Rebeca Plank: [00:22:15] When I used to use it much more frequently because yeah. 

Paul Sax: [00:22:18] The interactions, the opposite direction, of course. 

Rebeca Plank: [00:22:20] Right. Also, the indication was much narrower with rifampin. It's like you can use it for so many different things.  

Paul Sax: [00:22:26] Yeah. So, rifampin is an amazing, amazing drug. But you know, it's like, as I said, the problem child, but the brilliant problem child. And then the last thing I want to mention, because I chose five. Okay. And I have to because it's an HIV-related one. And it's the current HIV testing algorithm. It's sensitive. It's specific, you know, including the antigen and the screening test brings you like much closer to actual acute HIV diagnosis. And it even picks up HIV two differentiation assay, which is otherwise easy to miss. But all these changes have increased the number of false positives. Not only that, but related to that, you get this scenario where the screening test is reactive, but the confirmatory antibody test is negative, and that means it's one of two situations. It's either a false positive screening test or its acute HIV. 

Rebeca Plank: [00:23:16] Or they're on PREP. 

Paul Sax: [00:23:17] Or they're on PREP, or they're on HIV treatment and they're not telling you. I mean, there are all these situations. I wish we had diagnostic tests that were this accurate for most infections. So, I do love it. But you know what? This problem could be solved if the confirmatory tests were first, the HIV RNA. And the second test was a differentiation assay that would solve a lot of problems. 

Rebeca Plank: [00:23:40] So that's interesting because I actually I almost mentioned that one of my love/ hate things was when not an infectious disease doctor, but somebody who sees a person with fever of unknown origin or other fever sends an HIV test, which I really appreciate that people are thinking about it. I love that. But the thing that is less optimal is when the viral load is sent at the same time, and it's kind of like the beta glucan test because the viral load is like 140 or something. 

Paul Sax: [00:24:05] Yeah, the viral load test has gotten better, though it's not nearly as prone to those low-level false positives it used to be. Rebeca, I'm going to give you a chance to tell me about a non-infectious disease love/hate. 

Rebeca Plank: [00:24:18] Thank you. This actually has to do with the Covid-19 pandemic because I didn't cook a thing before the pandemic came. I had a repertoire of two recipes. And not only that, I had to consult the recipe every time I made them. 

Paul Sax: [00:24:29] You're like my sister-in-law. 

Rebeca Plank: [00:24:30] Oh, yeah. No cooking, no cooking. And so, then the pandemic came, and I could not either go out to dinner, nor could I join friends for dinner. So, now I was stuck. Well, of course, I had to join many CSAs, the community share of agriculture or something like that. These farm share rights where they get delivered to your house once a week. So, I love these things and I hate them. It's wonderful to get fresh fruits and vegetables from local producers, but at the same time, they can send you whatever they want. So, I had never known anything about the term kohlrabi before the CSA. 

Paul Sax: [00:25:05] Rutabaga? 

Rebeca Plank: [00:25:05] I mean, like these things come in this box. And so, but at the same time, it was great because it expanded my universe of not only vegetation but also of recipes. And I want to just say my cousins are universally outstanding chefs. They're really good. 

Paul Sax: [00:25:22] So, did you feel intimidated? 

Rebeca Plank: [00:25:24] Very. But also, then I'm like, oh, here are some garlic scapes. I've always wondered what those were, and it gave me an opportunity to really up my game. And now I probably cook 90% of the time. I don't even go out to dinner anymore. 

Paul Sax: [00:25:36] So, you love these CSAs? 

Rebeca Plank: [00:25:38] Yes. 

Paul Sax: [00:25:39] I hate them because. 

Rebeca Plank: [00:25:40] Because you can't control the stuff that you get. 

Paul Sax: [00:25:42] Okay. All right. My love/hate is YouTube. I think of YouTube as one of the greatest gifts to modern entertainment. I just want to share with you what's on my YouTube history. Okay. It is innumerable tennis instructional videos, innumerable cooking instructional videos, many vintage rock band performances. I could be on YouTube for hours. This is what I hate about it. I have to strictly limit my YouTube consumption. So, sometimes, like if it's late at night and I'm sitting either at my computer or watching television and I bring up YouTube, I look at the clock and I say, okay, you have half an hour. 

Rebeca Plank: [00:26:25] Wow. 

Paul Sax: [00:26:26] You cannot spend longer than half an hour on YouTube because otherwise you will be up past midnight watching old performances of, yes, Genesis, Elvis Costello, LED Zeppelin. That's just too long. So that's my love/hate for non-infectious disease topics. Okay, anyway, Doctor Rebeca Plank has joined me to discuss infectious disease love hates plus one non-infectious disease love hate. And we want to thank you for joining us. 

Rebeca Plank: [00:26:53] Well thank you Dr. Paul Sax. 

Paul Sax: [00:26:54] Can't wait to do the next draft. 

Rebeca Plank: [00:26:56] Thank you so much.