Professor Lamont, Doctor Aas, and the Bacteria

Dear All,

 I saw Urgelt’s video (http://www.youtube.com/watch?v=ld1azzZrfGQon) on probiotics which I thought was very interesting and it made me think of a story I wanted to share but didn’t quite know the context of how to do so — until I saw his video. Alright, so here goes:

Last month, I went to a grand physiology rounds led by the Chief of Gastroenterology, Dr. Thomas Lamont, at Beth Israel Deaconess Medical Center. We talked about a patient who had clostridium difficile colitis — an inflammed colon — and I remember distinctly that the patient sadly passed away.

For the patient’s treatments, we only discussed antibiotic therapies — hard-hitting antibiotics like vancomycin and metronidazole that kill nasty bacteria like clostridium difficile. Unfortunately, though, for some patients who relapse, the drugs don’t do the job. In these cases, long-term suffering or death is not uncommon.   Such instances make you wonder about the patients’ treatment: could there have been a better way?

Back in high school, I had read in a health magazine how probiotics, like the harmless bacteria found in yogurt, were good for serious problems of the gut.  Six years later, I was now in med school — at a grand physiology rounds no less — and I had the chance to ask an expert, “why?”

But I was hesitant. Dr. Lamont’s a distinguished-looking man in his 60’s with a crisp tie and few tufts of white hair.  In medical school, professors with his kind of gravitas tend to think about treatment in strictly four modalities: drugs, chemotherapy, surgery and angiogenesis inhibitors. Probiotics didn’t belong in these categories.  In fact, they fell way outside — somewhere in the territory of Hawaiian yoga and herbal healing centers. The chance he’d know about them?  Tiny.

Or so I thought.  I approached him gingerly and braced myself for a curt response. “Uh, Dr. Lamont, what’s your, uh, take on probiotics?” He paused for a moment, contemplating. Meanwhile, my face felt hot. He’s just going to think you’re a silly student, I thought to myself.

Suddenly, he nodded. “I think probiotics will be one of the frontiers of future research. The gut microbes are a poorly understood area with vast clinical significance if we can understand the mechanisms behind it.”

I was startled. I didn’t just hear what I heard — did I?

Lamont continued, “You know, there’s this guy in Minnesota who transplants gut flora from one person to another.”

Really?

“Yes, through stool transplantation.  What you need is to freeze dry the stool from a family member, administer using an enema.”

My mind raced wildly.  What? I didn’t quite comprehend what he just told me, but I sensed it was profound. Or profoundly weird. Or both. I wondered for a second whether I was actually in medical school, actually talking to the Chief of Gastroenterology of a famous hospital.

Lamont went on. “You have to understand, it sounds nuts, but there may be a case for that. Healthy people who have never taken a single antibiotic in their lives, can occasionally develop spontaneous ulcerative colitis, which suggests a disruption in the gut flora.”

I studied the creases on Lamont’s face carefully — he was all seriousness.  No joke, only complete earnestness.  What he was referring to, after I had time to process it, is that there are trillions of healthy bacteria in our intestines that keep us going. They help us digest, absorb food, protect us from the bad germs. But sometimes, there’s an imbalance between the good versus bad bacteria.  When “bad” wins, we get problems like diarrhea, or colitis (inflammatory colon).

When is there an imbalance? Most often it’s when people take antibiotics, which kill the good, the bad and the ugly — altogether and all at the same time. During this vulnerable state, certain bad bacteria like Clostridium difficile can overwhelm the good germs, causing the human host all kinds of complications and even death.

Dr. Lamont explained that most of the time, people only get clostridium difficile complications when they take antibiotics. Yet, there can be rare instances of colitis without antibiotics, which suggest that there’s more to the gut flora story than we originally thought there was. For some reason or another, with or without antibiotics, the fine balance between good and bad bacteria can be broken, and stool transplantation might be the last option. It could also be one of the most promising.

                                        ***

That “Minnesota guy” who does the transplant turns out to be Dr. Johannes Aas. Journalists love him. Gene Weingarten from the Washington Post wrote a dialogue about him (which I adapted for my video below) and Aas was featured in blogs like “News of the Weird.” Everybody else though — besides his patients — probably thinks he’s nuts.

But the craziest thing of all, might just be that he’s not nuts. For example, his published case reports on stool transplantation were featured in a prestigious speciality journal called Clinical Infectious Disease. This is a journal that’s peer-reviewed, with a high impact factor, meaning that it goes through a rigorous editorial review process and gets read and cited by lots of specialists.

I looked up this paper and read it.  The langauge certainly seemed “scientific,” capped off with a stern enough title: “Recurrent Clostridium difficile Colitis: Case series involving 18 patients treated with donor stool administered via a nasogastric tube.” But the real litmus test, as far as I know, involve the letters to the editor. Getting published in a prestigious journal is great — but bad studies do occasionally get published in great journals. When that happens, the letters to the editor can be swift and furious. Experts weigh in, critique this, critique that — in these letters, you can find some most insightful viewpoints.

After perusing through the entire National Library of Medicine database, I found one published letter to the editor. It was in electronic form, so I had to click a few links to get to the page. Oh boy, moment of truth, I thought. This was it.

I felt a faint dread — as I approached the link to the response on stool transplants, I readied myself for disappointment. Was this the letter that was going to expose the flaws of Aas? A cynical sneer of a report, tearing us apart the way Vioxx did to people’s hearts last year?

One click.

Two clicks.

I held my breath. Suddenly, the paper title popped open:

                     ” ‘It lacked aesthetic appeal.’             

                                           So what?           

                                         It worked.”