A promising anti-seizure treatment; AI in medicine; stool transplants: Upstate Medical University's HealthLink on Air for Sunday, June 18, 2023
Robert Beach, MD, PhD, explores a new era in treatment of severe forms of epilepsy. Amr Wardeh, MD, talks about the role of artificial intelligence in medicine. And Aamer Imdad, MBBS, explains why fecal transplants can be more effective than antibiotics.
Host Amber Smith: Up next on Upstate's "HealthLink on Air," a neurologist describes a possible new era in epilepsy treatment.
Robert Beach, MD, PhD: ... One of the best-known and characterized sources of seizures that are intractable in humans is those that come from the hippocampus. ...
Host Amber Smith: A radiologist looks at how artificial intelligence is used in medicine.
Amr Wardeh, MD: ... If you don't have good data you are not going to end up having a good output or a good answer from these machines. ...
Host Amber Smith: And a pediatric gastroenterologist explains when stool transplants can be more effective than antibiotics.
Aamer Imdad, MBBS: ... There is an imbalance, either in terms of the number of the good bacteria versus bad bacteria, the type of good bacteria versus bad bacteria, and then an absolute ratio between them. ...
Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, we'll explore the current and future role of AI in medicine. Then we'll compare stool transplants with antibiotics in treating a severe diarrheal illness. But first, an exciting new method of treating severe forms of epilepsy.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
Neurologists and neurosurgeons believe they can help patients who have uncontrolled seizures with regenerative cell therapy implants. And the biotherapeutics company behind this new treatment says the first two patients to try it have seen their seizures reduced by more than 90%. One of those patients was treated at Upstate, and today I'm talking with one of the patient's physicians, Dr. Robert Beach. He's a professor of neurology and chief of epilepsy at Upstate.
Welcome back to "HealthLink on Air," Dr. Beach.
Robert Beach, MD, PhD: Oh, thank you very much, Amber.
Host Amber Smith: Now, Neurona Therapeutics is the company behind this new treatment, and it has a national clinical trial underway. Data from the first two patients was presented at the American Academy of Neurology this spring. What can you tell us about how these patients are doing?
Robert Beach, MD, PhD: So, to start off, the very first patient in the world was our patient here, who received the cells 11 months ago. He's done very well, as has the other patient who's had them.
He was having about 30 seizures a month, the patient here. And he has had an average of around one a month over the last several months. The patient in Oregon also had a similar improvement, although not exactly the same.
Host Amber Smith: So it sounds like really substantial improvement.
Robert Beach, MD, PhD: Oh, yes. Really more than we anticipated, even.
Host Amber Smith: So this regenerative cell therapy implants, these are being tried as a treatment for someone with epilepsy that's resistant to medication. Is that right?
Robert Beach, MD, PhD: Yes. And a very specific class of those patients, because we're talking about putting a very tiny amount of cells in a very specific place. And one of the best-known and characterized sources of seizures that are intractable in humans is those that come from the hippocampus or the medial part of the temporal lobe.
Those have traditionally been treated first with medicine. Usually about a third of them are not controlled with whatever medicines in combination are used. And those have been treated for about 60 years now with what's called an anterior temporal lobectomy, which is where the hippocampus and a fair amount of adjacent tissue is removed.
And this has been quite successful. About 75% or 80% of these patients will have very few or no seizures. So the traditional surgery is a fairly large area of tissue, and there's been attempts over the years to take out smaller amounts of tissue, which is technically more difficult, but there's been long-term attempts to develop tools that might give a more precise treatment with less resection of tissue and less side effects. One of those approaches has involved implanting neurons.
These cells that are produced by Neurona Therapeutics are cells that are able to be made into very specific cells. Now, there's the ability to take stem cells, differentiate them into specific cell types, and then to save them in very specific parameters so that they're always the same in every sample. For this treatment of epilepsy, the cells are differentiated into inhibitory cells, and those are cells that release , or gamma-aminobutyric acid. It's a neurotransmitter that's used by inhibitory neurons to signal other neurons.
The cells that produce it are primary what are called interneurons, and they usually involve modulation of the major cells, the excitatory cells, both input and output. It's felt that much of the underlying cause of epilepsy has to do with inadequate inhibition or excess excitation.
Host Amber Smith: Well, let me ask you, when these implants arrive, before they're put into the patient, the cells are already part of the implant?
Robert Beach, MD, PhD: So the cells are a sample of a specific number of these differentiated inhibitory neurons in a liquid solution that are frozen into multiple different aliquots (portions) that are virtually identical. After they come here from the company in San Francisco, they are characterized, tested for viability and contaminants. And, then once that's all established, they're put into a cannula (thin tube) that is the delivery system.
The hippocampus is deep in the brain, and the best way to get to it without disturbing other tissues is using a long, tiny cannula that goes into it from the back of the brain. Once this cannula is in place, very tiny amounts of the cells are released at four or five different places and then are allowed to integrate with the patient cells.
Host Amber Smith: I'm envisioning this cannula like a tube. Is it like a skinny straw?
Robert Beach, MD, PhD: It's like a needle, much smaller than a straw, but it's the same principle, I guess.
Host Amber Smith: OK. So how soon after the implant is in place would patients notice a reduction in seizures?
Robert Beach, MD, PhD: Well, we don't really know. The initial hypothesis was that it would take integration to the cells, which could take months. However, we saw change in less than a month in both patients. So we think that it's not just integration, but possibly release of the inhibitory GABA even before the cells are directly interacting completely with other cells.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Robert Beach about a new procedure for treating severe forms of epilepsy.
So other than the improvements with the reduced number of seizures, are you seeing other improvements in these patients?
Robert Beach, MD, PhD: Well, it's a bit early, but in our patient we did notice some improvement in some memory measures. And also we were able to lower his medications, which were at pretty high doses prior to the implant. And I think some of his benefit comes from just reduction of the side effects of the high-dose seizure meds.
Host Amber Smith: That's encouraging. So what happens to the implant over time?
Robert Beach, MD, PhD: Well, we think it integrates, based on rodent studies. It can be demonstrated to persist for many months after implantation and appears to be stable. We assume that would be similar in the human, but we haven't really demonstrated that yet.
Host Amber Smith: Are there any negative side effects that you've become aware of?
Robert Beach, MD, PhD: I think the side effects that exist are related to the fact the patient has to be immune suppressed, and some of these immune suppressant drugs have side effects. And of course, they put the patient at increased risk for some infections -- which are generally carefully guarded against and has not happened in our patients -- but that's a risk.
Host Amber Smith: Well, I know it's still early, but does this seem to you like it's the dawn of a new era in epilepsy treatment?
Robert Beach, MD, PhD: Well, this is a very singular type of epilepsy, but it is one of the most common intractable types. And I think this will definitely develop into a treatment option that rivals the other ones and may be proved superior over time.
Host Amber Smith: As you were describing earlier, it's for a specific type of epilepsy that starts from a specific area of the brain, but now that it looks like it's beneficial for those patients, do you think it might be tried in patients that have epilepsy that starts in other areas of the brain?
Robert Beach, MD, PhD: I think so, as long as it's in a small area that can be very precisely identified, because we are only putting in a very small number of cells. To put in a large amount might cause some imbalance in the overall network. But there are other seizures that come from similar foci (microscopic cells) that can be fairly similarly characterized.
Host Amber Smith: Now, the patients we're talking about are adults. Is that right?
Robert Beach, MD, PhD: Yes. This is only for adults so far.
Host Amber Smith: In the future, would it perhaps be looked at for children as well?
Robert Beach, MD, PhD: If it's successful, it would definitely be looked at for children, yes.
Host Amber Smith: Now, could it be a strategy to treat milder forms of epilepsy?
Robert Beach, MD, PhD: Possibly, but the seizures that are most difficult to control are the ones that at least are most logical at this point.
Host Amber Smith: Can you think of any other neurological diseases that might be helped by regenerative cell therapy?
Robert Beach, MD, PhD: There's been trials of similar cell implants or different cell implants, I should say, in Parkinson's disease patients for more than 25 years. The success rate has not been as clear. The area where the cells need to be put for Parkinson's is perhaps a little less well-identified than the seizures. I think the more precise information on treating Parkinson's with similar cells may well turn out to be effective.
Host Amber Smith: That's good to know. Dr. Beach, thank you so much for making time to tell us about this.
Robert Beach, MD, PhD: Thank you for having me.
Host Amber Smith: My guest has been Dr. Robert Beach. He's a professor of neurology and the chief of epilepsy at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
The role of artificial intelligence in medicine -- next, on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
We've heard a lot lately about how artificial intelligence is being used in the computer industry, in manufacturing and social media. Today we'll explore some of the uses in medicine and health care. My guest is Dr. Amr Wardeh. He's a resident at Upstate with an interest in artificial intelligence and informatics.
Welcome to "HealthLink on Air," Dr. Wardeh.
Amr Wardeh, MD: Hi, Amber. Thanks for having me.
Host Amber Smith: I'd like to start by asking you to define what AI is, because we hear about its use in so many different fields.
Amr Wardeh, MD: Oh, absolutely. So AI, or artificial intelligence, broadly speaking, is a field that aims to make computers perform tasks that we usually attribute to humans, or to simulate human intelligence. For example, most of us use Siri or a Google assistant, and we can ask Siri, "Hey, what is the weather looking like today?" And it will give you a pretty good answer that kind of simulates what a human would answer.
Host Amber Smith: So does AI depend on having a lot of good-quality, robust data in order to be able to do that?
Amr Wardeh, MD: Oh, absolutely. A big part of AI is to be able to train these computer algorithms to perform tasks accurately. And in the field of computer science, there is a very common saying that is, "garbage in is garbage out." So if you don't have good data, you are not going to end up having a good output or a good answer from these machines. So it's actually crucial to have good data.
Host Amber Smith: As we have more and more good data, would it be possible that AI would become smarter than a human?
Amr Wardeh, MD: That is, that's a very good question. So the more data we give these AIs, the more they will be able to learn and know. And I'm going to refer to something that's been really making waves in many industries, which is ChatGPT, and these large language models. And so ChatGPT has been trained on an enormous amount of data, and because of that, it is able to make very intelligent-sounding answers when you interact with it. And more recently, OpenAI, the company behind ChatGPT, released a newer version of ChatGPT based off of something called GPT-4, which is even trained on more data, and it performs even better than the older model. So the more we train and the more we data we put into these systems, it seems like the better they become, more or less.
Host Amber Smith: Is ChatGPT, is that the same thing as machine learning? I've heard the term machine learning, but what does that mean?
Amr Wardeh, MD: Machine learning, broadly speaking, any computer algorithm that is able to learn from some data, whether it is image, text, or even sound data, and then able to make a prediction or give you an output based off of that. Specifically I want to talk about something within machine learning, or a subfield of machine learning, called deep learning, which is what ChatGPT is based off of, and most of these new AI things we're hearing about is based off of.
What deep learning is, is trying to simulate how our brains are structured in a computer machine, and then trying to teach that simulated brain, let's call it, how to perform a certain task. And it turns out, well, if you do it right, you can make them do amazing things, like detect cancer or chat with you and write essays for you.
Host Amber Smith: That's pretty fascinating because when you think about the first computers, they were able to -- I don't know -- solve mathematical problems, but you're talking about computers that you teach to be able to learn, basically. Do they have independent thought?
Amr Wardeh, MD: It's really crazy when you think about it and the types of things these things are capable of doing now.
Do they have independent thought? As of now, no. What we have right now is something we call Weak AI. So these are AI systems that are able to do specific tasks. So for example -- even though that is kind of changing, but -- let's say an AI that can detect cancer on chest radiographs, or x-rays. That system can only perform that one task. It might be able to do it very well, but it won't be able to do anything else really well.
But the idea of having an intelligent system that can do multiple tasks and learn like a human would across multiple domains is something that is referred to as artificial general intelligence. And that is one of the goals, actually, depending on who you ask. That's the goal of some people who make these AI models, is to create this artificial general intelligence that can do everything that a human would be able to do.
Host Amber Smith: Well, let's focus on the field of radiology, since that's your specialty, and specifically on mammograms, which are used to detect breast cancer. Typically, radiologists look at a mammogram for early signs of cancer, but now there are AI systems that can double-check the radiologist. Can you explain to us how that works?
Amr Wardeh, MD: Yeah, absolutely. There are a lot of new AI tools that are coming up where they can point out where a cancer might be on a mammogram, and even on other types of imaging like chest radiographs or bone radiographs that tell us, "Oh, there is a fracture" or "There is a pneumonia," et cetera.
And these AI tools are proving to be extremely good, in the sense that they are a machine, so they don't get tired. They will do things in a very systematic way, most of the time. So, where a, let's say a human might not be able to maintain focus or might miss a small thing, an AI might be able to pick up on that and actually aid the radiologist. So there is a lot of talk right now in radiology and other areas of medicine about how to incorporate these AI tools to help us help the patient better and not miss cancer, for example.
Host Amber Smith: So in this instance, is the artificial intelligence that's reading mammograms, is it learning from each mammogram that it studies. And is it getting better the more that it reads?
Amr Wardeh, MD: Most of the AI tools that are available now, they don't really learn once they are deployed into a clinical environment. So they simply do the tasks they have been trained on initially.
Some newer companies and groups are working toward making these systems that kind of gradually learn over time from feedback or continuously learn over time. That is something that will be happening. But as of now, once the AI has been trained, it is locked. So it doesn't learn anything new. It just does the task it has been trained to do.
Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Dr. Amr Wardeh, a radiology resident at Upstate, about the use of AI or artificial intelligence in medicine.
I read a study in the journal Pediatric Radiology that looked at bone fractures and whether they could be spotted on X-ray. The study showed that AI scored higher marks than emergency physicians, but it could not beat experienced radiologists. Does that surprise you?
Amr Wardeh, MD: Not really, actually. Because recently we are seeing a lot of studies coming out showing that AI can perform on par with radiologists in certain areas. An emergency doc, even though they might see a lot of fractures, they are not trained to look at images like a radiologist would. And so an AI that is trained to detect these fractures would perform probably similar to a radiologist rather than an emergency doc. Surprisingly, but unsurprisingly, this is expected.
Host Amber Smith: What other areas of medical care do you think that we might see AI being used in the coming years?
Amr Wardeh, MD: Within the coming years, we are going to see a lot of integration of AI into clinical workflows. So, one of the things that we're going to see, if you have ever chatted with your doctor over the health care system chat feature, a lot of work is actually being done currently to make ChatGPT or similar tools, draft responses to kind of automate and improve the efficiency of the physician, potentially providing more thorough answers and information to patients.
That's one of the major things that can help both physicians and patients. Because on average, doctors spend about 15 hours per week doing administrative tasks that are not really related to patient care. So if AI can help reduce that administrative time, where a doctor can focus more on patients or other tasks that might benefit the patient, then it's a welcome change.
Host Amber Smith: So patients might feel like they get more time with their doctor because their doctor's not being pulled away to the administrative tasks, maybe?
Amr Wardeh, MD: Absolutely. And another area where current work is being done is, AI will, for example, be able to listen to your conversation with your doctor when you go in for a visit, and your doctor won't have to sit down facing their computer the whole time and writing notes. They can actually look at you in the eye the entire time and discuss things. The AI will listen and write and document everything in the background. So all of those things would be welcome changes.
Host Amber Smith: But AI wouldn't be talking to the patient and telling them what they think is wrong with them or what they think should be happening?
Amr Wardeh, MD: Right. So that is actually, it's a dangerous area right now because a lot of these AI systems are not perfect. These large language models like ChatGPT, they, tend to "hallucinate." So if you ask them a medical question, they might answer with a lot of confidence. But, their answer might not be factually correct. In the setting of healthcare, specifically, that's very dangerous.
So autonomously answering or interacting with patients, I don't think we're going to get there soon. You would need a physician to basically review the work of the AI before interacting with the patient. So it'll be AI-aided physician interaction, rather than just AI by itself.
Host Amber Smith: You used the term "hallucination." Is that the same in AI as it is? -- I think of that as being like a drug-induced stupor of some sort in a person. But in AI, what does that mean?
Amr Wardeh, MD: That's a great question. We usually use the term hallucination specifically with the large language models like ChatGPT, where sometimes they, if you ask them a question where they're not, they don't really know the answer, they might just simply fabricate an answer that might sound very, like a very good answer to somebody who does not have experience in that topic. And so it's very dangerous to, for example, have a tool like that interact with patients, provide recommendations that might be completely wrong, without oversight.
Host Amber Smith: So does this tie in with virtual health care? During the pandemic specifically, we saw this sort of exploded, where you could connect with your doctor virtually, out of necessity because of the pandemic, but it's still in use today. And more so now than it was before the pandemic. Does AI have a role in virtual health care?
Amr Wardeh, MD: I think so. So for example, when you're talking to your doctor over videoconference, your doctor might not have to write notes anymore, like we were saying earlier. So everything will bedocumented by the AI so that your doctor can actually spend more time listening to you and talking to you.
Other things that AI might be able to help with is, when you're chatting with your doctor, like we were saying earlier, if the AI can assist the doctor with, let's say, drafting a response to a question that a patient asked, they might be able to save them, let's say, five minutes per response, which amounts to a significant time savings per day they can spend on seeing other patients or taking care of more important things.
Host Amber Smith: Some people are afraid that AI will replace human doctors. Are you concerned about that?
Amr Wardeh, MD: That's going to take a while to happen. As of now, the tools that we have will not be able to replace physicians. At least I wouldn't be comfortable going to a, let's say, a hospital or to a clinic visit, just have the AI see me and then tell me, "OK, go do this and that," without having a human component. Especially if they're prone to error and hallucinations.
But what we're going to see a lot of, I believe in the near future, is AI that assists doctors, where a doctor might be able to see more patients, might be more productive. And that will definitely happen where maybe you won't need as many doctors to do the same amount of work, but will AI completely eliminate the need for doctors? I think we're still far from that.
Host Amber Smith: Well, it's certainly a fascinating field and also a little bit scary. I really appreciate you making time to explain it to us, Dr. Wardeh.
Amr Wardeh, MD: Absolutely. It was a pleasure. Thank you for having me, Amber.
Host Amber Smith: My guest has been Dr. Amr Wardeh, a radiology resident at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air," how stool transplants can treat a severe diarrheal illness.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
An Upstate doctor did research that shows a better way of treating a life-threatening diarrheal illness, and he's here to tell us about it. Dr. Aamer Imdad is an assistant professor of pediatrics, and he specializes in nutrition and pediatric gastroenterology.
Welcome back to "HealthLink on Air," Dr. Imdad.
Aamer Imdad, MBBS: A pleasure. Thank you.
Host Amber Smith: I'd like to start by having you tell us about this diarrheal illness that can be so severe. What's it called?
Aamer Imdad, MBBS: The name of the infection is Clostridioides difficile. It used to be called Clostridium difficile. In short we call it "C. diff."
It's an infection that can cause diarrhea because of inflammation in the colon, which is the large bowel.
Host Amber Smith: Where does C. diff come from? How does somebody get it? ,
Aamer Imdad, MBBS: Many of us actually have C. diff in our large bowel. The C. diff infection happens when the balance of good bacteria versus bad bacteria tilts towards the bad bacteria, so it is present in the form of spores, so it can survive for a longer period of time.
And as it gets the opportunity to grow faster and produce a toxin, that can lead to the illness, which could be very severe, especially in older people.
Host Amber Smith: Is that why it can be potentially life-threatening? Is it mostly for older people or people with compromised immunity?
Aamer Imdad, MBBS: To a certain extent. So, it can happen in immunocompetent patients as well. So, what we have seen over time is that it is actually the most common gut-associated infection acquired from the hospitals, so it's more likely to happen in patients who have been admitted in the hospital for a longer period of time. We have also seen patients getting this infection in the community as well, and we have seen it in children, young adults and then adults in old age as well.
It tends to be more severe in patients in older age, but it can happen at any age beyond the childhood period.
Host Amber Smith: And how is it usually treated?
Aamer Imdad, MBBS: We can actually go back and kind of say, why does it happen at the first place? So the most common reason for having C. diff infection is use of antibiotics.
Most of the time, a patient will go on antibiotics for reasons, let's say, pneumonia or urinary tract infection, or, in children, for example, they could be treated for ear infection. And that not only kills the bacteria that was causing that infection, but it also kills the good bacteria in the gut, and that gives an opportunity for the C. diff to grow, leading to infection.
So, once somebody has diarrhea, and they get tested positive for C. diff, the initial recommendation is to treat the C. diff infection with antibiotics. And there are certain types of antibiotics that work better for C. diff compared to some of the other antibiotics.
What we discovered over time is that even though these antibiotics could be effective in treating C. diff infection, they actually increase the risk of having another infection because the very first infection happened because of use of antibiotics. So then we use the antibiotics to treat the infection of C. diff, but that exacerbates the imbalance of good versus bad bacteria, leading to risk of another infection.
So, if we talk in percent risk, if a person has a C. diff infection for the first time in their life, there's about a 25% chance that they will have another one. But if they get treated for that other one with antibiotics, the chances of having another one is about 40%. And if you have C. diff two times, the chances of getting a third is about 60%, which is really high.
So it's very important to kind of understand that we think the antibiotics not only help treat, but behind the scenes, it may actually exacerbate the problem in the long term.
Host Amber Smith: So it doesn't sound like it's the best solution.
Aamer Imdad, MBBS: Indeed.
Host Amber Smith: Is that what prompted you to consider or look at stool transplants?
Aamer Imdad, MBBS: Indeed. Stool transplant helps us to break that cycle, where there is an imbalance of good bacteria versus bad bacteria. There's a term called "dysbiosis" for that. Dysbiosis happens when you use antibiotics for any reason, and that dysbiosis can increase the risk of C. diff infection, and once C. diff infection gets treated with antibiotics, that dysbiosis continues to worsen.
Fecal microbiota transplantation, or stool transplantation, reverses that dysbiosis because we essentially take the stool from a healthy person who does not have dysbiosis, and we transplant that to a patient who seems to have dysbiosis and is getting these C. diff infections because of that.
Host Amber Smith: That's very interesting.
So, healthy people have a microbiome that's " even" -- you have good bacteria and bad bacteria, but they're in a better state?
Aamer Imdad, MBBS: Yeah, this area, of research is expanding, and we're getting to know more and more about how the microbes in our body kind of interact with us.
We have bacteria in our gut. We actually have fungi in our gut. We also have viruses in our gut, as well, that live very happily with our body and not only live happily, but actually produce a lot of useful things that really help our body do its functions. Some of the bacteria, for example, are involved in some of the vitamin productions, hormone productions in the gut.
What has been noticed over time is that if there is an imbalance, either in terms of the number of the good bacteria versus bad bacteria, the type of good bacteria versus bad bacteria, and then an absolute ratio between them.
So, we are working more and more to get to know exactly what kind of imbalance would increase the risk. But initial data does show that at least for risk of C. diff infection, there is a very noticeable imbalance of bacteria in our gut that increases the risk and gives the opportunity for C. diff to grow and cause the C. diff-associated diarrhea.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.
I'm talking with Dr. Aamer Imdad. He's an assistant professor of pediatrics at Upstate, where he specializes in nutrition and pediatric gastroenterology, and we're talking about research he published recently showing that stool transplants do a much better job treating C. diff infections than the commonly used antibiotics.
So can you tell us about the study you did?
Aamer Imdad, MBBS: We did a study called a systematic interview and meta-analysis, under Cochrane Collaboration.
Cochrane Collaboration is a group of experts that help synthesize all the available evidence for a particular health care intervention. Cochrane Collaboration helps produce the Cochrane Reviews that are in Cochrane Library, and we all have access to that library. It is considered the gold-standard piece of evidence synthesis that typically leads into a final say in how the clinicians are going to practice.
So, for example, our work from these two Cochrane Reviews will be used by American Gastroenterology Association to issue their guidelines. It feeds into how the clinicians practice.
So, the process starts with a clinical question. We, as clinicians, were very interested to know that if patients are getting recurrent C. diff infection, can the stool transplant be helpful?
So, scientifically, in order to answer that clinical question, the best type of evidence comes from randomized control trials where patients with that particular condition are randomized into either, say, in this case, a fecal microbiota transplantation, or stool transplantation, versus the standard of care.
So, once the results are available from more than one randomized control trial, they can be synthesized quantitatively or mathematically into meta-analysis, giving us a summary estimate that will indicate the final efficacy, or effectiveness, of the intervention to help us guide our clinical practice.
In this particular study, we found that fecal microbiota transplantation, or stool transplantation, helped resolve the recurrent C. diff infection more often than the standard-of-care antibiotics.
Host Amber Smith: So, based on your findings, would patients with C. diff infections be candidates for stool transplants, or would you only recommend it for someone who has recurring C. diff infections?
Aamer Imdad, MBBS: This is a very good question and a very important one to differentiate. Our study looked at prevention of recurrent C. diff, so the stool transplant will be done in between the episodes. So, for example, if a patient had one episode of C. diff, and then they had another one, and then they had another one, and it keeps happening, typically within one to two months of the previous infection.
Not only that, it can cause illness, obviously it can also affect the quality of life in terms of the number of days somebody could be sick, or they could be admitted (to a hospital) because of the infection. So, the stool transplant is helpful to break that cycle and is done in between the episodes, when the patient is not having active symptoms.
Host Amber Smith: So, at this moment, are stool transplants readily available, and does health insurance pay for them for this?
Aamer Imdad, MBBS: There are very important advancements that have happened over the last few weeks, actually. Historically, there were stool banks in the country that were collecting the stool specimens from the donors, screening them for common infections and then freezing them and then transporting them to the facilities where they could be transplanted.
And Upstate is one of those sites, and I myself, and my colleagues here in pediatrics and in adult gastroenterology have performed the stool transplant. Now, more recently, FDA has approved a stool transplant product. I won't take the name here, but it was approved, that could be delivered via enema, and because it is FDA approved, it will most likely be covered by insurance as well.
Host Amber Smith: I was going to ask you how, practically, the stool transplants are done. So there are stool banks, so people make donations, and then the stool is processed. Is each stool transplant from one person, or is it blended from a bunch of people?
Aamer Imdad, MBBS: So, for the purpose of treating recurrent C. diff infection, a stool coming from a single donor is effective in most of the patients, and we typically do not have to mix the stool from multiple donors. There are some additional studies going on, and we have looked, in a separate, systematic review and meta-analysis, on the effectiveness of stool transplant for treatment of inflammatory bowel disease.
And over there it seems like stool donation from multiple donors will be required, for them to be pooled, to increase the richness and diversity of the bacteria in the stool. And it might have to be given more often compared to a one or maximum two to three doses for treatment of recurrent C. diff. So for the purpose of treating recurrent C. diff, it's typically a single-donor stool specimen, and that is transplanted into a single person.
Host Amber Smith: And you mentioned that it's transplanted via enema. Are patients hospitalized for this, or is that done in an outpatient setting?
Aamer Imdad, MBBS: Stool transplant can be done in multiple ways. So now there are actually capsules or "poop pills" that could be taken. It can also be administered through a nasogastric tube, which goes from the nose into the stomach, or nasoduodendal tube, which goes from the nose into the first part of the small bowel.
It could also be given via the enema.
And historically, it was initially started by giving it via colonoscopy, in which a colonoscope is taken to the very start of the large bowel. And it is distributed from start of the large bowel towards the end of it.
The pills and the enemas obviously can be done as an outpatient. For a colonoscopy, the patient typically has to come to the hospital, or at least an outpatient GI (gastrointestinal) clinic, where the colonoscopies could be performed.
Host Amber Smith: How quickly might a patient feel better after this?
Aamer Imdad, MBBS: It is a very effective therapy.
The key here is to understand that it is done when the patient is asymptomatic. So, the efficacy of a single microbiota transplantation is somewhere around 75%. So, if the patients have another recurrence, and they get a second transplant, the efficacy goes up to 90 to 92%, and there are very few interventions in medicine that are as effective as fecal microbiota transplantation for treatment of recurrent C. diff.
Host Amber Smith: Are there any side effects to watch out for from the transplant?
Aamer Imdad, MBBS: Remember, the stool is a donor-based stool specimen, and obviously, it not only has the good bacteria, it also has the bad bacteria. So there is a risk of transmission of infection, and FDA has issued some warnings about the possibilities of transmission of infection, including the COVID-19 infection, the monkeypox infection, which are both rare, but then there are other types of infection, and especially the patients who are immunocompromised, severely immunocompromised, they could acquire infection from the donor-based stool.
So, as part of the processing of the stool, all of the stool specimens are screened for common infections. And not only that, the donors are also screened for other health conditions. For example, if the donors have diabetes or hypertension or any other chronic disease, their stool will not be taken as a donation for the transplantation.
Host Amber Smith: So, it sounds like there's a structure to it, like the blood banking in the U.S., where the blood is surveyed before it's used.
Aamer Imdad, MBBS: It is.
It is less regulated compared to, blood donation, but we're probably moving towards that. Currently, there is not a very universal donor-screening protocol that we have, but we will most likely see that there will be guidance from organizations like FDA to help establish and run the stool banks as we gather more and more evidence for the usefulness of fecal microbiota transplantation for not only C. diff, but other conditions as well.
Host Amber Smith: I was going to ask if stool transplants can be used to treat C. diff, are there potentially other uses, too?
Aamer Imdad, MBBS: Indeed there are, and there is a lot of interest in studying the stool transplantation for other health conditions. And we as gastroenterologists are very interested in its use for treatment of inflammatory bowel disease.
So we did a sister publication on it where we looked at patients who have ulcerative colitis, which is one subtype of inflammatory bowel disease, and patients who are having active disease, can the stool transplant be used for their treatment?
And the data is actually very promising. It's not where we can recommend it for change of practice, but more and more studies are being conducted, and over the next two to five years, it is likely that we will have some sort of a conclusive evidence to say if the stool transplantation can be used for the treatment of active ulcerative colitis.
People are also looking at other conditions, like irritable bowel syndrome, obesity and beyond. Frankly, a lot of basic science data is finding association on how our gut microbes interact with our rest of the body. And a lot of scientists now think that some of the conditions that we experience in our body could be associated on how, and what kind of, microbes do we have in our gut.
Host Amber Smith: Well, this is very interesting work. I appreciate you telling us about it, Dr. Imdad.
Aamer Imdad, MBBS: Absolutely. My pleasure.
Host Amber Smith: My guest has been Dr. Amer Imdad. He's an assistant professor of pediatrics, specializing in nutrition and pediatric gastroenterology at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
Here's some expert advice from Dr. Ioana Medrea from Upstate Medical University. How can we prevent random headaches, and what causes them?
Ioana Medrea, MD: The more common things are dehydration, so make sure you get enough water if you feel like you're having a headache, especially if you think you're dehydrated. Another common trigger is missing meals. So, getting some nutritious sort of sources of sugar, because that's really what causes the headache, the withdrawal from sugar.
And then the other thing is stress. So, trying to manage stress well. What does that mean in terms of managing stress well? So, there's a few evidence-based methods that I recommend to my patients with frequent headaches. Exercise is actually a great stress management strategy, so aerobic exercise, three to five times a week is one thing. The other thing that I often discuss with my patients: mindfulness based stress reduction techniques. There are many of them out there, and a lot of them have evidence, very good evidence, behind them. One of them is meditation. Another one would be tai chi. The other things would be mindfulness-based apps. So we have a lot of them now, and some of them even have evidence. So "Calm" is one. "Headspace" is another.
And then, if you're not into devices, there's yoga classes or there's tai chi classes, anything that sort of requires you to turn off your brain and follow a regimented sort of movement is a mindfulness practice. Even religion and praying, and sort of having some spiritual activity like that is a mindfulness-based practice. So, any of those I would qualify as being able to reduce your stress. So, those are the most common triggers for the common headaches that we all have.
Host Amber Smith: You've been listening to neurologist Ioana Medrea from Upstate Medical University.
And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: Is there anything better than a love poem? Especially in these times? Vincent Casaregola, who teaches at St. Louis University, sent us a gorgeous and yet bittersweet testament of a love now gone. Here is "This Poem Is Just About You":
This poem is just about you, not you,
not some substitute to hold you
out of time's reach and cost --
this poem cannot touch you, cannot
feel the softness of your skin beneath
a fleeting brush of fingers,
cannot reclaim the sight of you
reclining on a chaise or standing
in the window's morning light,
cannot be the light reflected
in your glance across the table
or be the gentle tilt of your head
when listening, or speak your thoughts
with your voice, tender or alarmed,
angry or soft, as moods propel.
No, this is a thing of words, poor
currency that barely pays the price
of simple goods on ordinary days,
passing words, mortal and fleeting,
with no eternity in store, no marble
meaning etched in history.
And when your rebel cells collude
again, rise in secret, then strike,
bringing insurrection to the lung
or brain, these words, bring no relief
from any throbbing pain, no salve
for the sting of doubt and fear
as you, sleepless, outstare
the darkened midnight ceiling, nor
can they ease the ache that grows
stronger with each morning, or feel
the tangled tightness in your grip
as you reach for help to cross a room.
These words bring me no comfort,
not even cold comfort, but lie
dry as old paper in the musty attic,
less comfort, even, than a cold,
post-mortem final kiss that seals
the moment in the dim, grey room.
These words themselves have little or no
life, no breath for me to hear as from you
when you'd lain asleep beside me,
and they will fade, as ink on paper fades
in heat and angry sun, or as screens will
fade when the grid itself will die --
carve them on our stones, if you will,
the stones themselves erode to dust,
and even while they last, the sharp carving
smooths with age, making words clefts
for blown sand, for spores of lower plants,
for fibers of what, once, had flowered.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.
Next week on "HealthLink on Air," advice for working out in the heat. If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at HealthLinkonAir.Org.
Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.
This is your host, Amber Smith, thanking you for listening.