 Okay, take it away. All right. Marty, are you going to ask a question? Yeah, I wanted to ask this question to Alex, two questions, but I can't remember the second one. So the first question is, have you or anyone studied people who have fecal transplants that failed and to look at the composition of the failed donor microbiota and to compare that with the successful microbiota? Okay. That overlaps a little bit with the gap that I mentioned. So I've done 120 fecal transplants for refractory recurrency difficile infection. Out of those, so there's a 90% efficacy rate, which is very good, considering how difficult this condition is. So that means out of those 120, we have about a dozen failures. And those would be a wonderful group to study. Had we anticipated that we need to propose a study for that many patients. I believe that every patient walks in, gets something like this done, or walks in an academic health center, should be part of a subject, should be part of a research study, that some material should be saved and to go back. But we just didn't have the resources to collect everybody on that scale. So at this point, yes, I wish we had. Now, I did show on the slide, we did have one failure there, and it seemed like it was poor engraftment. There was still a big proteobacteria fraction there. That particular patient got treated with the same donor material and did fine. There may be multiple factors. We studied the households of these people, for example. They're universally contaminated with C. diff. That isn't the question. The question is, what's the difference in the microbiota between the successful donor and the failure? Certainly that should be looked at in the future. I can add two, Marty, it's over here. I can add one microbiologic failure, but not symptomatic. In other words, a patient who continued to shed C. diff, but didn't, but was still shedding, but was not symptomatic, not having diarrhea. And one where there was a clinical sort of failure. And these are samples that I got from Johan Baca and Johana Sos. And those still had that proteobacteria dominance in there. So, again, that's an N of three out of how many. But again, is that cause or effect? Is that just a marker that there's still C. diff there? It's still dysbiotic? Is that just a marker of dysbiosis? Or is that responsible for the fact? No, my question is about the donor. Oh, about the donors. Those two donors look fine. But maybe they didn't engraft the same thing. Detailed informatics could identify something that's missing. So clinically, we've used majority of our cases, just two donors. And the success rate in the failure of doing the repeat procedure is still 90%. Yeah, so you have two very good donors. So now I remember my other question. And that is that the literature says that about 3% of adults are carrying C. diff. But 100% of babies in the first year of life have C. diff. Or some very high percentage of babies. And my question is, what happens to the C. diff from baby to adulthood? And where are those babies getting their 100% C. diff from? I'm not sure. I know the answer. But it seems to be squeezed out as they mature. The babies are not symptomatic. There's really not much C. diff associated disease in the first year of life. So squeezed out makes sense. Except then the question is, where are they getting it from? Well, there's probably a lot of it around. We've gone around in swap places and we find a lot of it in the environment. And it is moving in the environment. It used to be a hospital associated disease. And as Elaine alluded, they get antibiotics. They get a C-section. That floor may well be contaminated. We've gone to the homes of people with recurrent disease. And they are universally contaminated as well. And 50% of C. diff today is acquired in the community. Question of that? Yes. I hate to have the fecal transplant dominate. But they're obviously a very hot topic. So the discussion today revolved around replacing a totally disrupted microbiota. But there's great enthusiasm for at least the potential of therapeutic fecal transplant with dysbiosis. So do you or anyone else on the podium have thoughts on how one might prepare a patient with Crohn's disease, osteoclitis, other dysbiotic conditions, obesity, whatever. How one might clear the existing organisms to best have a niche, to have a hope of an effective replacement? It's an entirely different situation in my mind than trying to complement something that used to replace something that used to be there rather than totally replace an existing microbiota knowing that it's less diverse than the norm, but still a lot of niches are covered. Right. And then that is exactly the next thing that we would like to do. There are last count, 12 ongoing trials for osteoclitis with fecal transplant. And to my knowledge, they're not taken into account this question. So doing a fecal transplant for C. diff is like doing a bone marrow transplant after a Hiroshima. Right. The patients are naturally conditioned by the radiation in that case. All they need is some stem cells. These C. diff patients are exactly the same. They've been carpet bombed with antibiotics for long periods of time. You look at them, there's not only lesser diversity, but there's just fewer bacteria. So the niche is open as possible. I think it's the closest adult human version of germ-free human that we have. So that just needs to be studied. I don't think just putting in poop and thinking you're going to reverse something. That sounds too naive. There's a little, I think not a lot, this past DDW with one before, there was a European study and a small pilot study in IBD and they didn't see any effect of fecal transplant, but they also looked at engraftment and there was no sustaining engraftment either. So I think we need to explore that. How exactly do you, what antibiotics do you choose? For how long do you target particular suspected species that may be involved in IBD? Probably not just look at the fecal material, but also look at what's in the mucosa because that may be a more resistant place, as we heard from Sarkis. Bacteria could hide in the mucin layer and be undisturbed, et cetera. It needs to be done. Yeah, I totally agree. Yeah, and in my view, the murine studies could actually, you know, preclinical studies and mice could actually answer some of those questions rather than human experimentation. Thank you. Gentleman in the middle? Don't say Raju from NICHD. It's a great session. Getting back to the fecal transplantation issue, YEC factor. Much of it is in the name. Instead of calling fecal transplant, why not just say gut microbiome transplant or GMT, something like that. Just a comment. Right, and when I started writing about it, I said it was a gut microbiota transplant. And then we got together with a group of people who were doing clinicians and to write some guidelines. And there was a uniform opposition. They felt patients know what fecal means. It's an honest thing to do. That's not confused them. And that's why the fecal word was chosen. I'm trying to get away from that now and have some sort of center at the university. I don't want to have a fecal U of M center. The names, thanks for now. Thank you. Okay, any more questions? I'd like to ask Dr. Blazier if he feels that the use of antibiotics in infants is contributing to the increase in food allergies? Yeah, it's a good question. I don't have any data about it. But certainly food allergies is one of those diseases that has been rising in recent years that has to have an environmental factor. We know that the microbiota plays a role in providing context for the developing immune system. So some microbiota effect is good. And one could imagine that antibiotics and other aspects like caesarean sections or cumulative approach could have an impact. And that's the kind of thing that should be looked at in cohort studies. Does anybody else have any information about it? Okay. Dr. Wendelback? Yeah, sorry if I bring it back to the fecal transplant. But maybe I can broaden it up a little bit to the clinical and research side. So with all this research on the microbiota, the idea that we have maybe a method to manipulate the microbiota and make things right again is very exciting. And there's a lot of different initiatives, not just C. diff, where it works really well. But there was a study in Europe on obesity. But there was another study, I think in the literature that talked about ulcerative colitis patient that was symptom free for years and was treated for a C. diff infection and had a U.C. flair after the fecal transplant, I believe. So I was just wondering what your ideas or your perspective, where should this all go from here? Should we keep on trying fecal transplant for all kinds of microbiota associated problems? I mean, we don't really know what's happening yet, right? But it seems to work in many cases or at least have an effect. So what do you think where we should go from here? Well, I think the answer is we need systematic approach and go step by step. Perhaps starting with the question Dr. Balfour asked, how do you actually do it in a non-C. diff case? I also think we need to take control of the donor pool, either with what Elaine is doing with actually designing it bottom up, or if you're starting with full spectrum microbiota, then you have to know everything about those donors. You can have, of course, you can do taxonomic classification of what you're actually putting in, but also metabolomics and also donor characteristics, some end product, microbial community end products, fecal gases, whatever. You collect as much information as possible, so you have a panel of biomarkers, and as these things go into different trials, whoever has a passion for a particular disease, we should know everything about the donor as well as learn everything about the recipients because there's a lot of variability there, and I think that's the only way to make progress forward. Until we haven't made much progress in this field since 1958, it has remained static. It's been practiced all along the way at a small scale. The C. diff epidemic made it much bigger, but to look at this as an opportunity to learn a lot about microbial ecology and host physiology and that interaction, I think the opportunity is there, and it's one of the challenges and gaps that NIH can help us with. I mean, we're focusing a lot on replacing bacteria, so we see this biosis and we think we could replace it with different taxa that could protect or restore homeostasis, but like Jonathan was pointing out this morning, we need to know more about the physiological action of these bacteria. So if we think about IBD or cancer, is there an activity promoted by bacteria that could be blocked or replaced with another activity? Do you really have to start from a complex community and try to put back an environment and a new ecosystem? Or could you just have a function put in back to restore disease? That's where we need to move into more detail activities. What are these bacteria doing and how do they relate it to health and disease and come up with a little bit more focused approach? If you go transplant, we haven't progressed that much in terms of medicine. It's like a little bit of a stormage. But I mean, we've seen with L.N. Petrol that you could narrow it down and then come back with maybe some activities that will refrain C. diff action. This is where we need to move. That's a great point. Sure. I actually have a non-FMT question. One challenge that seems to be emerging for us as a community to deal with is we've seen a lot of very interesting data presented over the last couple days about the impact of antibiotics on microbiome. Dr. Blazer presented some fascinating results today. And I guess I'd like to ask the question, especially since Dr. Goodman is here, how is the FDA and also how should we as a community be having a conversation not just about how we should be thinking about safety and regulation of potential microbial-based therapeutics but of antibiotics themselves? Well, I think that understanding that antibiotics have more than potential acute side effects and benefits is a really important conceptual leap that understanding the microbiome better helps us make. I think we need a lot more data to understand what those effects may or may not be because right now there's also a lot of people who die because they don't have antibiotics. So I think it's a complex issue. It should certainly make society... We have a lot of good reasons to reduce the unnecessary use of antibiotics in our society without any of this information about the microbiome. So I think some of these concerns should really add impetus to that movement. And I get back to I think we need science such as people here are trying to do to understand where bacteria are good, where they're bad. And I was interested that in some of the studies presented, for example, the use of an antibiotic created what seemed to be a healthy phenotype, for example, with respect to carnitine, et cetera. So I think antibiotics perturb a complex ecosystem and the effects are going to be complex and not always predictable and they do clearly have a role in saving many people from life-threatening infections. But I think it's a blunt instrument and people have thought of it as a very finely tuned instrument and it really isn't. It's a blunt instrument because we think of it just treating the pathogen but it's obviously also dramatically affecting the host in other ways. And I also think, again, there were plenty of other reasons for doing it but I think Marty may have mentioned this. To me, it's another reason to point us in the direction of more targeted antibiotics, narrower spectrum antibiotics. But I will say frankly to do that we also need a model, for example, of reimbursement and healthcare behavior and improved diagnostics that will let clinicians responsibly use narrow spectrum antibiotics. So to me it's very exciting because it lends weight to something that I've been passionate about for a long time is that antibiotics are a very important tool and we should really optimize how we use them and not use them when we don't need them and use them properly when we do need them. Okay. Did you want to respond to that? I just wanted to perhaps continue this discussion a little bit and the data like Dr. Blazer presented look very convincing that there's correlative data linking for obesity and antibiotic use and there is great animal data. At what point does the FDA come out at least to warn the pediatric population with a little black box warning that there are potential risks that are still unknown? I mean I think you need some pretty credible data and at this point I would focus more on this as part of educating physicians about prudent and responsible use of antibiotics. We do, by the way, we did introduce labeling that does pertain to the inappropriate use of antibiotics potentially leading to resistance because we did this some time ago but so the FDA has taken a position on the label about appropriate use of antibiotics but there's not something magical that the label on the FDA product does. As you know, they can be difficult to read, they're technical. What we're really talking about is a healthcare technology and tool that is, like many others, has appropriate uses and inappropriate uses and I think it's also our responsibility as a medical community. There's also not a lot of science that helps us know how best to use some antibiotics so I think it's a broad issue but if evidence develops that there is harm to children that needs to be balanced with benefit then that's the appropriate time to look at that kind of thing. Just before we take that question, is the person who asked a question from the first day about probiotics and regulation of health claims around those or lack thereof still here? Did you want to ask that question again because it just seems relevant to... Where is the hype? I mean we see commercials daily on TV for probiotics and how do we separate the hype from the reality and the promise of them? I think that's a major issue because the public is going to be thinking they do things that they may not do and yet there can be significant advantages in the right situations. Well I would say that's why we need sound science and clinical trials in some of these areas where the use is being promoted and I also think the scientific community... I was a couple of times struck by... I think in general people have had a very measured approach to their data but there are a few times where people even in this meeting showed this study or that and there's an inference about something like autism or whatever. I think the scientific community in our excitement about some of the data and some of the associations we see needs to be very, very careful not sort of to send patients down a road that could be potentially harmful to them or maybe at best just might not be the right road to help them when they have a desperate problem and again I'm really enthused and I heard from some components of NIH that there are a number of studies starting to be done in these areas to really address where do probiotics have effects in some of the areas that they've been shown potential promise. And as I think I had said earlier in response to questions what FDA's role is in probiotics is sort of determined by the authority FDA has been given and if a manufacturer makes a disease claim then that becomes a drug claim in essence and they really have to provide evidence to support that but short of that is where sometimes confusion develops. So I think the community has to be... the science community and the clinical community should be very... people are intelligent and I think if they hear from responsible physicians and scientists that we see promise here but what the reality is about the gaps in the data and what's not known about many of these products at least they can make informed decisions and most importantly is when we reach that threshold for a clinical trial something makes sense there's promising data, there's a defined product then for important public health needs hopefully begin to get that kind of information. Patient desperation is a big force in driving them to alternative medicine. I'm not saying probiotics is alternative medicine I'm saying that it's an easy... the way they claim is put to them it's an easy potential treatment for them and it's the wild west that's for sure and the claim just came going up. I will say we recently took action on for example people may have seen a diabetes issue where some supplements were being claimed to benefit in treatment of diabetes and obviously that's something where we do have medicine where it is a potentially fatal or unstable disorder and that's where we would normally prioritize limited resources in terms of going after concerns that might really endanger people. So I think there's a question I think maybe more for NIH or maybe a comment maybe David can comment on this as well when I'm done but one of the challenges that I face working on probiotics or even trying to develop next generation probiotics from the gut microbiota is that there really isn't a study section for me to send my grants to at this point. Most microbial research in NIH is focused on pathogens the only microbial physiology study sections that's left is now called PCMB there used to be two study sections that's collapsed into one and so I find it really difficult to figure out where to send a grant unless there's an RFA or a specific call for beneficial microbes so I would implore NIH to try to figure out how to take at least this big program that we have and maybe have a study section that allows for R01 that are specific and I just want to point out David made some really important points today one is that the strain specificity of activities is really dramatic so just knowing what a 16S sequence is is not going to tell you what that bacterium is going to do and David really nicely highlighted that and that's where I think the need for microbial physiologists microbial geneticists and a mechanism to study these bugs without necessarily having to have a big focus on a disease and a grant is really critical again self-serving this is what I do but I do it because I believe so strongly in it and so I don't know if David wants to comment on that or anybody else does but I think that that's going to be critical moving forward can we get a microphone to David does anyone from NIH want to respond well I want to say it's not self-serving because that's what I do too I appreciate that yeah there's, I mean NCAM is where we've been submitting and there really isn't a spot unless you partner with somebody and you're addressing some other issue so you become a tag along on another grant so it would be nice if there was is this on? it would be nice if there's a focus on these organisms I wanted to actually amplify what you said before and that in addition to strain specificity is this issue of genetics we have a lot of organisms that we're investing a fair amount of money in clinical trials and NIHs in terms of probiotics that we, in many cases we don't have genetic systems for it all and so the ability to try to get down to a mechanistic level so you know which genes are turning on what mechanism it becomes impossible unless you have decent genetic systems and you can't write as Rob pointed out before that kind of grant and so there's a tool development aspect that's desperately needed we have done lots of mechanistic work on bifidobacterium infantis we have yet to knock out a gene you know we do what we can but the tools don't exist and it really hampers the research moving forward so that would be another area that I would also amplify as well thank you any other responses to that? okay have some questions here the topic of self-administered people transplants certainly been brought up and I know it's somewhat controversial certainly I understand the concerns although I run a website that gets lots and lots of questions for various people out there and one of the questions was what can people do if they're doing these outside of a clinical setting to I guess do them in a way that would be basically safe and effective because I know for many people I wasn't even aware until today that you were doing these and had such a standardized process set up so many people aren't aware that there's access to these types of things for people doing it in a non-clinical setting what would be some recommendations to make sure that they're safe and effective and conform to standard medical guidelines did a question for me or for the FDA well that's a question for you well I guess we have standardized and we're material and we're trying to work on it it's not it's not a approved license it's not ready for distribution to anybody and certainly there's a lot of resources that went into that setup so that material hopefully will go through a series of trials and will be reviewed and hopefully make it to a licensed product and then it will become a lot more available to physicians anywhere to administer in an easier fashion than this is done currently I don't have a particular I do get emails like yours can you help me with some technical tips on how to do this and I'm going to do this anyway and I'm placed in this position because a lot of these stories are really heart-wrenching and the people that really are suffering and you want to listen and you want to make sure they don't do something that is completely crazy or if you read something in their email that just doesn't sound right and I kind of point it out but I don't give out advice and solve to do home transplants because that's just too far removed from the patient for me to treat a patient and to see the patient have to do the physical exam I have to form that doctor-patient relationship if it doesn't exist that's whatever it's not exactly a professional advice at that point so I try to draw that line but it's a challenge with every email where exactly do you find that line or if you feel there is something that you think is potential harm you have to probably step in and step back and not encourage something that you have no control over do we have another question of that? so speaking of understudied aspects and standardization I was wondering if you guys have thought about characterizing the phage in the fecal transplant material or in general that's something we haven't really talked about aside from rick bushman's talk about phage I've thought about it during this meeting for sure and another thing to characterize we haven't looked at archaea we just looked at bacteria so far all of those are interesting questions and phage is probably important to the stability and behavior of the microbial community is rick still here? no I think he just left so I just wanted to address a question that came in through the emails that we've been receiving which changes the topic slightly a few of you I've spoken to about the issue of evolution we've talked about a lot about dynamics and descriptive studies and a few people have mentioned the evolutionary context of the microbiome but this question says we throw around the term of co-evolved microbiome but I think a grand challenge for us as a field is to establish what this means and how we might prove or disprove this claim I think we need to look much more at conserved functions rather than hosting the microbes performed for each other and evidence for selection on these traits rather than just focusing on phylogenies and this will require broad comparative studies across many host species rather than just humans and their close relatives does anyone have any response to that? I mean obviously evolution has a way to select for the microorganism that you need I mean if you eliminate a group of microorganism that involves in a new environment but you conserve the activities I'll conserve in some ways but the taxa is gone because another one could take the same function this is a dynamic selection that happened we heard from ancestral community that we have quite a different microbiome but we live in a different environment we said that all these functions that we have right now with these microbes for our lifestyles I mean we have disease associated with some microbial dysfunction is it because we are evolving in a more harsh environment than ancestral community likely but the evolution is I think an action that is happening from your environment I don't see a problem of making the evolution of microorganism selection with how we are now housing and coexisting what I would say is we know a lot about how pathogens have co-evolved with hosts but there's been very few studies I think that have looked at commensals I would point you to one paper from Yens Walters labs at the University of Nebraska where they actually looked at lack of social right distribution across a lot of different vertebrate that kind of track nicely they group together based on their animal host and so I expect we will see more studies like that coming out as we start being able to culture and it does raise the point that we do have to look at other animals other than just humans which hasn't really been part of HMP yet and just adding to that about the co-evolution there's another study out of David Rehlman's group where I think it was a cell paper last year where they took microbes and put it into germ free mice and then human microbes and put it into germ free mice and they actually saw there was less T cells in the intestinal compartment of these mice so they kind of pointed to the fact that maybe there is some sort of co-evolution that you have if you've got microbes over time and this could be kind of due to some sort of host factors and colonization factors that the host has and our lab has seen similar things when we've come in with trying to humanize germ free mice and they become somewhat immunodeficient and they don't actually there's no particular components in the immune system that can actually recognize microbes so that's maybe another kind of paper similar to that as well Okay so I had a question for David that was along similar lines your studies with milk glycans have you looked at the relations between the effects that those have on microbiomes in other mammal species or has anyone else, do we have any other data on that? Human milk glycans are kind of hard to get a lot of and so we haven't really been able to take large quantities and put them elsewhere if you look across the animals you can look at the milk glycoms across different animals and actually none of them are as complex as human human has a large number by comparison even to lower primates but we start to see the same trends across different animals and so it's clear that these are selective across different animals but they're selective in different ways and one of the ways that it sort of follows what Rob was saying about Jen's Walter's work which is really wonderful work in addressing this evolutionary question we've isolated bifidobacteria longum from monkeys and from cows and sequenced their genomes and it doesn't have all the glycolytic capacity that the ones we get from humans have which makes a certain amount of sense matching to the milk glycom of that particular animal but that's just early early data and so one would imagine that it tracks but we have to play it out Okay there's no one standing from Mike so am I taking it that there aren't any further questions I want to ask kind of a crazy question No, not that crazy but sort of taking a lesson from the FMT talks David's talk and Julian's call for important metabolites has anybody tried to experiment with the fecal water we always target the microbes in that stool right but is there anything of benefit that can be learned from looking at the fecal water, the metabolites in the stool, are there any important beneficial compounds or anything that people have tried to explore which is an open-ended question anybody in the audience or we just throw away all that stuff and just keep the microbes John Braun is gone but the studies he showed this morning were on fecal water he has this cool way of in the rectum inserting a sponge and actually soaking up the free fluid and then does metabolomic analysis on that and he's compared to a proposal kind of that's not really fecal water but that's luminal water but I would imagine the same concept to be amenable to fecal water it's just that some of the metabolites are volatile and aren't in source maybe better than in a stored sample and that's one of the challenges is how to metabolomic materials from metabolomic analysis how long how do you store it, how do you collect it how do you process it, how do you store it how long can it go great and what about I don't know any prebiotic properties or anything in that material do you know anything about that oh here's somebody in the back do you know no, quite an answer to yours okay I mean I can't speak for John but I think that certainly the proteomics side of this, it needs to be compared with the proteomics at the same time to see what residual that's actually wouldn't be proteomics because those are carbohydrates in general so I would think that that would be part of the metabolomic analysis although they're usually looking at products rather than residual substrates okay, thank you in answer to your question regarding studies of specific metabolites I'm a director of a group in Canada that's looking at short chain fatty acids the simple metabolites propionate acetate and butyrate which have been talked about a lot in the talks with beneficial properties, cholesterol lowering and in low amounts very useful but from our approach we've taken propionic acid which is interesting because it's a main metabolite of autism associated bacteria, clostridial populations so the models we've been using in an animal model also clinical we found that these compounds as a bit of a worry they're beneficial in some ways but small amounts given in a particular times of development cause autism associated hyperactivity antisocial behavior effects in lipids gene expression and mitochondrial function so that's there's a good point about translational cleaner studies using simple metabolites that we take for granted but again it's a caveat where you have compounds that seem to be beneficial in terms as I mentioned in low amounts, coloprotective lowering cholesterol talked about as an appetite suppressant and actually I would note with propionate also used as a food preservative and at the wrong time or in the wrong place can lead to autism associated features and these are good points too the other really excellent work that's suggesting even though it may be against at one level what we're doing using vaccines against autism associated bacteria clostridial associated ones it's a very intriguing possibility and it's partly what we're looking at in Canada but and again a caveat some of these clostridial populations early on in development are actually very good they're the bacteria that seem to promote catecholamine development it's almost like the microbiome is jump-starting brain and cardiovascular function because a lot of preemie babies don't have any bugs and they look hypotensive so meetings like this are great in terms of finding potential risks and benefits carnitine was discussed as well but again it's the caveat of trying to do good translational science to show some things are good in some patients and maybe bad in others thank you one more comment over there I was just going to add to let us when we do our human fresh fecal collections we usually have to get those within 15 minutes because someone already mentioned the volatile short chain fatty acids if you can't get those acidified they're you know floating away so moving into the metabolon and those kind of data sources so just making sure you're moving and processing those samples very quickly otherwise you know the translation of that data they're just floating away essentially what you can smell is part of the reason when you're doing the fecal collections and then phenols and endols you can measure those someone was speaking about tryptovan metabolism you know in humans higher protein diets associated with you know higher phenols and endols because remember in humans we're very heterogeneous and we all eat very different diets and so we've got you know different material populations in our colon because of what we're feeding them and so you know makes it difficult to measure that as well but we have some PCA analysis with one of the posters that was here and was in Journal of Nutrition with George Fahey and Kelly Swanson is some of the groups that will do those things in humans thank you okay just with one quick question and then another one you mentioned there are 12 I believe 12 current studies fecal transplant used for ulcerative colitis can you briefly expand a little bit on a little bit about some of those studies oh this is just a catalog of things that are listed on clinicaltrials.gov they're around the world so there's I mean most of them are just toxicity studies see if it does any flares and certainly in ulcerative colitis there is a real concern that doing that because you don't have a protected barrier to see a little barrier that actually could trigger a flare of ulcerative colitis and I think those kinds of things should really be done under very very very close supervision because of that are there any studies then basically using anti-inflammatory drugs or other drugs to restore the barrier as much as possible in preparation for fecal transplant maybe say making sure that immunosuppressives or other drugs are used before and maybe during the fecal transplants do you know of any studies that are currently doing that I don't know those details okay question over that so just going back to Alita's question just putting in a plug for the robo guts for you because we've been doing a little bit of stuff on fecal water essentially looking for metabolites in fecal water is tricky because it's just so complex and everyone is so different and so one of the things that we've been trying to do is standardize a little bit by taking samples from the robo gut now that has a benefit so this would be for any chemist that kind of study so it would be equally applicable to the sort of things that Rob's doing too but the real benefit of that is that a lot of metabolites are rapidly absorbed by the host and if you have an in vitro system those made of glass you're not going to get that absorption so you're perhaps going to see some of those metabolites a bit better plus you can much more strongly control for what you're putting in and the effects that you might have so we've been collecting all of our Elaine called it waste we call it liquid gold we keep it and we have a whole repository of this stuff it's different between different people we're starting to do some proton NMR stuff on it now and that was really tricky at first because when you try and do that with fecal water you get a mess but when you do it with chemist that liquid waste you can really start to pick out some patterns and so I think that's probably where it needs to be expended let me just ask the kind of connecting question there's no way that the fecal water in the absence of the microbes could be beneficial to treating any of these patients that's something that we want to look at yes I think that would be a really useful way of looking at things because then you're taking a live organism out of the picture and making a lot more controllable and there's definitely some work going on in my lab and other labs where that's exactly what we're trying to do but it is really like pulling needles out of haystacks it's really tricky to do well if our hypothesis is correct as I said there could be multiple others it could be secondary bile acids in fecal water maybe what actually fecal transplant does that's why I'm asking the question comment over that I just wanted to speak back to the fact that a couple of questions and issues have been brought up about review over the course of the meeting and we're met with kind of a resounding silence from program officers from the various institutes and there is a reason for that there's also I'm still sitting down because I'm trying to stay under the radar but we don't have anybody from Center for Scientific Review here I want to remind all of you that they review the bulk of the investigator applications that come in the institutes don't really have much to do with that but they do have ongoing reorganizations they look at science as it changes and I think the way to reach the attention of the Center for Scientific Review is for large groups of people like this to get together the scientists, the investigators universities, academic societies contact them on a large scale level I'm not talking thousands but certainly more than an individual investigator to let them know of your concerns I think if you get their attention that will make a difference Thank you Hi this is a question for Eric I've been sitting struggling with a little bit of an intellectual conundrum from one of the stories you told and yesterday Maria Domingo's Bello told a very beautiful story looking at comparisons of the diversity and composition of microbiomes from more western microbiomes to the sort of more ancestral state in the in Venezuela and in those populations they are having in many cases a higher diversity of microorganisms and a different composition from our western microbiomes however adhering towards sort of our western diet and western lifestyles we tend to have higher incidences of immune problems and GI problems that aren't necessarily witnessed in more of these third world situations but you are telling sort of vignettes about how vaccines have decreased efficacy in those types of environments can you think of a way to reconcile that? Yeah I don't think diversity can actually explain all of it so yeah there is increased diversity in these areas of the world and I think what you maybe were confused about too is the paper I presented from Claire Fraser and Marcelo Stein where they showed increased diversity and microbiota actually helped the cell media responses but I think you can't just view it through a diversity issue I mean obviously you need a diverse microbiota to stimulate the immune system but I think in regards to the Venezuelan study and that there is all kinds of other effects such as parasites which can shift your microbiota and really can dampen some immune responses and of course exposure to more environmental antigens so yeah I think there is much more of a complex issue that you can't just start tying just diversity but maybe other aspects of their gut physiology there is some sort of asymptomatic gastrointestinal issues a lot of these children have in the rays in these areas such as environmental entropathy which is sort of this subclinical disorder of the gut where they get this flattening of the villi and less nutrient uptake and we're kind of thinking of maybe that's one of the reasons that this reduced vaccine efficacy is actually sort of more of a physiological gut response to the microbes all right we have pretty much one last quick question we've got two minutes I was going to follow up on Lita's question I think that's an important point to especially in the context of the fecal transplant we're focusing a lot on living bacteria either I'm not aware or there's not much much research on whether you really need the living bacteria or whether there might be some interactions happening between bacterial components and the host that might be responsible for a lot of the effects we see so I think it's an interesting question I would like to know if the people know more about that whether there could be other factors involved whether for example a fecal transplant with killed cells would still have potentially healing effect or maybe even in other contexts which would get around a lot of the problems that we see that maybe we're establishing a wrong microbiota in the patient which we would not have to if it's just about triggering some response through parts of the cell that don't require living bacteria okay any quick responses to that for what it's worth the way we prepare the donor material it is washed extensively and most of the fecal material other than the microbial fraction is washed away and that's still the therapeutic part we thought of as a control in a trial to irradiate this so it would look identically and that would be our placebo actually in our pre-IND conversation with the FDA we didn't like that control because we needed to do a lot more science on the irradiation but that's a one idea if I could just add one more question it sort of follows with LIDA when you look at germ-free animals their intestinal epithelial renewal rate is so much slower than conventional rates and when you look at different lactobacillus the studies that have been done suggest that there is a real differential in lacto-embifid intestinal epithelial renewal rates so in a way it argues that the commensals play a role in intestinal epithelial growth and renewal and therefore that there's something about being alive bioactive that may have potential overall value in the fitness over time but I would really really appreciate a comment from any of you on that okay very quickly time for one response well I mean if you use a germ-free mouse remember you never saw in a microorganism at least bacteria we're not controlling strangely for virus so when you introduce a new brain there's a profound response that you could see but we're not germ-free if we introduce lactobacillus in our system right now I doubt you're going to see this massive epithelial response because you never saw the immune system never saw it you epithelium never saw it you don't have a biofilm formation musin is not there very little so the interaction is totally different maybe if you have a C. diff patient prepared for transplant where you have massive round of antibiotics maybe they're going to get some proliferative response I'm not sure if someone looked at that but in term of germ-free mouse this is a transient response profound response and after that you look at the germ-free mouse that is colonized with one box of cocktail of bacteria it's really similar to a complete biome and then they just have a separation status and everything is comparable so it's a transient response alright let's call that a wrap thank you very much for everyone who participated in this discussion thank you very much to our organizers our speakers and the trillions of microbes that have kept them well fed and healthy for the course of three days please go home