Dr. Mark Puder - Intravenous lipid emulsions in health and disease

you you so I'm going to get your wire right there. All right. I just want to make sure that you're mental. I'll scale to get only. Switch. I'm going to follow your shoe jacket. That's the. That's. That's. I don't think it. It's definitely on. I'm going to go to the room right here as well. Throw me a little bit of an indication that it's back to like last within the room. That's really be able to help those that are on zoom. You'll pick up your place on. I should return that off when I use this. The two of them can stay on at the same time. They should be fine. They're not going to find each other going there. We should be okay. Oh my god. Hello. Good morning, everyone. Wu is on vacation today. So I will endeavor to fill in his place. So I'd like to give a little bit of an introduction to our speaker today. Went to medical school of Vanderbilt. Then went to former New England deconess for residency. Went out for research. Loved it so much. Stayed out for five and a half years and finished his doctorate in Viralogy and biochemistry from Harvard. Returned is one of our own a fellow from Boston Children's. He has over 200 peer reviewed articles. A current R01 funded grant for relis orb. I also am looking back at the distinguished B.I. General surgery residency graduates. One of the things that stuck with me is that. Not only does he have a passion for research, but that passion for research comes from his passion for patient care. A quote from him and that was that I was taught in residency that no matter what it took, you always did what was best for the patient and you didn't give up. Whether I'm in the lab with a clinic, the dedication to patients has been a driving force throughout my career. For the fellows, Dr. Peter's door is always open. If there's such a thing as a shoulder to cry on in surgery, I think that person is Dr. Peter. So without further ado, I introduce the vein of pediatric transplant surgeons around the country. Dr. Mark Puder. Thank you. Can you hear me? Okay. Well, thank you for the introduction and glad to get started. I do have a few disclosures. I have license and patents on all the things I want to be. Most of the things we'll be talking about. The biggest disclosure I want to make is that all the lipids, including a mega-venor bat, it's just a degree of badness. So they're all poor. So I'm going to talk a bit about fatty acids, a little bit, and roles of fatty acids, a little bit of liver disease, about the critical data that we use for a mega-venor. And then the new lipid emotions that we're developing and also new approaches to liver disease. So as you know, PN has given intravenously. We have one bag usually that has the sugar and amino acids in that vitamins and trace elements. And then there's the fatty acids, which are very important, of course. But it's life saving and it has complications as well, no, which is mainly liver disease, but also infections and play a lot of other things we don't even know about. So the main slide here is that there are a mega-three, a mega-six, and a mega-nine fatty acids. They're also medium-changed from fatty acids, which we'll talk about in a minute. But a mega-three just means the double bond is at the three, a mega-six double bonds at the six, a mega-nine, the double bonds at the nine. And these are all acted on by the same enzymes. And that's really relevant when we talk about more detail about the fatty acids. And these fatty acids, when I was in medical school, were there just primarily for structured membranes. But actually they're very important as messengers by active metabolites. Very important for platelet aggregation and function and also vascular tone. So this is the key slide I want to go over. There's the omega-three fatty acids, the mega-six fatty acids, and the mega-nine fatty acids. The two, you have to have a mega-three fatty acids and a mega-six fatty acids, because that's essential, because humans cannot make a three or six fatty acid. The mega-three, which is alpha-lenoletic acid, the alpha tells you that it's the omega-three, goes to EPA and DHA, which we all have heard about and know about. The mega-six, which is linoleic acid, becomes a recadonic acid, and that becomes more of an inflammatory for more inflammatory maloo. But it actually is very important for brain development. It's very for lung development and eye development, as well as the DHA. Now, these were considered the main essential fatty acids, but as I'll show you, is that you can just give a recadonic acid in DHA alone, because that's what the body is actually trying to make. Now, a mega-nine fatty acids are made by the body to compensate for the lack of double bonds in the essential fatty acid deficiency. And a mega-nine fatty acids are very, very high in olive oil, which we'll talk about. Now, essential fatty acid deficiency is defined as the trientetring ratio, which you see in a lot of the labs for our patients, is the meat acid, which is the mega-nine fatty acid, over the recadonic acid, and the ratio greater than 0.2 is considered essential fatty acid deficiency. But symptoms generally don't occur until 0.4 or even higher. So just briefly, a recadonic acid becomes more of the inflammatory prostate glands and lupitrines and a mega-threes become more of the anti-inflammatory molecules. So these are really important for fatty acids, or really important, as you know, for growth, brain and eye development, inflammation, coagulation, and, believe it or not, fertility. So the type of lipids that are out there, and this is relevant to what we provide for our patients, they're soybean oil, olive oil, which offices from olives, medium-chain triglycerides, which are from palm and coconut oil, and fish oil. Now, the soybean oil, olive oil, and fish oil are polyunsaturated fatty acids, so they have double bonds, and are easily oxidized. The medium-chain triglycerides are absorbed differently, and they are not oxidized, but they're very anti-inflammatory. Olive oil, we know, is anti-inflammatory when given orally. So when something's given orally versus intravenously, it's a very different outcome. The lipids also contain amulsifiers, which the breakthrough was in the 1960s, where you can emulsify lipids, glycerol, water, and one of the main components is vitamin E or alpha-to-cofferal. So because the double bonds are what gets oxidized, that's when you go to a fish market, it smells fishy. It's the oxidation of the double bonds that causes that terrible smell. And so one of the things that's added to fish oil and other oils is alpha-to-cofferal. And alpha-to-cofferal or at least vitamin E, there's several types of vitamin E's, is very, very important in anti-inflammatory effects too. So a lipid with high vitamin E is good, low vitamin E lipid is not good and easily oxidized. So lipids also contain phytosterols. Now phytosterols, as you see on advertisement on TV, are really healthy for you. Well, because they're not absorbed when you take them mentally, they compete for the absorption of cholesterol, and they compete for absorption and incorporation into the micelles and the gut. And so therefore, it keeps your cholesterol level low. Given it intravenously, it's been shown by others, and also by us, and many others, is that it is very toxic to the liver. And so we would like that to be low. In fact, the FDA strongly recommends. And then as I mentioned before, the Lyclinolac acid, alpha-linolac acid, or racodonic acid in DHA are in some of these lipids. Now here are the lipids that are available. I just want to start out that all lipid emotions that you, we use here, are over 25 years old. Smoff is 25 years old. Incholipid is 60 years old. Clintolipid is well over 20 years old. And like I said, smoff is over 25 years old. And soybean oil lipid emotion contains a lot of lyclinolac acid, which our data and other data shows, is one of the main inflammatory agents. And so, the Lyclinolac acid has no EPA DHA and no racodonic acid. So a baby who takes soybean oil has to convert to racodonic acid, which is essential for brain development. But the livers are immature and they don't do that very well. Fisual oil has lyclinolac acid and alpha-linolac, but it has a lot of EPA and DHA. And mole is mixed oil lipid emotion and that's the smoff. And it has a fair amount of lyclinolac acid, but a little more than a third. Minimal EPA DHA, but it has fissualing it, but it's not the same quality fissual that's in fissual of a megaban. And has minimal racodonic acid. Now one of the key things, these are the same slides. Also, they also have the same amount of glycerol, egg phospholipid, which is important for multiplication. A look at the phytosterols amount. So soybean oil has about 400. A megaban has about 3.66. And smoff has 207. You can give one gram of soybean oil, but you generally have to give around three grams of smoff. So you're given 600 when you give smoff to these patients. So that's important. As I mentioned, it's life saving, but there are problems. And that's colostasis. This is one of our patients who's now 17 years old, but she's a very jaundice. And when she came here, when you turned down her TPN, she just go to sleep because a blood sugar would drop her liver, would not be able to maintain her glucose levels. Now, colostasis is called peanut or eye-fout intestinal feathers associated liver disease is defined as a direct delivery room in a greater than two. And that's what we used rigor, regrettably. I wish we used this lower number because histologically when the patient's belly ribbons already to deliver has a significant histochemical histology changes. So who gets criminal nutrition liver disease? Those are the premature infants. That's mostly the older children don't tend to accept after several years adults get it, but that's a longer term problem. But a 30% adults do get a liver disease. Young age, low birth weight, substance and self-patients develop colostasis, even without parental nutrition. Patients with shortcuts in room multiple operative procedures and of course absence of entral feats. The best treatment of all for liver diseases to give entral feats. And the diseases we all know may be progressive reverse. And go on to full feeds, reverse, can also reverse spontaneously on any lipid. They develop cirrhosis of a liver failure liver trick and undergo liver transplant or pass away. And there are many potential treatments, which I'm not going to go in a lot of detail, but we do cycle the beyond with advanced feeds. We've reduced fat doses in the past. We don't know about the amino acids that much, whether that how much that contributes, but I'm sure it does. We talk about different fats, really important to eliminate the patotox medications. And one of the biggest ones are the antifungals. The bacterial growth is a risk. We do give us a dial. Blood when it breaks down becomes a billy-rooven. And so as you often see after you transfuse a patient, patient is called a static. The billy-rooven will get a little bump from it. Many searchable procedures and. And one of the things that's been most helpful is the multidisciplinary team. Well, what was it like? Well, basically 40 to 60% of our patients develop colostasis. And there was a 78% mortality if you had a direct billy-rooven greater than three for three months. And if your billy-rooven was elevated for a year, there was a 90% mortality. This is from Paul Wells. The 90% mortality is because 10% of the patients got a transplant. And so we did account for 1.4% of all deaths of children aged four years of aging younger. And so, you know, we do have small in the United States. And this is data that we just published in JP and from our NICU. That the incidents of colostasis compared to one gram per kilo about one gram per kilo, intro-lippid. If you take intro-lippid, the incidence is about 22% and the small flip at incidence is anywhere from 63 to 78%. Depending on how the data is analyzed. And this is the probability of colostasis all on small versus intro-lippid. So actually, we've got a little bit backwards. What about the laboratory data? I won't go too much into this because I presented this many times over the years. But, you know, one of the things that when we started working on liver diseases that we really didn't know what components were causing the liver disease. And I'm sure it's the sugar. So I've searched them, you know, assets. And I just think it's the lipids. But at least we hypothesized that in part it may be related to the lipids. And so we did a really simple experiment. This model was developed by Dr. Fulkman and Dr. Schamberger in rats where they gave piano orally and then gave the basically gave the piano orally and the animals developed the fatty liver disease. What we did is we just took the animals and gave the lipids intravenously or orally to see maybe there was some problem with the lipids. So basically we gave chow or oral PN. We gave saline IV IV soybean oil or oral so we know well and look at this. And this is a standard normal chow liver. But when the animals drank PN or oral PN it was a high sugar diet that actually developed essential fatty acid deficiency and this white bubbles are fat. When the PN was given with the soybean oil IV the liver looked fine and when they were given soybean IV the liver did not look so good. And so we thought well maybe that's what the problem is and we quantified the fat by MR spectroscopy and showed that the livers were fatty when they received IV soybean oil or piano alone. And we looked at essential fatty acid deficiency because one of the arguments is that the mega band or that these animals were developing essential fatty acid deficiency. The ones that were developing deficiency relative deficiency are the ones that did not receive any fat but all animals did not have essential fatty acid deficiency. So what was the alternative? Well worked extensively with Cathy Gurren. She said well there's something in Europe called the mega band. Why don't we try that? And it was based on fish oil. I really didn't want to because fish oil is kind of a gimmick and I didn't really want to deal with fish oil and I really didn't want to do fatty acids because that's what my PhD was in. We tried it and we you know we defined what we would think would be an ideal lipid emotion which there is not one one that reverse essential fatty acid deficiency which was already done in one patient was with a soybean allergy. We would not produce a fatty liver, prevent enzyme elevation and get normal growth and development and there was nothing. But we decided to test this and we tested this we got gathered every lipid available in the world including smoth and other things made by bebra on to see what would work in our model. The one that did seem to be good was the mega band and we did the exact same experiment but the astrology came back that when we gave official orally and gave the official IV the liver slick completely fine for both of them and that brought us to exactly 20. 20 years ago I gave the grand rounds showed these same exact slides and and rusty Jennings had a patient that was caused static and developing it's a russus and has to try that try this in those patients whom we actually we did. But we found also we looked at it because the argument would be that the fish oil didn't have alpha lental and cast it a little a cast it or very little that they develop a deficiency but we didn't the animals the animals did not develop any sort of deficiency. And so this is all these are well read states of the different lipid emotions that are available this is child the red is the fat in the liver this is the PN plus soybean oil this is the PN plus smoth this is the fish oil this is clean a lipid which is made by backstreet just want to emphasize that everything that's available to us is now made by for seniors so it's a lipid small and a mega band are all made by the same company. Talk about a conflict. So, fish oil is not was used in Europe and not for any particular purpose it was just given potentially to feel better maybe decrease inflammation it was not used for PN liver disease the max dose was 0.2 grams per kilo per day we used by five times that it's not used to be a loan which we used a loan is not to be used in children we use it in children and not to be used in liver disease and that was our main indication was the liver disease. It's all go briefly over this but we did what we when we first had our data in the animals we contacted prusineous copy and said listen let's do randomized control trial see if this works but they had no interest because of the conflicts and only a couple of times in children a year we're dying from it. It kind of remind me a little bit of for Pinto and their fires you know was a 25 cent device would have prevented the fires in the for Pinto but anyway that's a whole other lecture which I'm given at nine o'clock at the men's school by way we looked at our patients and and just did a compassionate trial because we couldn't do the randomized control trial to not agree to it and so we just went on and on and took patients with Billy Rooming greater than two compared it to our historical controls that exclusion criteria that other liver disease was not allowed to be used they were not allowed to be in the study. We gave the fish one gram per kilo per day and all the rest of calories were provided by sugars and you know when we went to the FDA we said well look at our data the amalgamant group was far worse than the amalgamant but then the small sorry into a lipid group and because patients that are younger or worse off they were smaller or a better way to do it. Well these were about the same size just as you know age they were younger the length of time they were on PN was almost twice as long. The Billy Rubin in the fish all group was higher and here's the P values and the total Billy Rubin was higher the ALT was higher and the album and was actually believe it or not a little bit better at the soybean well group. The platelet counts were lower the liver disease was further along in the official group and the outcome was death and transplantation combined because that our institution if someone needed to transplant we had readily available and they received a transplant and the difference was 0.007 now all this data was already harvested by the company and the results came out to be same except with many more patients than in this compassion trial and this is this is the group of patients on a megaband the most important thing is the patient. This is on a megaband that says the direct Billy Rubin and this is the group on intralipid most of them continue to have elevation of their Billy Rubin levels and this was the probability of reversing color stasis on the old megaband and this is the probability on soybean emotion. And the ALT the blue is the soybean oil ALT started lower went higher album and got better on the fish oil we looked at many things like essential feds deficiency infections leading. Growth nor development we did a lot more experiments in the animals than was requested by the FDA because I wanted to be as sure as possible that we weren't suggesting something to use the beat highly dangerous and come to bite us someday in the future. So we looked at lipid profiles and we looked at our patients at the beginning and the end of when they were on the fish oil emotion and the triglycerides were lower the clusters were lower HDL was only slightly higher the LDL was lower the LDL was lower and the CRP which is very important for inflammation were also lower so. That was good we looked at deficiency no one developed essential feds deficiency. We looked at the trying to treat ratios has mentioned infections so the IRB was really concerned that our infection rate would be high but actually so this is all data our infection rates are lower all across the board because the care team and ethanol locks and all the teaching and it's just amazing but. At that time the infection rates were approximately half of what they are were in the historical so you know control room. We looked at bleeding because Eskimos bleed more Eskimos eat a lot more fish therefore fish all causes bleeding. But we went ahead and did studies on that looked at platelets actually the platelets climbed over time on the fish oil and we thought that that was mostly related to anti inflammatory process but we're in collaboration with the platelet people in the vast global G lab. They noted that the polyunsaturated fatty acids actually increase the fluid in the membranes and also released platelets more readily so that's one of the reasons that probably platelet counts go well. The regulation was normal and we looked at our patients and all the patients and looked at bleeding and so did the company going back work back and I'm not going to go into all the details about it. We looked at all the procedures that the patients were receiving and that we have if you look at stoma bleeding, look at an asthmotic bleeding and the bleeding rating children for after operations was between 2 and 8% and the bleeding on a fish oil was 0.68%. So there was not a signal that we had increased bleeding. One of the things that people concerned is because it would lack essential fatty acids but this is so you know all versus fish oil and for a Z score age for the Z score for growth for these patients for length for Z score. There's the fish oil did better or weight for Z scores they did better on the weight and so did and they did also better on the head circumference and what's interesting about that it's not that so much that fish oil is good that the patients on soybean oil were developing worse in liver disease. So it's not a true head to head comparison we have that head to head comparison in our perspective trial that we did and we did not see any differences between the two. We did neurodevelopment studies which the FDA did not request we did them in humans and we did them in mice we took animals and took them for up to 10 generations put them through a battery of intelligence tests and anxiety tests and. Nice to know that mice are less anxious on a mega three fatty acids they're not any smarter so if you want your mouse to be smart that's not going to be it but they're highly reproductive so a mouse will stop reproducing at eight months of age to year. But if you give them a mega three fatty acids they will reproduce updating months near up to equivalent of 80 years of age in the human anyway. If you want a lot of mice but when we did our human neurodevelopment we did not see any difference between soybean oil and fish oil there was a trend on the parent reported. Patients there's only ten in each group here approximately but the. But there was no difference in one of the patients in the interlibrary group is a genius and I messed up all our data so there was no significance. Now this is. This is kind of a key slide anyway. It's okay yesterday anyway so what the company looked at was all the things and the comorbidities associated with this is published in journal pediatrics and it was all that ran up at the prematurely bronchopulmonary disease and believing and infections which were bacteria and focal infections were less in the. Visual group rather than the soybean group. So basically we did our first experiments in 2002 we got the I.M.D. first I.M.D. in 2004 company was not interested pushed him for many years finally submitted the 20 and Indian 2017 and the drug was approved in 2018. So what's next well as I mentioned at the beginning that. The mega isn't that good it's it's okay but I felt like we can do better. So a small and in the lipid and kind of lipid were all designed long before what we knew about the lipids in fact the only evidence before these were designed was that in adults they saw that they develop. So we had a lot of cases of lipid and alcoholist cases reducing in the lipid was improved the patients did better Dr. Goulet and published in 2001 that in children if you reduce the lipid some patients were reversed the call of stasis. So I wanted to develop a new lipid emulsion that would be important for the general population a new lipid emulsion that would be a part of preterm methods and then also since I suspect we're not going to be successful and completely preventing intestinal failure liver disease work in the development of a drug to treat and prevent the liver disease. So it's important things I mentioned at the beginning is MCT's anti inflammatory it's not toxic is low in phytosterols and is metabolized almost like sugars it's very rapidly metabolized. And so we wanted to test hypothesis that if we made a lipid emulsion that was composed of visual and medium trig triglycerides it would be better than say so even oil and actually mega band we're actually trying to keep better than the mega band. And when we make these lipid emulsions this was done by Gillian fell in the lab we have to follow all the FDA requirements USB requirements which we're capable of doing in the laboratory. And so what we did it was take animals and we wanted to develop an emulsion that had raised different ratios of physical and medium chain fatty acids. And so as you can see I hate say that see here that the we did different ratios of visual to MCT oils. And they all grain again weight nicely we did all the safety which we won't go into too much detail. And on the histology on the histology the PM Fischel was okay the 70 30 looked good that's 50 50 looked good and the 30 70 didn't look quite as good if you look at the bottom right you see some bubbles there so that that is in a perfectly round that's fatty liver. So the one that 50 50 looked the best at that time and this is with oil red O staining to confirm that they looked okay in the fat and they did then we looked at essential fatty acid deficiency and none of our lipids developed any fatty acid deficiency. And then we decided because patients with short bowel syndrome have basically a continuous LPS challenge which is like a polysaccharide and then it's sepsis and we saw that the 50 50 MCT Fischel and the 30 70 were best on the elevation of pile six and TNF alpha which are the markers this is just the normal groups we didn't see any inflammation till you gave LPS. And so we thought it was safe and very interesting to use and so what that new lipimulsion has been all of our data has been confirmed and performed by a pharmaceutical company which is licensed it for worldwide use and going to go through the FDA process first as it's go through GMP talk studies and then go ahead and the pharmaceutical company. So go phase one two three patients now that's that lipid amulsion the next lipid amulsion which is even more important but for fewer populations is for the preterm infants the preterm infant the brain is a large percent fat and 25% of the fat in the brain is DHA and a recademic acid and as I mentioned soybean oil. Has no DHA and a recademic acid and the preterm infant has a difficult time making DHA and a recademic acid which are very important for brain development that's why DHA and a recademic acid are put in formulas as it's been shown clearly that it improves the intelligence levels of patients and important for brain development. So when a baby is born preterm they are receiving DHA and a recademic acid from the mother the increase of DHA and a recademic acid is extremely high higher than which you can provide entry for a patient and within the first week the levels drop off dramatically and there's a huge deficit in these patients and we get we have nothing to give them. They would provide anything now now we provide if you give them fish or others plenty of DHA but there's not enough for recademic acid probably in it and this is the rocket or academic levels also that just in the first week these levels drop off dramatically and they never get it. So these are associations but a deficits in these are associated with low levels of DHA and recademic acid associated with death, sepsis, intracurricular hemorrhage, BPD and retinopathy and prema-turity and it's been clearly demonstrated that DHA helps prevent retinopathy and prema-turity. As mentioned patients do not have enough for recademic acid in DHA. The recommended amount is in the blue for DHA and recademic acid. This is how much the mother gives the baby and these are the lipid emulsions. Well, fish oil gives you plenty but small fluid gives you the recommended but not as much as the patients get needed and the recademic acid is very low in all the emulsions and this is the deficit of recademic acid from what the mother actually has given the baby. So we decided to develop a new lipid emulsion for the babies which would have high DHA. We wanted an anti-inflammatory which would be the DHA and we also want to minimize liver toxicity by reducing the amount of phytosterols. And also important to note that in a megaban is a 10% emulsions so you have to give twice as much as everything else because everything else is 20%. So what we did is we, what Scott Fligger did, is he, we obtained low phytosterols soybean oil, we have got fish oil and a fungal oil which is enriched for recademic acid. And the fungal oil has a fair amount of phytosterols, fish oil has very low phytosterols and of course low phytosterols soybean oil. Now it's not all phytosterols that are considered toxic, it's stigmasterol which is, which we'll talk about in just a moment. So the lipids are made in the laboratory, sent off for testing to be sure it's the same level of quality that we would give patients because the mice deserve that. And what's important is we, he developed three different lipid emulsions we call A, B, and C with different, different amounts of erectonic acid in DHA and soybean oil in it. And it's important to note that here is the stigmasterol and this is the level, these are the levels in our new lipid, these are the levels in, levels in Smoth and Intralipid. So the lipid was much lower and we did a lot of preclinical data and compared these lipid emulsions in these patients. However, this study is, remember all the studies I showed you, we gave the lipids IV and Orally. This was just a safety study where for a month they received these different lipid emulsions, Intralipid, Smoth, Lipid, OmegaVen and the new lipid emulsions Orally. And there's some surprising results based on that. One is that not surprising was that Smoth lipid, the animals developed essential fatty acid deficiency, whether it's looking at the plasma fatty acids or the liver fatty acids. And histologically, we looked at AB and C and B and they all looked pretty good. The white you see in here is actually a surest in the PAS positive staining. The MGV looked okay, it's a lipid look bad. Smoth lipid Orally even looked bad. And these were the lipidosis scores that we sent these off to be scored by a mass pathologist and Smoth had a fatty liver, Intralipid had fatty liver, but the new lipids did not. And then the same procedures were done, but this is intravenously. And we also followed the way change and body weight and they all did well. And the Billy Rubens were okay, the liver enzymes were elevated in Intralipid. I don't have the Smoth one here, but the Billy Rubens were okay. And histologically, Intralipid did look so good, our A didn't look so good, our B was good and C was good. And so we've chosen B to go forward with this is the Smoth lipid, Intralipid and that's the Omega Ben and the control sailing group. And so these are the lipidosis scores by blinded pathologists to look at that. We again, shows B because we thought that was the best one. And we looked at trying tetranetriose. They were all good, we didn't have Smoth here, but they were all good and again B was fine. It was at the level of the Omega Ben. And so based on that data, we saw no toxicity or any problems with that. And so what we're doing now, we're forming a company based on this because companies often, the reason we're doing it much, shopping it to the big pharma companies is because we want to make it the way we want to make it. Because they often don't have the best interest in the patient and I thought it would be fun to do. So we're establishing that right now. The last part I want to discuss is in Tesselfair, the Associated Liver Disease. And this is the Scott Fliggers work also. And we mentioned earlier that medium chain, fatty acids are anti-inflammatory. Well, a company that we're working with, Pronova, which was bought by BASF, which is, makes this product, showed us this compound. And we thought this compound might work pretty well for PN liver disease. It's absorbed readily in the GI tracks. It would be entral. It's an agonist of several important molecules and it's anti-inflammatory. So we did some mirroring model studies, the same kind of studies. And when the animals received the drug, the livers looked fine versus when they did the drug. So here's the whole redostaining. So that looked pretty good. Lots of studies went on, spray the details. But then we went to the large animal. And this was the most work that any of our fellows have ever had to do. They had to run at Nicky. They had to do C section on 700 pound pig on the floor. They'll deliver the babies, assembly line of people trying to keep them alive since they were preterm, central lines, and 24, 7 care of these patients for they receive. PN. And so there's a 15 day study. Patients either received the vehicle, which is empty tea oil or this drug called C for six, 179, which is an analog of the medium chain triplus ride. And we looked at colostasis enzymes, looked at stainy and fibrosis in these animals. And one of the things that's important to note is that preterm piglets don't have an albumin level. And then over time the albumin level was actually higher in the C for group. And that may be because these animals have less inflammation and their liver was not as injured. And we looked at Billy Rubin levels at different time points. And the Billy Rubin remained in the normal range for the piglet while the animals that did not receive the drug had elevated Billy Rubin levels. This is the direct bill. These are the direct Billy Rubin levels, which are also normal. And the GTT, which is a marker of biodect inflammation. And that also remained normal in that side. And then biolasted levels are very important. Biosolastic to accumulate when there's liver disease and the biolasted levels. I look this up. It's hard to know what true normal biolasted levels are, but that's a normal level for a baby. And they're elevated in the non-treated group. And this is the histology on the left is the vehicle, the MCT and the piglets. And this is the histology in the animals' radius, even the drug so it's anti-lippidosis molecule. And when it's quantified, there's a big difference between the amount of lipids in the liver of treated and untreated animals. Another interesting thing was fibrosiscores. And this was also performed by a mass pathologist. The fibrosiscore was much higher in the animals that just received MCT oil versus the animals that received the new drug. And so basically this new drug seems to be a good molecule, what the whole team performed. There's a lot more data behind it. Many bowel resections to determine PK and absorption for FDA purposes. And what patients could take it antially. Do we need an IV type molecule for this? And so the we performed all these studies, submitted all the data. A phase was then it went to large animals and went to non-human primates. And then that passed. And then it went to phase one clinical trial in the last year, which did not show any problems. And the phase two trial will start this summer at the Mayo Clinic, Cleveland Clinic, and do these are centers that have adult short bowel programs. Otherwise most adults are treated with by the local gastro analogous. They often go to centers like short pediatric short bowel patients. So once it's used in adults and looks okay, then it'll go to patients, but in the children. But in the meantime, it'll the talk studies that are required by the FDA will be performed. And that's it. So this is the young lady. The beginning. And now she is in high school. She's a senior in high school. We just operated on her last summer for a bowel obstruction, but she's still on parental nutrition. And the funding here is a lot of funding. And I like to thank, of course, my department, which had a lot to do with that. And the Vazca biology program providing all the facilities and help Dr. Garag who has been working with me on this the entire time. Dr. Folkman and Dr. Moses and Dr. Bistry and were on my first K award advisory, but also saw my career through. Of course, Stanley Dudrick, Dr. Schamberger. Financially and helped us move this along also for the patients for between the hospital. The hospital has been in almost a million dollars a year for the omega venn for the in patients. And our department also funded a lot of the lipids and all the experimental studies beyond what the grants performed. And I also like to thank the care team because they're the ones who took care of the patients. And of course, the biggest supporters were the nurses and the families who volunteered to come forward to do so. And that's my talk. Thank you. Well, thanks Mark and I think with what you've all just seen is. Not an entire career. It's worth of work because Chris not at a day in the month, but a very long duration of work and and one of the things that I think is essential. It's actually the credit that Dr. Prudger gives to all people who did this work with them and not too typical for a surgeon to partner a career along with a pharmacist, but Kathy Gurra has indeed been there as. Dr. Prudger. I'm a co-PI and I'm a mentor at all of this, but there's a whole lot of people here who have gone on to careers in pediatric surgery who've done this work. I, we've sort of lived many of this evolution and and watch the suspicion and the doubt and acceptance. I wonder one thing. I think I know your answers. That's going to be. Although you say that there is no perfect lipid. And you, but you demonstrate superiority of some of another. Why does the infillipid still exist? Why does it still exist? Well, if you give it a low dose, it's pretty good. A lot of countries, that's all they have. So for example, in Japan, it's just in the lipid. So, you know, the reason why any lipid other than entry lipids in the United States is because the company being coerced to bring it to the United States. It's really interesting that in the, I'll speak a little longer about this little I meant to say this, but in the 1950s and 60s, there was a race that developed lipids right in the United States. The US had caught and see the oil. And that was approved. And it just killed so many patients and so many patients had reactions and inflammation that they didn't get. Then it got taken off the market in 1960, and the lipid was developed, which was pretty good as a big advancement. It didn't come into the United States to the mid 70s. So in the United States. For 15 years after something was available in Europe, it was it wasn't there. So people also don't believe in the lipids that have. And so that's one of the reasons now what's happened recently is, in short, lipid was made by for Zinias, marketed by backster. And now that relationships are sort of purely. Intial lipids from for Zinias. And so they they're keeping it for now. Right. So that's what's getting it. So this is the. Lots of stuff in medicine happens because that's the way we've always done it. There was a classic study in the early 90s. On the used by cardiologists of beta blockers versus digitalists and lay six for heart failure. And those who were trained before before beta blockers. It was publishing the journal in 30 years later. We're still not using beta blockers. I just because what they did. There's also economics and sociopathics of the companies here. But now that all of the lipids are made by the same company, why is it in their interest to have what it'd be coerced? Why wouldn't they just. I think they're going to use the better. I think they're going to get rid of. Intial lipid. I think small is better in adults are children. I think it's better than intial lipid. I think the same small is not so good in the preterm. I think small is is better in adults. I really do. And our young children, we actually published that. Kathy. I'm brand published that, you know, in the children in the short valve program. It seems fine. My only beef is the preterm efforts. I also want to emphasize that the reason small one that it's interesting that small in Europe. I've got approved, but they didn't have any fatty acid profiles. So it's like doing a blood pressure medication and not testing blood pressure. So they didn't look at fatty acid profiles. So the reason we probably have article of stasis in the preterm evidence. Is we followed fatty acid profiles and turns out we have to give a higher dose to prevent that deficiency. And while intial lipid, you don't have to give that dose. So you just have to give a lower dose. So the last point I want to make is that it's not that it's not so much the lipids are all bad. But it's probably given the sugar. It's not going through the portal circulation. You know, the amino acids are not going through the portal circulation. We're giving it basically the liver is seen in through the panic artery, which is completely backwards from what it should be. That's why this is a battle that we're it's just going to be a battle because I don't think we're going to be able to make it a non toxic. For being a. Fisher. All the really administrations of problem. So, thanks for a remarkable talk. Truly excellent work. You mentioned that until the 70s, we didn't even use. Lippits other than donated lipids from parental sources. In patients. And just for the residents another way you can destroy a liver is to overfeed. And we used to call. A branchal nutrition hyperalimentation. We gave a huge surfeit of calories. And there are. Very good case reports of cirrhosis and death. In children during that time. So it's very important to give exactly what they need. Yeah, I hope it have a slide to show you an overfed baby. But yeah, overfeedings are. Yeah, we don't use the term hyperal anymore use just piano. That's exactly right over feeding. And one of the difficulties or to distinguish between. In short between the oils and the PM is that even before there were lipids. When they gave PN alone without lipids, agents, valve callous cases. And that's all in part due to a developmental central fatty acid deficiency. They were being over fed like you said. And so when in to lipid came along patients were still getting callous cases. And so that's why. Most of us thought that it wasn't the lipids or at least lipids were not a major contributor. Again, it's not only the lipids. It's how we give it. You have inflammation from having a central lie. The fact you're all over growth. You have leaky gut and translocation of bacteria. We have such a line of infections in the unit as you know all the time patients on a ventilator. They get pneumonia. All these things contribute to deliver disease. They require transfusions. So it's a lot. I forgot about the history I trained at the program where. Hyperal was invented where it finished the Christian was and we called it hal orders and not PN orders and. Wasn't too much later that we stopped calling a hyperalmitation. Yes, we do learn over history. Other questions or comments for that. Well, thank you, Mark. It's a constant pursuit of trying to fine tune this for different patient populations and certainly not a one size fit all. My question is in just out of curiosity, how you do a study design in the short, bow patients that are improving their internal nutrition component. How do you control for that among the different groups because when they start out, there's going to be a constant improvement and we know that that will improve their liver function as well. That is the big difficulty in this. And so that's where we lean on the stat. So remember this is still a rare disease. That's where we lean on the statisticians to take all of that into consideration. But we say it's, you know, the problem is, is are they missing their helium or they miss their genome or they miss their colon. They're all different. So you have to do it in a population and then they do all this sub analysis that's required and that was required by the FDA to do all that. And then which makes it more difficult is it's. Even if you do a control trial, it's hard to do a control job at. The control trial in this population is very difficult to get the numbers. So the small study, Kathy and I, uh, wrote the protocol for that for the company to do. We didn't participate in the study, but we did that. We tried to do everything we could to control for all those different parameters. So the next so then. So this isn't going to be hopefully the end of the story. So once we developed this new one for the preterm infants. The next step would be that there's. There's other type of lipids that probably need to be in the lipid emulsion. Maybe I won't be around to do it, but the. I really think the next step are going to have this single mile and very important for brain development. Certain lipids that probably need to be there already for the brain and the highs and the lungs. And so that's going to be the new home. One last brief question. Mark, I'm interested in your thoughts of how the microbiome of these kids do influence what's happening intravenously. Just in my own daughter, you know, the influences of the microbiome in terms of getting rid of her yeast just made a huge difference of getting her off the piano. And it just, you know, the fluctuation. That's a really interesting area. We, you know, at Harvard Research, say Brad Warner was looking at that. A lot of people look at. So the microbiomes really important in the metabolism of the bile assets. And. There's a beautiful study that was from. Shaw. I reviewed and accepted. I was a little bit rejected, but it was a beautiful study on the microbiome showing that certain bacteria create a more toxic. File acid and causing more injury, more liver injury and certain bacteria also increased the leaking us of the. The battle, the junk type junctions in the bowel. And so just patients being on piano and get leaking us. So all this inflammation goes on just by receiving the parental nutrition. The other problem is you know is that these patients often get overgrowth and we give them antibiotics and that changes their microbiome dramatically. So I think it's going to be a player. I don't know how big of a player, but there's huge differences in patients with short-pile syndrome and or patients who have intestinal failure or patients who are unable to just tolerate more interest needs. The story goes on. Thanks for incredibly enlightening talk and we look forward to additional advances in congrats to you and all the many people who have contributed to this work over the over the decades. I'm with the academic. Thanks. You know what's really not the same. I could give. I mean, I have to get 20 years in. I'm sorry. Let's just on the side of the real stories. Thank you so much. Okay. Oh, that's just a little bit of a little bit more. I don't need to do that. I don't need to do that. Yeah, I need to do that. I don't need to do that. I don't need to do that. No, I don't need to do that. I don't need to do that. It's just a little bit more. I don't need to do that. It's just a little bit more. Yeah, I don't need to do that. I don't need to do that. I don't need to do that. I don't need to do that. I didn't have a question, which is the result. Now, before we start studying. There's a bit of a problem. I don't know if I can do that. I don't know if I can do that. But I want to give it a shot. I want to give it a shot. I want to give it a shot. I want to give it a shot. Yeah, you know, I want to give it a shot. Yeah, I want to give it a shot. you you you you you you you you you you you you you you you you you you you you you you