News

CDC has issued “Interim Guidelines for Preventing Sexual Transmission of Zika Virus” and “Updated Interim Guidelines for Health Care Providers Caring for Pregnant Women and Women of Reproductive Age with Possible Zika Virus Exposure.”

Written by: Pui-Ying Iroh Tam, MD

When is the testing that we do too much? This is not at all a novel issue, but a dilemma that physicians have long voiced. In fact, in 2012, 42% of US primary care physicians believed that patients in their own practices were receiving too much care, which occurred most commonly as a result of malpractice concerns (76%), clinical performance measures (52%), and inadequate time to spend with patients (40%) [1].

Recently, I consulted on an 11 month-old male who had been transferred from a rural hospital with several days of fever and an expanding rash that began on his buttocks. On exam he was noted to have red, cracked lips, but there was no bulbar conjunctival injection, nor any of the other features of Kawasaki disease. Most notable were the targetoid lesions on his face, chest and trunk, which were clearly evident at the time of our involvement in his care.

Given the history of sick contacts in the household, and mindful also of the rare but fatal adverse effects of intravenous immunoglobulin therapy that I had personally witnessed, I elected further testing to investigate for infectious causes such as mycoplasma and herpes simplex virus, among others. I had thought that my workup would help rule out other potential etiologies and would bring clarity to the management of an infant with possible atypical Kawasaki. However, when the next attending came on-service a few days later, all the pending tests proved to be more of an encumbrance than an assistance, since the consult team now felt bound to follow up on the results – though my more experienced colleague felt quite certain that the patient had Kawasaki.

The healthcare costs that have been generated as a result of overtesting are increasing and unsustainable: in 1980, costs were $253 billion, in 1990 it was $714 billion, and in 2008 it was $2.2 trillion [2]. Out of this, excessive testing is believed to cost $200-250 billion per year [3]. One paper examining high-value cost-conscious care provided a list of 37 clinical situations in which a test did not reflect high-value care. The six relevant infectious disease scenarios included [2]:

  1. Serologic testing for suspected early Lyme disease;
  2. Serologic testing for patients with chronic nonspecific symptoms and no clinical evidence of disseminated Lyme disease;
  3. Performing sinus imaging studies for patients with acute rhinosinusitis in the absence of predisposing factors for atypical microbial causes;
  4. Performing pre-discharge CXR for hospitalized patients with community-acquired pneumonia who are making a satisfactory clinical recovery;
  5. Obtaining CT scans in patients with pneumonia that is confirmed by CXR in the absence of complicating clinical or radiographic features; and
  6. Performing follow-up imaging studies of incidentally discovered pulmonary nodules ≤4 mm in low-risk individuals.

However, if we expanded this to other aspects of pediatric infectious diseases practice, should we not also include in the list of unnecessary overtesting: daily complete blood count with differentials and inflammatory markers in patients who are making a satisfactory clinical recovery; the ordering of both C-reactive protein and erythrocyte sedimentation rate tests in patients with suspected illness, infection or inflammation; or even the repetitive ordering of blood cultures for febrile patients after the first several sets are negative? If one accounts not only for excessive testing but also follow up testing for unnecessary diagnostic tests and procedures, as well as extra days in the hospital, nearly one-third of all healthcare spending – or $800 billion – is wasted [3], without arguably an improvement in clinical outcomes.

With this patient one could fault the numerous studies I requested, which all ended up being negative, as prevarication. Eventually, intravenous immunoglobulin therapy was administered to the patient, who rapidly defervesced, clinically improved and was discharged soon after. In retrospect, the reasoning behind the workup could be attributed to all the survey responses listed above, as well as by my limited experience [4], particularly compared to that of my older colleague. As a specialty that relies heavily on diagnostic testing to manage and follow our patients, we are as much bound by the need to consider high-value, cost-conscious care as other physicians. In the primary care survey, 76% of respondents stated that they were interested in learning how aggressive or conservative their own practice style was compared with that of other physicians in their community [1]. This openness and receptivity is something that we as a specialty should also be cognizant of, and the findings of which we should strive to address, for the sake of our patients.

References

  1. Sirovich BE, Wooshin S, Schwartz LM. Too Little? Too Little? Too Much? Primary care physicians' views on US health care: a brief report. Arch Intern Med. 2011 Sep 26;171(17):1582-5. doi: 10.1001/archinternmed.2011.437.
  2. Qaseem A, Alguire P, Dallas P, Feinberg LE, Fitzgerald FT, Horwitch C, Humphrey L, LeBlond R, Moyer D, Wiese JG, Weinberger S. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012 Jan 17;156(2):147-9. doi: 10.7326/0003-4819-156-2-201201170-00011.
  3. Reuters. American College Of Physicians Tackles Issue Of Excessive Medical Testing. 7 December 2015. http://www.huffingtonpost.com/2012/02/16/american-college-of-physicians-medical-testing_n_1281277.html. Accessed 7 Dec 2015.
  4. Grady D. Reasons for overtreatment: comment on "Too little? Too much? Primary care physicians' views on US health care". Arch Intern Med. 2011 Sep 26;171(17):1586. doi: 10.1001/archinternmed.2011.461.

Written by: Galit Holzmann-Pazgal, MD

Zika virus is a previously relatively unknown flavivirus. Originally discovered in 1947 in the Zika forest of Uganda when a rhesus monkey developed infection, it was subsequently reported only sporadically in humans from 1951-1981 via serologic evidence in people from multiple African countries and parts of Asia.

The first large outbreak outside of Africa and Asia was reported in 2007 in the Federated States of Micronesia. Illness was relatively mild consisting of rash, arthralgia and conjunctivitis. Subsequently, the virus spread further, and an outbreak was reported in French Polynesia in 2013. This outbreak was characterized by more severe illness including neurologic and autoimmune complications such as Guillain Barré syndrome.

In 2014, localized (autochthonous) transmission was first reported in Chile (Easter Island). In 2015, Brazil confirmed autochthonous transmission with subsequent spread within the country and in late 2015, reported a 20 fold annual increase in cases of newborns born with microcephaly linked to maternal infection with Zika virus during pregnancy. The virus was also determined to be spreading throughout Central and South America. In December of 2015, the first confirmed case of Zika virus locally transmitted in Puerto Rico was confirmed, and in January of 2016 the first U.S. case of a newborn born with microcephaly due to Zika virus infection was reported in Hawaii. That infant’s mother likely became infected in Brazil. No autochthonous transmission in the United States has been reported to date.

Zika virus is spread via the bite of the Aedes species of mosquitos, particularly Aedes aegypti, the same mosquito responsible for the spread of Dengue and Chikungunya in the Americas. It is a single stranded RNA flavivirus related to Dengue, Yellow Fever and West Nile Virus. Additional routes of transmission include perinatal and in utero. There are also reports of Zika virus RNA in blood and semen with solitary reports of possible sexual and transfusion related transmission.

The symptoms of Zika virus infection include fever, headache, malaise, arthralgia/myalgia, maculopapular pruritic rash and conjunctivitis. Many of these symptoms are similar to Dengue and Chikungunya but are typically milder. Severe disease is rare. It is estimated that 1/5 infected people will develop symptoms. The incubation period ranges from a 2-7 days and duration of illness is usually just a few days but can last up to a week.

Diagnosis can be made via RT-PCR on acute phase samples (within a week of symptom onset). In addition, serology can be performed. IgM testing should be done > 4 days after symptom onset. As Zika virus typically occurs in areas with other mosquito borne illnesses such as Dengue and Chikungunya, these infections must also be considered in the differential of symptomatic patients and returning travelers. Diagnosis can be complicated by cross reactivity of Zika virus antibodies with other flaviviruses.

Testing is available via the CDC or some state health departments. Information can be found at http://www.cdc.gov/zika/hc-providers/diagnostic.html. An algorithm specifically for testing of pregnant women with potential exposure to Zika virus has recently also been released by the CDC. http://www.cdc.gov/mmwr/volumes/65/wr/mm6502e1er.htm 

Care of infected individuals is supportive. There are no currently available antivirals or vaccine available for Zika virus.

At this time, there are CDC travel alerts (level 2) to areas of the world with ongoing local transmission of Zika virus. Travel to these areas is discouraged for pregnant women and steps to avoid mosquito bites should be taken in affected geographic locations. http://wwwnc.cdc.gov/travel/notices

In conclusion, Zika virus is an emerging pathogen with rapidly spreading global significance. Since the vector of spread, the Aedes mosquito, is found throughout the world and is common in urban areas with dense populations, the virus is likely to continue spreading through both South/Central America and possibly the Southern United States.

References:

  1. Hayes EB, Zika virus outside of Africa. Emerging Infectious Diseases 2009 Sep; 15(9):1347-50.
  2. Zika virus outbreaks in the Americas. Wkly Epidemiol Rec. 2015 Nov 6; 90(45): 609-10.
  3. www.cdc.gov/Zika

The CDC, in consultation with the American Academy of Pediatrics, has developed interim guidelines for the evaluation, testing, and management of infants born to mothers who traveled to or resided in an area with Zika virus transmission during pregnancy. The document provides guidance to healthcare providers caring for 1) infants with microcephaly or intracranial calcifications detected prenatally or at birth or 2) infants without these findings whose risk is based on maternal exposure and testing for Zika virus infection.

Pediatric healthcare providers should ask mothers of newborns with microcephaly or intracranial calcifications about their residence and travel while pregnant and about any symptoms of illness compatible with Zika virus disease (acute onset of fever, rash, joint pain, and red eyes). Healthcare professionals should also obtain the results of any Zika virus testing performed before the mother gave birth.

The Interim guidelines recommend that doctors and their teams consider possible clinical issues when caring for infants who might have been infected with Zika virus infection. For example, cranial ultrasound is recommended for all infants with possible Zika virus infection unless prenatal ultrasound results in the third trimester demonstrated no brain abnormalities. Also recommended for all infants with possible Zika virus infection, regardless of symptoms, are repeat hearing screening and developmental monitoring.

Treatment of Zika virus infection in babies is supportive and should address the infant’s specific needs. Investigations are ongoing to better understand what services will be most appropriate for affected children as they grow.

These interim guidelines will be updated as more information becomes available.

The guidelines can be found here: http://dx.doi.org/10.15585/mmwr.mm6503e3er 

Please forward to other colleagues as appropriate. If you have additional questions related to Zika virus, please contact CDC-Info at 1-800-CDC-Info or http://www.cdc.gov/cdc-info/.

Written by: Janet Gilsdorf, MD, FPIDS

As 2015 slips behind us, it’s a good time to reflect on the many successes of the Pediatric Infectious Diseases Society over the past year. Our journal, JPIDS, was accepted for MEDLINE indexing, meaning ...

Written by: Gregory P. DeMuri, MD

Article Summary

In the December issue of the Journal of the Pediatric Infectious Diseases Society Koningstein and colleagues report the results of an epidemiological study of extended-spectrum-cephalosporin-resistant (ESC-R) Escherichia coli in day-care centers in the Netherlands.1 This study was performed over a 22 month period from 2010-2012 in 44 different day care centers throughout the country. It was conducted as a part of a national prospective cohort study of infectious diseases in day care centers. Stool samples were taken from randomly assigned attendees monthly and cultured for E. coli. Isolates were screened for ESC-R using disk diffusion testing and confirmed by PCR. In addition, demographic and environmental risk factors were studied.

Overall, 852 stool samples were analyzed from the study population. The mean age of sampled children was 20 months. The authors found that 38 of 852 (4.5%) of children were colonized with ESC-R E.coli. There was a trend for an increase in the prevalence during the first part of the study compared to the second: 3.2% in 2010-2011 and 5.8 % in 2012 though the results did not achieve statistical significance. The majority of ESC-R E. coli strains detected contained blaCMY-2, blaCTX-M-1, or cAmpC mutations. Significant risk factors for ESC-R colonization in day care center attendees were: age < 1 year old, attending centers where paper towels were available, restricting ill children from attending day care, performing extra checks on handwashing of ill children, and always reporting notifiable diseases to local health authorities. The authors conclude that day care attendance leads to exposure to both colonizing agents such as ESC-R E. coli and community –associated pathogens such as respiratory viruses, resulting in the higher chances of receiving antibiotic treatment, which may impact on ESC-R carriage, especially in infants. They call for further study of day care practices to prevent colonization and infection with these organisms.

Comments

This study caught my attention after I consulted on a 6 month old infant who had been admitted to the hospital for a febrile UTI secondary to E. coli. The infant had been treated with an oral cephalosporin and then admitted when susceptibility testing showed resistance to all cephalosporins, and all oral agents. She was treated with a course of meropenem and discharged. What is a bit disturbing is that she had no traditional risk factors for a multi-drug resistant organism; no prior illnesses and no prior antimicrobial exposure. She did, however, attend day care. What should have been treatable with an oral antimicrobial required several days of inpatient IV therapy.

In this investigation about 5% of children attending day care harbored ESC-R E. coli in the stool and a trend in increased detection was observed over the 22 month study period. This study has several limits in interpretation. First, it was done in the Netherlands and the results may not apply to other populations of children. Secondly, this was a study of colonization as all study subjects were asymptomatic. The rate of drug resistance in invasive strains might be different. In addition, children not attending day care were not included as controls. Nonetheless the results are concerning. In this same issue of JPIDS Stillwell et al describe an outbreak of KPC-3 carbapenem resistant Klebsiella pneumoniae in a US pediatric hospital.2 Also in this issue Drew et al studied 551 isolates of ESBL for the UK producing Enterobacteriaceae and found extensive associated antimicrobial resistance in these isolates and the only consistent antibiotic class to which the isolates remained susceptible were the carbapenems.3

Children in day care settings tend to be the canaries in the coal mine for pediatric infectious diseases. The detection of antibiotic resistant, gram-negative organisms in presumably healthy children is disturbing. Further epidemiologic studies are needed to track these organisms and to determine effective means of controlling spread in the population. Meanwhile the results of this study may suggest that in the near future we will treat more and more “community acquired” multidrug-resistant, gram-negative infections in children.

References

  1. Koningstein M, Leenen MA, Mughini-Gras L, et al. Prevalence and Risk Factors for Colonization With Extended-Spectrum Cephalosporin-Resistant Escherichia coli in Children Attending Daycare Centers: A Cohort Study in the Netherlands. J Pediatric Infect Dis Soc 2015;4:e93-9.
  2. Stillwell T, Green M, Barbadora K, et al. Outbreak of KPC-3 Producing Carbapenem-Resistant Klebsiella pneumoniae in a US Pediatric Hospital. J Pediatric Infect Dis Soc 2015;4:330-8.
  3. Drew RJ, Ormandy EE, Ball K, et al. Antimicrobial Susceptibility Patterns Among Extended-Spectrum beta-Lactamase-Producing Enterobacteriaceae in a Large Pediatric Hospital in the United Kingdom. J Pediatric Infect Dis Soc 2015;4:e147-50.

Written by: Saul R. Hymes, MD

It’s becoming a late November tradition: rake the last of the leaves before winter; reserve the Turkey at the butcher; engage in one of the largest worldwide media, social media, education and advocacy events around antibiotic resistance and judicious antibiotic use...wait, what?

Since 2008, the Centers for Disease Control and Prevention (CDC) has organized an annual week-long set of activities aimed at increasing awareness about antibiotic resistance (which, if you don’t know by now, is a huge problem) and antimicrobial stewardship under the auspices of their existing year-round Get Smart program, led by Lori Hicks, DO. The observance of this so-named Get Smart Week (this year from November 16-22), in the CDC’s own words,

...is a key component of CDC’s efforts to improve antibiotic stewardship in communities, in healthcare facilities, and on the farm in collaboration with state-based programs, nonprofit partners, and for-profit partners. The one-week observance raises awareness of the threat of antibiotic resistance and the importance of appropriate antibiotic prescribing and use.

Every year the program attracts more partners and more followers and this year seemed to cross a threshold in two important ways. While Get Smart Week has often coincided with similar day-long or week-long events in other countries (European Antibiotic Awareness Day, Australia's Antibiotic Awareness Week), this year was the first year that it coincided with a new World Antibiotic Awareness Week sponsored by the World Health Organization (WHO). Additionally, for the first time ever, the week was made official by the White House, with President Obama proclaiming November 16-22, 2015 as Get Smart About Antibiotics Week.

It’s only fitting that this year’s week should be even bigger and more official than previous years—it’s been a banner year for antibiotic stewardship in general, with the initiation of the Combatting Antibiotic Resistant Bacteria (CARB) Action Plan and Advisory Council, The White House Forum on Antibiotic Stewardship, and impending rules by CMS and JCAHO requiring antimicrobial stewardship programs of various types of hospital facilities. But the best part about Get Smart Week, and the thing that really makes it run, is the activities—by all of its official partners and also by all of us. So how can we all Get Smart ourselves and help others do the same?

If your hospital is a member of the SHARPS group, it may be involved in activities for Get Smart Week. SHARPS is a multi-center data-sharing and QI collaborative formed to improve antimicrobial prescribing and stewardship and co-led by Jason Newland, MD, MEd; Adam Hersh, MD, PhD; and Jeff Gerber, MD, PhD, MSCE. Many of the SHARPS institutions put up posters, organize educational sessions, make t-shirts and pins, and in other ways raise the awareness of antimicrobial stewardship at their hospitals. Even if your hospital isn’t a SHARPS institution, or if you aren’t based at a single hospital, you can very easily use the pre-made flyers, posters, and other materials the CDC makes available on their Get Smart website to put together a local awareness and education campaign. And who among us doesn’t have some slides about antibiotics or antibiotic resistance? Choose Get Smart Week to give that lecture to your medical students or residents.

But if you’re a PIDS member (and chances are good that if you’re reading this, you are), you’re already a contributor, at least a little, as PIDS was an official partner in Get Smart Week this year. PIDS participated in a global twitter chat on Wednesday, November 18, and was in the top ten for most tweets during both the 2-hour chat period as well as the for the entire day. PIDS also co-led a twitter chat on Friday, November 20th, focusing on antibiotic use in animal agriculture. This topic received further emphasis this year, with all of Friday devoted to activities designed to educate on the issue, and the early release during the week of a report by the AAP on the pediatric impact of antibiotics used in animal agriculture.

The Twitter chats deserve further special mention, as this is an opportunity for all to get involved in Get smart Week in a very easy and high impact way. We have already seen the potential role for social media in medicine discussed here in PIDSNews; but more than a research tool, social media can be a powerful avenue for advocacy, education, and outreach. The CDC itself provides a social media toolkit to partners and encourages participation via Facebook posts or Twitter activity; and they measure the impact this activity has. Last year Get Smart Week generated over 60 million individual impressions—the number of times someone viewed a Get Smart Week-related social media message. This year the Twitter activity alone on one single global twitter chat day (November 18th) led to over 163 million impressions. At 27,000 impressions averaged among each of the 6,000 participants, that’s far more people than any of us could hope to reach in a lifetime of practice or local stewardship efforts.

This year’s Get Smart Week has drawn to a close but hopefully, for next year, some of you reading this will be inspired: to organize activities at your institutions, to join Twitter and join the social media conversation, and in general to advocate as broadly as possible to our fellow physicians, governments, and the public to Get Smart about antibiotics.

Dear PIDS members:

The information recently forwarded by IDSA and HIVMA regarding alternative sources of pyrimethamine for treatment of toxoplasmosis contains a link to order pyrimethamine + leucovorin from Imprimis, a compounding pharmacy. Please note IDSA, HIVMA and PIDS are not endorsing any particular medication or pharmacy for alternative treatments for toxoplasmosis.

The order form from Imprimis lists six fixed combination ingredient formulations, all pills, containing pyrimethamine + leucovorin.
http://www.imprimiscares.com/ImprimisCaresOrder_Form.pdf 

The recommended* treatment for congenital toxoplasmosis is:

  • Pyrimethamine: 1 mg/kg every 12 hours orally for 2 days; followed by 1 mg/kg once per day orally for 2 or 6 months; followed by 1 mg/kg once per day every Monday, Wednesday, Friday
  • Sulfadiazine: 50 mg/kg every 12 hours orally
  • Folinic acid (leucovorin): 10 mg three times weekly orally

The total duration of treatment usually is one year.
*Long/Pickering/Prober, Principles and Practice of Pediatric Infectious Diseases, 4th edition, Table 273-1.

While the fixed combinations of pyrimethamine and leucovorin contained in the Imprimis pills will not provide the correct doses of both drugs for young children, Imprimis is able to compound liquid formulations with specified amounts of pyrimethamine and leucovorin to meet the required doses for an individual baby.

Compounded products are not subject to approval by the U.S. Food and Drug Administration, but may be appropriate for individual patient use. As with treating any condition, providers will need to evaluate the most appropriate treatment option on a case-by-case basis in consultation with their patients. More information on pharmaceutical compounding is available from the American Pharmaceutical Association.

If you have difficulty obtaining the drug for your young patients, we suggest you call Imprimis 866-551-7195 (toll-free) or work with the pharmacists at your institution to understand the best options for obtaining appropriate liquid formulations.

The 7th Annual International Antimicrobial Stewardship Conference, jointly sponsored by Children’s Mercy Kansas City and The Pediatric Infectious Diseases Society will occur on June 2-3, 2016.  We are currently developing another outstanding program. New this year will be a Thursday morning basics of antimicrobial stewardship session targeted toward medical and pharmacy residents and fellows as well as people just starting their antimicrobial stewardship program. Also another great aspect of the conference is the Thursday night dinner that gives everyone a chance to network and enjoy a night of fun and Kansas City barbeque.  Finally, this year we will have both oral and poster presentations so please submit all your abstracts to This email address is being protected from spambots. You need JavaScript enabled to view it. by February 29th, 2016. (Please be aware of the much earlier date of when the abstracts are due.)

How do we overcome the mindset of anti-vaccinators, a.k.a. anti-vaxers? I sat down with Adam Strasberg1, a political strategist and ad creator, to discuss how to improve the medical community’s approach to vaccine advocacy. He gave me new perspectives on the issue with insights on behavioral economics, ethnography, and the mindset of the lay person.

  1. Brute force does not work. Drilling more science into the minds of college-educated anti-vaxers does not work and may actually produce contradictory results. Nyhan et al. recently published two articles showing current scientific-based public health communications may actually increase misperceptions or reduce vaccination intention with MMR and influenza vaccine.
     
  2. Emotions matter. Communication is more than just about being on message. Personal stories influence more than the scientific data. Emotions move more than facts. The rise of social networks, blogging and instant internet access on handheld devices has empowered all-comers to tell their stories. Professional degrees are not needed, and are often a hindrance to telling good stories. We, as doctors, need to improve our story-telling techniques. To support the science, we also need to talk about the college freshman we cared for who was left without legs from meningococcal infection or the 6 year old boy who died from the “strangling angel” diphtheria this year in Spain. Stories are emotion delivery vehicles.
  3. Young pediatricians need more experience. Because our vaccines have been so successful, graduating pediatricians today have never seen chicken pox let alone polio or measles. How can they powerfully tell stories about patients they have never cared for? Some effective ways to stir emotion in our trainees beyond lecturing and showing pictures are: 1) Send them abroad. One case of neonatal tetanus or watching a child die from Hib meningitis knowing that the illness was preventable by vaccination will remain etched in their memories for a lifetime. 2) Bring all of your trainees to see the child with exposed muscle following surgery for group A strep necrotizing fasciitis. Remind them that these patients were common before the varicella vaccine. Take them to the pertussis baby on ECMO in the PICU. All trainees should at least see the pertussis cough video. 3) Bring in patients who have recovered from meningococcemia or dealt with HPV and cervical cancer to talk about their experiences. Our trainees understand the science but they will be better vaccine promoters if they also understand the emotions.
  4. Community immunity. Belonging to a community can be a powerful motivator. Everyone wants to be a part of a community. Members of a community feel responsible to help and contribute to their community. Using the phrase “herd immunity” creates the wrong frame for anti-vaxers. A herd follows unthinkingly; most anti-vaxers do not want to be part of a herd. The terminology should be changed to “Community Immunity,” to incite a sense of belonging and purpose.
  5. Mother vaccine spokesperson wanted. We need to reconsider how the medical profession is delivering the message on vaccines. Currently, pro-vaccine spokespersons are experienced male doctors who are revered in the scientific world for their enormous contributions to vaccine science. However, anti-vaxers frequently view them as patriarchs in a social system in which males hold primary power. Anti-vaxers are often young, educated new mothers who want no part of this historically patriarchal society. While there is value in male physicians providing vaccine guidance, the pro-vaccine messages additionally should be articulated in our media sources by women who are mothers as well as doctors. They can more effectively start the discussion with, “I know that you want to do what is best for your children...”
  6. Understand what drives Anti-Vaxers. We continue to speak of vaccination as a public health and science issue, despite the inability of those constructs to influence anti-vaxers. Instead of speaking to parental rights, perhaps we should focus more on protecting innocent children. Instead of promoting science, we should emphasize the naturalness of the vaccination process – it is not a scientific or artificial occurrence, but a natural one, akin to lifting weights to get stronger. We need more research to understand the levers that move anti-vaxers so we can learn to speak with metaphors and constructs that influence them to reconsider their objections. Our children deserve it!

Written by: Pia S. Pannaraj, MD, MPH
Children's Hospital Los Angeles

1 Adam Strasberg is the son of acting teachers. He was raised in the world of actors, theatre and books. With an MFA from NYU Graduate Film School, Adam eschewed the bright lights of Hollywood, instead finding his element fusing his creative talent with his desire for social change inside the world of politics. He is a partner at a marketing consulting firm in Washington, DC. He can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it.

Article summary
In the June issue of the Journal of the Pediatric Infectious Diseases Society, Schwartz and colleagues describe their experience with invasive fusariosis, a relatively rare but often fatal infection. This is a retrospective review of all cases of culture-proven, invasive Fusarium in immunocompromised children at a large, tertiary care facility from 1996-2011. Of 13 children at the authors' institution with positive cultures for Fusarium species, 5 were immunocompromised hosts with invasive infection. Four of the 5 children described previously underwent hematopoietic stem cell transplant (HSCT) with subsequent prolonged neutropenia. All 5 cases had lung involvement, while 2 had skin findings, 2 had brain involvement, and 1 had a positive blood culture for Fusarium. All cases were treated with amphotericin B, while 3 also received voriconazole, and 1 child received granulocytes. Four of the cases were coinfected with bacteria, viruses, or other fungi. All 4 of the children who had undergone HSCT died, with Fusarium believed to be a contributing cause of death.

In addition to these 5 cases, the authors reviewed all reports of invasive Fusarium infections in children available in the literature, summarizing 33 published cases from 1973 to 2012. In this review, the skin (21 cases) was the most common site of infection, followed by blood (14) and lung (11), with brain (3) and sinuses (2) reported less frequently. Treatment was variable, though amphotericin was the most common antifungal used, reported in 25 cases.

Commentary
Fusarium species are second only to Aspergillus spp. as the most frequent mold implicated in human infections, with invasive disease occurring almost exclusively in immunocompromised hosts. Given the high mortality rate, relative resistance to antifungals, and interspecies variability in susceptibility profiles, treatment of infections due to Fusarium spp. remains a challenge for both adult and pediatric infectious disease physicians. Furthermore, the paucity of available pediatric data introduces an added layer of difficulty in the management of these often complicated patients. In addition to nicely summarizing the available pediatric literature on invasive fusariosis, the article by Schwartz et al also reinforces some important features of Fusarium infections in children.

First, despite reports of the changing epidemiology of fungal infections in children and adults with cancer,1,2 invasive fusariosis remains an uncommon diagnosis. A previous retrospective study reported an overall incidence of ~6 cases per 1000 HSCT, higher in allogeneic compared to autologous transplants.3 While the present article does not report the local incidence, with only 5 cases in a 15 year period at a location with the highest number of new cancer diagnoses and HSCTs in Canada, it seems unlikely to be significantly higher than that previously reported. Second, the authors highlight the variability in treatment of these patients. Although the majority of children received amphotericin, there was inconsistency in the use of combination therapy and adjunctive therapies, such as granulocyte colony stimulating factor and granulocyte transfusion. Finally, it appears that although the prognosis remains poor we may be making progress. Mortality in this series remains high at 50%, but this is an improvement compared to 92% mortality rates reported less than 30 years ago.4 This is likely multifactorial, reflecting differences in the management of patients with malignancy, improvements in diagnostic techniques, changes in the use of antifungal agents, and overall advancements in medical care, among others.

Another noteworthy finding of this case series is the number of coinfections. In the 5 cases described by the authors, 4 had at least one other pathogen detected: 1 child had Staphylococcus aureus, 1 had Aspergillus fumigatus, 1 had both adenovirus and cytomegalovirus (CMV), and 1 had both CMV and Stenotrophomonas. Although a high rate of coinfection has been described in patients with invasive pulmonary aspergillosus5, this has not been widely studied in patients with fusariosis and may have potential implications for both the pursuit of additional diagnostic evaluation following detection of Fusarium spp. and empiric antimicrobial therapy.

Due to its infrequent occurrence and uncertain applicability of in vitro susceptibilities, the optimal management of patients with invasive fusariosis remains unclear. A number of questions have yet to answered, including the role of combination antifungals and adjunctive therapies, such as granulocyte transfusion. This article underscores the need for continued research into this often fatal disease in order to provide evidence-based recommendations for diagnosis and management. --Rebecca Wallihan, MD

References:

  1. Ben-Ami R, Lewis RE, Raad, II, Kontoyiannis DP. Phaeohyphomycosis in a tertiary care cancer center. Clin Infect Dis. Apr 15 2009;48(8):1033-1041.
  2. Maron GM, Hayden RT, Rodriguez A, et al. Voriconazole prophylaxis in children with cancer: changing outcomes and epidemiology of fungal infections. Pediatr Infect Dis J. Dec 2013;32(12):e451-455.
  3. Nucci M, Marr KA, Queiroz-Telles F, et al. Fusarium infection in hematopoietic stem cell transplant recipients. Clin Infect Dis. May 1 2004;38(9):1237-1242.
  4. Richardson SE, Bannatyne RM, Summerbell RC, Milliken J, Gold R, Weitzman SS. Disseminated fusarial infection in the immunocompromised host. Reviews of infectious diseases. Nov-Dec 1988;10(6):1171-1181.
  5. Georgiadou SP, Kontoyiannis DP. Concurrent lung infections in patients with hematological malignancies and invasive pulmonary aspergillosis: how firm is the Aspergillus diagnosis? J Infect. Sep 2012;65(3):262-268.

It's been quite a year in vaccine news. The year has been full of triumphs and full of gloom – from the declaration of polio almost being eradicated in Africa1 to the return of vaccine-preventable diseases like measles in the United States2. We felt the palpable fear of acute flaccid paralysis due to enterovirus D683 to the media hysteria of Ebola. And we celebrated the achievements of vaccine immunologists with the successful trials of the Ebola vaccine4 while dealing with the mismatched prediction for last year's influenza season5. In many ways, the news has captured the entire cycle of public perception of emerging infectious diseases and vaccination – from fear to triumph to forgetfulness of the dangers of vaccine-preventable diseases to suspicion over the value of routine vaccination.

Although these cycles have always occurred throughout the history of modern vaccination, the events of the past 18 months have felt more jumbled as numerous emerging infectious diseases and vaccine-preventable diseases have dominated the public consciousness. And unfortunately, many children continue to suffer from vaccine-preventable diseases due to lack of access to vaccines or misguided parental mistrust6.

But maybe the tide of public opinion is shifting. In a recent survey from the Public Policy Institute of California, over 65% of California adults agreed that children should be vaccinated in order to attend public school7. This public sentiment, along with advocacy from California State Senator and Pediatrician Dr. Richard Pan, eventually culminated in the passage of SB277 in California eliminating public belief exemptions in children attending public school8. In doing so, they joined Mississippi and West Virginia as the only states that do not allow personal belief exemptions. As a California resident, I am amazed at this turn of events. It was only a few years ago, we were watching personal belief exemption rates rise, celebrity talking heads rallying against vaccination, vilification of the human papilloma virus vaccine, and erosion of confidence in the vaccine schedule. While there is still a vocal minority espousing many of these misguided sentiments, there appears to be a change in overall public opinion.

What caused this change? There's no doubt that the California measles outbreak was a major factor in raising awareness about vaccine-preventable diseases. In addition, the recent pertussis outbreaks in California reinforced the importance of vaccination and herd immunity. Finally, there was the general concern surrounding the West Africa Ebola outbreak, MERS-coronavirus, and Enterovirus-D68. Perhaps it was all of these fear-inducing events that led to change. There's no doubt that fear is a powerful motivator. Researchers recently demonstrated that the best strategy in changing people's minds about vaccination was to communicate the dangers of a child getting measles or mumps9. But fear to change minds can only accomplish so much for so long. The real challenge is to continue to affect change when people forget about the fear. This is why the efforts of advocates like Dr. Pan in passing SB277 are so important. This will lead to lasting public policy change to improve public health and to protect children from vaccine-preventable diseases. But the battle is not over. Anti-vaccine groups have already vowed to fight SB277 in the courts and at the ballot box. And they have already targeted individual lawmakers who supported the bill. Dr. Pan's efforts have been met with death threats and a petition to recall him.

In the end, our mission as PIDS members doesn't change: continue to advance the science of vaccines, continue to communicate the safety and efficacy of vaccines, and continue to advocate for common sense public policy to increase vaccination coverage. As we celebrate the 60th anniversary of the polio vaccine and the prospect of a polio-free world, let's press forward to achieving our goal of "Freedom from infections for all children". --David K. Hong, MD

REFERENCES

  1. McNeil DGJ. A Milestone in Africa: No Polio Cases in a Year. The New York Times 2015 8/11/2015.
  2. Zipprich J, Winter K, Hacker J, et al. Measles outbreak--California, December 2014-February 2015. MMWR Morb Mortal Wkly Rep 2015;64:153-4.
  3. Greninger AL, Naccache SN, Messacar K, et al. A novel outbreak enterovirus D68 strain associated with acute flaccid myelitis cases in the USA (2012-14): a retrospective cohort study. Lancet Infect Dis 2015;15:671-82.
  4. Henao-Restrepo AM, Longini IM, Egger M, et al. Efficacy and effectiveness of an rVSV-vectored vaccine expressing Ebola surface glycoprotein: interim results from the Guinea ring vaccination cluster-randomised trial. Lancet 2015.
  5. Flannery B, Clippard J, Zimmerman RK, et al. Early estimates of seasonal influenza vaccine effectiveness - United States, January 2015. MMWR Morb Mortal Wkly Rep 2015;64:10-5.
  6. The Editorial Board. Children Die Because People Are Wrongly Afraid of Vaccines. The New York Times 2015 August 20, 2015.
  7. PPIC Statewide Survey: Californians and Their Government. Public Policy Institute of California, 2015. at http://www.ppic.org/main/publication.asp?i=1153.) 
  8. Mello MM, Studdert DM, Parmet WE. Shifting Vaccination Politics - The End of Personal-Belief Exemptions in California. N Engl J Med 2015.
  9. Horne Z, Powell D, Hummel JE, Holyoak KJ. Countering antivaccination attitudes. Proc Natl Acad Sci U S A 2015;112:10321-4.

Since the chickenpox vaccine became available in the U.S. in 1995, there has been a large reduction in chickenpox cases. Hospitalizations and outpatient visits for chickenpox have continued their decline after a second dose of the vaccine was recommended to improve protection against the disease, according to a new study published in the Journal of the Pediatric Infectious Diseases Society. The findings also suggest that increasing vaccination coverage against the once common childhood illness helps protect those who are not immunized themselves.

Chickenpox, also known as varicella, is a highly contagious and sometimes serious disease caused by the varicella-zoster virus. In people who are not vaccinated, it typically causes a blister-like rash, itching, fatigue, and fever. Before the vaccine was available in the U.S. in 1995, about 4 million people would get chickenpox nationwide each year, according to the Centers for Disease Control and Prevention (CDC). Nearly 11,000 people were hospitalized annually, and 100 to 150 people died. A second dose of the vaccine was recommended in 2006.

In this latest study, CDC researchers Jessica Leung, MPH, and Rafael Harpaz, MD, MPH, drawing on national health care claims data from 1994 to 2012, found that there were 93 percent fewer hospitalizations for chickenpox in 2012 compared to the period before the vaccine was introduced. During the two-dose varicella vaccination period (2006-2012), hospitalizations declined 38 percent. Outpatient visits for the illness also dropped significantly. There were 84 percent fewer outpatient visits in 2012 versus the pre-vaccination period. During the two-dose varicella vaccination period (2006-2012), outpatient visits declined 60 percent.

"We found that, in our study, rates for varicella in the U.S. continued to decline as the varicella vaccine program has become fully implemented," said Leung, the study's co-author. "We saw significant declines in rates of varicella after the one-dose vaccine was recommended in 1995 in the U.S., and we're continuing to see additional declines in varicella after two doses were recommended in 2006."

The largest declines were among children and adolescents 1 to 19 years old, a population targeted for vaccination against chickenpox. But the researchers also saw substantial declines in outpatient visits and hospitalizations among infants younger than 12 months, for whom the vaccine is not recommended, and in adults, who are often not immunized, suggesting the possibility of herd immunity. "The surrounding population that can be vaccinated are not getting sick, and therefore the data suggest that these infants are also being protected," Leung said. "We're seeing that for adults as well."

The study also found a considerable rise—from 6 percent in 2003 to 17 percent in 2012—in the proportion of outpatient visits for chickenpox in which patients were tested for the disease. The authors noted that lab testing will become increasingly important for distinguishing chickenpox from other similar rash conditions as cases of chickenpox continue to decline and health care providers become less familiar with its clinical presentation, and the increasing proportion of chickenpox cases among people are who are vaccinated, which are typically mild and difficult to diagnose based on symptoms alone.

Impact of the Maturing Varicella Vaccination Program on Varicella and Related Outcomes in the United States: 1994–2012

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Published quarterly, the Journal of the Pediatric Infectious Diseases Society represents the spectrum of peer-reviewed, scientific and clinical information on perinatal, childhood, and adolescent infectious diseases. The journal is a publication of the Pediatric Infectious Diseases Society (PIDS), the world's largest professional organization of experts in the care and prevention of infectious diseases in children.

PIDS membership encompasses leaders across the global scientific and public health spectrum, including clinical care, advocacy, academics, government, and the pharmaceutical industry. From fellowship training to continuing medical education, research, regulatory issues and guideline development, PIDS members are the core professionals advocating for the improved health of children with infectious diseases both nationally and around the world, participating in critical public health and medical professional advisory committees that determine the treatment and prevention of infectious diseases, immunization practices in children, and the education of pediatricians. For more information, visit http://www.pids.org

I had a hallway consult from one of our pediatric hospitalists recently about a toddler with a clear cut case of Kawasaki disease who had been discharged from the inpatient unit. Her question was straightforward, about aspirin dose and duration, and she added at the end of our conversation "I assumed you didn't want to see the patient, since it was uncomplicated." I was taken aback at first, and as I digested this brief encounter I realized why. Just a few years ago our service would have been involved in every case of Kawasaki disease in the hospital either in consultation or as the primary service. I wondered if we are facing competition from our hospitalist colleagues.

Pediatric hospital medicine has been one of the fastest growing sub-specialties within pediatrics. The American Academy of Pediatrics formally recognized pediatric hospital medicine as a discrete area of practice in 1999. In the past 15 years hospitals have increasingly adopted the hospitalist model of care in the inpatient setting. 1,2 It is estimated that about 3000 Pediatric Hospitalists practice in the United States. 3 Hospitalists have taken a wide role in caring for children including direct inpatient care, medical consultation, procedures, outreach clinic and teaching.4

As the field of Pediatric Hospitalist Medicine grows it will present new challenges and opportunities to our subspecialty. As hospitalists gain more experience and confidence they will feel comfortable caring for children with more common bread-and-butter infectious diseases such as complicated pneumonia, osteomyelitis, intra-abdominal abscess, meningitis and even Kawasaki disease, perhaps without involving Pediatric Infectious Diseases. We may find ourselves in competition with our colleagues in the hospital setting. Unlikely most other sub specialist we do not have a unique set of procedural skills, such as endoscopy or placing tubes and lines which would give us a defined niche and job security. Our specialty is primarily cognitively based and this makes us a bit more vulnerable.

Even more concerning is the competition that we face for residents entering fellowship programs. Our subspecialty has had a very challenging year filling fellowship positions. Hospitalist positions have become very attractive and popular options for graduating residents. It is likely that we are finding ourselves in a competition for candidates for fellowship. Although the number of fellowships in hospital medicine is growing, most hospitalist jobs do not require training beyond residency. As residents carry a larger and larger debt load from medical school, the ability to pay off students loans earlier by taking a hospitalist position right out of residency, as an alternative to pursuing a fellowship becomes attractive. In addition, the 2014-15 Association of Academic Administrators in Pediatrics national compensation survey reported that median salaries for assistant professor hospitalists were $157,165 as compared with assistant professor in pediatric infectious diseases of $134,464.

In many institutions hospitalists are taking leading roles in medical student and resident education, as well as hospital administrative roles, areas where Infectious Diseases has always had a solid presence. As quality improvement and outcomes based care become more important to administrators and payors, hospitalists have embraced these areas. Much of the research published in hospitalist journals is on quality improvement and resource utilization.

So how do we best interact with this youngest of pediatric specialties? First we need to point out to our colleagues the added value to patient care of a Pediatric Infectious Disease consult. Our knowledge of antimicrobial therapy, microbiology and immunology and our ability to understand and interface with the laboratory are all strengths we add to the clinical care of patients. The ID specialist also plays an important role in the transition to home or outpatient care. A study in 2013 demonstrated that ID consultations were associated with improved patient care outcomes, including lower mortality, lower readmission rates, length-of-stay, and costs.5 In addition, sub-sub specialty areas such as transplant infectious diseases are areas we can grow and differentiate ourselves. We have long been advocates of quality improvement in infection control and antimicrobial stewardship and we must continue to show our value to hospital administrators and to our clinical colleagues. Lastly, the lifeblood of any subspecialty is a robust supply of trainees. We must improve our ability to attract residents to our field and show them what a rewarding career they can have in pediatric infectious diseases.
--Gregory DeMuri, MD

References

  1. Wachter RM. Hospital medicine in 2015: Remarkable successes and a crucial crossroads. J Hosp Med 2015.
  2. Wachter RM. The hospitalist field turns 15: new opportunities and challenges. J Hosp Med 2011;6:E1-4.
  3. Friedman J. The hospitalist movement in general pediatrics. Curr Opin Pediatr 2010;22:785-90.
  4. Freed GL, Brzoznowski K, Neighbors K, Lakhani I, American Board of Pediatrics RAC. Characteristics of the pediatric hospitalist workforce: its roles and work environment. Pediatrics 2007;120:33-9.
  5. Schmitt S, McQuillen DP, Nahass R, et al. Infectious diseases specialty intervention is associated with decreased mortality and lower healthcare costs. Clin Infect Dis 2014;58:22-8.

THE PEDIATRIC INFECTIOUS DISEASES SOCIETY IS PLEASED TO ANNOUNCE:
The Journal of the Pediatric Infectious Diseases Society has been accepted for MEDLINE indexing!

About a week ago, I sat down to fill out my annual review at the academic institution where I work. As part of this, I listed the goals I would like to attain over the coming year. Each goal is assigned a category, and while some categories are easy to fill, such as academic research, the "clinical productivity" category remained blank. I struggled to identify my goal in this area.

The changing landscape of medicine has resulted in various compensation mechanisms for physicians, such that models once seen mainly in private practice are bleeding into academic institutions. This results in changes in how physicians are paid as we move toward models that align targets for volume and quality. As a pediatric ID physician, I normally do not give much thought to the number of patients that I see when I am in clinic or on service – that may need to change soon. Now that our hospital has moved to a primarily Relative Value Units (RVU) productivity based system, I must now think about numbers, complexity, and time. This feels foreign to me, as I picked a career I loved without much thought or consequence of these real life issues of "compensation" and "benchmarking." Pediatric ID is not traditionally seen as "revenue generating" compared to other specialties1. This bodes for particular concern for cognitive specialties limited by referrals and with few, if any, profitable procedures.

The major models by how pediatric ID physicians are compensated are varied and changing2. Pure 100% salary based (hospital funded) positions are increasingly rare. Instead, there may be any range of seemingly complex models currently in practice: grant funded, production (RVU) based, quality benchmarking, internally funded positions (such as directorships, chairs, fellowship coordination), hospital system efforts (such as antimicrobial stewardship, infection control, and OPAT) – and any combination of these such that salaries are often patched together. A growing number of Pediatric ID physicians are also in hybrid positions, commonly hospitalist, ER/urgent care, even primary care. Others may be the shared pediatric ID physician among several hospitals in a given area.

Significant work is being done by both adult and pediatric ID societies regarding the value of the ID physician,3,4 the ramifications of which we hope will translate into some protection from these new compensation models that are emerging. I spoke with Dr. Julia Szymczak regarding her abstract presented as a platform at PAS this year, titled: "Beyond the RVU: Exploring the Value of a Cognitive Pediatric Subspecialty." She conducted interviews with key stakeholders, including hospital administrators, surgeons, subspecialists, and pediatric infectious disease physicians, at 5 different hospitals across the country to explore and understand the value of a pediatric infectious disease physician to a healthcare organization. Several domains of how we are valued were recognized. Unfortunately, many of these areas escape capture by current measures that administrators use to justify the finances needed to retain a pediatric infectious diseases physician (manuscript forthcoming).

We, as a group, know we are important. Papers have been written about the value ID physicians add to patient care and a health system5-8. Additionally, Szymczak et al. demonstrated that others know our value too9. Why are we struggling to translate value into sustainable positions and comparable salaries? That is a bit more nebulous to answer but one we wish to make progress toward. In the meantime, there are some actionable items now, several of which Dr. Szymczak captured in her study and have been discussed in recent literature and on the IDSA website, such as maximizing our billing and coding efforts, most of which are likely time based, to ensure that we don't miss out on giving ourselves value for the time we spend with patients9, 3. Thinking about creative ways to expand referral bases through telemedicine10 or contracting to offer phone consultations are also ongoing efforts.

Other interventions may require a system based approach: negotiate with our hospital administrators and local insurance providers regarding bundling of payments, or fund programs like OPAT via the surgical specialties that use it the most. We must be adept in the language of what hospital administrators want to hear (Triple Aim?! Hospital Strategic Plan?! I'll show you how our work meets these and more!). Advocating for increased hospital funded time to sustain system efforts like infection control and other programs may be helpful when we share with each other how we do this in our respective institutions and how successful (or unsuccessful) we have been.

And while we are doing this, I do think we must move away from the stigma that we are a "revenue losing" specialty by developing ways to better capture how much money we SAVED a hospital or health system. For example, the undocumented and uncompensated work that we often undertake includes curbside consults from our colleagues and phone calls from outside physicians and providers, recently highlighted by Dr. Paul Sax's blog11. Creating and validating tools to measure the time and activities we do to prevent a hospitalization or readmission or that could be handled through an outpatient visit will be extremely helpful. Personalizing system based efforts, such as the impact of hospital based guidelines or outbreak management and translating that into cost-savings may also be a worthy effort.

The RVU system is here at my institution. And while things may change in another few years when reimbursement strategies are overhauled yet again, this has been a valuable time for me to think about these issues, which will likely follow us through the years.

For now, in the blank box for clinical productivity goals on my annual review, I've written:

  • Know and understand the strategic plan and priorities for my institution
  • Work with coders to determine if I've been appropriately billing, and if not, improve on this
  • Begin to engage colleagues to better understand how others are faring at their respective institutions to see where value has been recognized.

I'll let you know how I fare in a year! -- Louise Vaz, MD, MPH

References:

  1. Rochlin JM, Simon HK. Does fellowship pay: what is the long-term financial impact of subspecialty training in pediatrics? Pediatrics. 2011 Feb; 127(2):254-60.
  2. Castle VP, Gilsdorf JR. Assessing the value of pediatric consultation services as bundled payments evolve: infectious diseases as a model. J Pediatr. 2014 Oct;165(4):650-1
  3. Infectious Disease Society of American. Value of ID specialists' toolkit. Website: http://www.idsociety.org/Value_ID_Specialist/ Accessed 6/14/2015.
  4. Gilsdorf, J. Presidents' Letter http://www.pids.org/news/460-pids-president-letter.html Accessed June 15, 2015.
  5. Fariñas MC1, Saravia G, Calvo-Montes J, et al. Adherence to recommendations by infectious disease consultants and its influence on outcomes of intravenous antibiotic-treated hospitalized patients. BMC Infect Dis. 2012 Nov 9;12:292.
  6. Honda H, Krauss MJ, Jones JC et al. The value of infectious diseases consultation in Staphylococcus aureus bacteremia. Am J Med. 2010 Jul;123(7):631-7.
  7. McQuillen D, Petrak R, Wasserman R et al. The Value of Infectious Diseases Specialists: Non–Patient Care Activities. Clin Infect Dis. 2008 47 (8): 1051-1063.
  8. Petrak RM, Sexton DJ, Butera ML, et al. The value of an infectious diseases specialist. Clin Infect Dis. 2003 Apr 15;36(8):1013-7.
  9. Szymczak J, Lee GM, Woods C et al. Beyond the RVU: Exploring the Value of a Cognitive Pediatric Subspecialty. Presented as Platform. Pediatric Academic Societies Meeting 2015, San Diego CA. April 25. Abstract No. 1180.8.
  10. Kahn, J. Virtual Visits — Confronting the Challenges of Telemedicine. N Engl J Med 2015; 372:1684-1685.
  11. Sax, P. Seriously, How much would you pay for a curbside consult? http://blogs.jwatch.org/hiv-id-observations/index.php/seriously-how-much-would-you-pay-for-a-curbside-consult/2015/04/22/ Accessed June 15 2015.
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