Dr. Diana L. Farmer - Fetal Surgery for Spina Bifida: From Bench to Bedside

I think we can go ahead and get started. So I have a really distinct honor this morning of introducing Dr. Farmer. And Dr. Farmer's CV is a little bit of a challenge to walk through in terms of how much she's accomplished and I've had the opportunity to hear her speak in other forums before. She's currently the Pearl Stamps Endowed Chair and the Chairperson of the Department of Surgery at UC Davis as well as the Chief of Pediatric Surgery at Triners Hospital in Northern California and also Co-Director of the Center for Surgical Bioengineering. Her lab focuses on regenerative medicine, specifically in utero cell therapy for myelum and ninke seal and the most severe form of that being spina bifida. In 2000 Dr. Farmer's team is credited with making the seminal discovery that pine brain herniation could be ameliorated by prenatal surgical repair and fetal sheep. And this has led to multiple developments and multiple opportunities thereafter. I want to talk a little bit. I always try to give a little bit of a personalized introduction up here. And I actually did have the opportunity to meet Dr. Farmer before at SBAS in 2018. I was in on reforge lab at the time. And I remember hearing and speaking with her and seeing her reception at SBAS really led into the in my mind the most impressive part of her CV and that's the last 12 pages of her CV. The last 12 pages of her CV are all a list of her, the people that she has mentored and mentored over her time. And I think in terms of Dr. Farmer's personal accomplishments that really needs no introduction. I don't think there's anyone in here who doesn't know who Dr. Farmer is. But when I think about being a trainee and I think about what I want at the end of my career to have 12 pages of people that I've mentored and people that I've brought up, I think that that really speaks to one's legacy within the surgical community. And so this morning she's going to be talking with us about fetal surgery and spinal bifida. But as a trainee I just want to thank her for all of the people like me that she has brought up over the many years. Well, first of all, thank you for that kind introduction and Tink-Ile pivot and make things a little more informal than I had originally thought and just say a few things. I was sitting there looking at this. I think at some point the title has been from the barn to the bedside and I started reflecting on what I often tell my parents, which is for patients I'm taking care of that my name is Farmer. It's not very glamorous, but it's easy to remember. And I will say that being in the barn is part of what moved me from San Francisco to UC Davis way back when because UC Davis is the veterinary school. It started as the agricultural school for the University of California. They only recently moved the cows from kind of being on the main campus, which I thought was sort of disappointing. But apparently the alumni and more importantly the parents of new students really didn't like the smell in the spring time, which is when they were bringing students around. So the cows have been moved off, which I kind of think was wimpy of them, but I was not on that committee. So I will just say that I have had the most amazing fun doing what I have done for now. I had just had my 40th medical school reunion and I thought, wow, that's really been a long time. I remember it because it's also the same year I got married and there was some conflict with my mother and my parents who were in a way much more proud that they'd finally gotten me married off than I was graduating from medical school. I remember having this conflict with them that, no, getting married was sort of nothing. Medical school seems like really hard work to me. But I will say it's been super fun ever since. So I'm going to talk about my little journey and kind of what we're doing right now, which is just super exciting. So I happen to be at the right place at the right time, many times during the course of my career and it's just been a blast. But fetal therapy, very simple concept, all of you guys know, none of this is new anymore. It is about 40 years old. The idea that you could treat a problem before birth and do things better. We treat all kinds of things now with fetal intervention, all kinds of things. I mean, along came ultrasound and we could see things inside. If you think about your grandparents, they were counting fingers and toes when kids were born. We treat tumors and lung obstructions and things, no one knew existed, particularly in places like children's hospitals, right? A baby who was born with a completely occluded trachea, which occurs, you know, never made it out of a delivery room, never made it to children's hospitals in the early days. So some of these diseases are new in a way for us in the last 30 to 40 years. But Spina Bifida was the first of the nonfatal defects that one felt could be sort of attacked or approached by fetal surgery. Because in the early days, the concept of maternal safety really dominated everything we did. And I will say it's a credit to the early pioneers, my mentors, my carousine, that the development of fetal surgery was quite slow. For the first 20 years, it basically only existed in San Francisco. And I think in retrospect, that was quite wise because they once sort of the doors exploded and lots of people got involved, there were many more complications, there were lots of issues and had it not been a slow start, I think we would never have learned a lot of the things that helped us be successful later on. And I think many of the pioneers who sort of worked in their own private labs starting whether it was transplant or heart surgery or things like that share similar experiences. But Spina Bifida is interesting because it's not a disease that any specialty owns, right? When you don't go into pediatric neurosurgery because you care about Spina Bifida, you go into pediatric neurosurgery because you care about brain tumors essentially. I mean, what do pediatric surgeons know or care about Spina Bifida? Well, we get called the put in G-tubes, we get called to help the neurosurgeons fix the umpteenth peritoneal shunt that's now stuck, you know, ventricular peritoneal shunt and it's now stuck and they've got to put it someplace else. I mean, it's not a disease that anybody owns. The orthopedic surgeons work on the club feet, but they didn't go into pediatric ortho for that either. So a pretty neglected disease, but a pretty miserable, a pretty crummy disease because if you think about it for a minute, all babies are incontinent and can't walk when they're born, unlike our four-legged animal colleagues, right? I am sure that if babies had to walk when they were born in order to nurse, which is what four-legged animals have to do, someone would have cared about this disease a lot longer. In retrospect, I realized when I was a little girl, my mother taught what they called Handicap Sunday School at the time and they divided children into the educable and the trainable groups. Pretty immature approach to disability in the days. I'm not telling you how many days that was because you can do the math now, so I don't want you to do that. But so I realized in retrospect that I was aware of children who didn't have the same abilities that I did and it was kind of scary and intimidating and in retrospect, many of these in the educable group or patients with spina bifida. And kids now live a long life. In the early days, the only reason people did anything for spina bifida and often family practice docs just closed the skin in the back to prevent meningitis. That was really the sole goal. There was really nothing you could do for these kids. But even though it wasn't a fatal defect, it seemed like a pretty lousy one. And the other piece of the Les Clamers piece of the story, which will come to light for another, when I talk tonight, it was also like the leftover project in the land. Everybody else got the cool project, Cypher, Magna Cernia, you know, etc. So I got the leftover project. So there's a guy named John McCleone who is a neurosurgeon who came up with a hypothesis that this was a two level defect. The first was what happened in utero. We all remember sort of seeing those developmental embryos where the spine closes. But so that happens at about six weeks' gestation, like almost everything does. But if it didn't close all the way, so that first one was an error in neurology and the second was exposure to quote the toxic environment in the amnion, in the amnetic fluid in the womb. So that was the basis for the call concept of the mom's trial, which was very, very simple, like most of the early fetal surgery questions were. If we did the same operation before birth, that we do after birth, would it make a difference? Would what is happening in development influence the outcome? And so that was the mom's trial. And it took eight years to do. And it was interesting. More patients had been had fetal surgery for spina bifida before the mom's trial than during the trial. Because it was really interesting once you actually started telling people the truth that we really didn't know the answer. And that whether it was better to do this before or after, and that there were a lot of risks. And you could be premature or premature. And with that effect neurologic outcome, there was much less enthusiasm. Plus, you can sell almost any operation to a pregnant woman. If you told a pregnant woman that if you cut off her right arm, her baby would walk, she would give you both arms. I mean, pregnant women are, forgive me, any pregnant women in the audience. Just sort of biologically programmed to do whatever is necessary to save their unborn child. So it's a very vulnerable population. And this procedure was kind of being sold, if you will, in the early days. So once there was sort of mandatory stoppage of all the procedures outside of the trial, which is a whole nother story about how that occurred, the enrollment slowed way off. And we thought we were going to be closed down for lack of enrollment. And the, the trial was done using the ventricle peritoneal shunt, the need for shunting as the primary outcome variable. So it was great. Ended up, we were closed for efficacy, which almost never happens, right? That it actually worked. So it was felt to be unethical, to not offer the care to families. So essentially, it reduced the disease in half, the need for ventricle peritoneal shunting, which is huge if you now know these kids that have this stuff. And if you think about that cancer drugs get approved because you get three extra months of life. It was a huge, biologic difference. And there was no intellectual property. There was nobody made any money on this. And we saved, you know, society in patients, the zillions of dollars. It's just interesting how our system works. But what I thought was the most interesting about this was that there was indeed an improvement in the distal neurologic function that in fact, kids that they didn't think could walk, could walk. And but it went from 20% to 40%, which also is great. That's also a 50% improvement, but or 100% improvement depending on how you look at it. But still 40% of the kids were unable to walk and did not get improvement. So 60% of the kids still. But the fact that you could get a little improvement, meant you could probably get more. And so this is the, you know, this is the mom's trial, it's a whole mother's story. But this is what took me in particular back to the lab. And the question was, could we do it better? And this was all at a time when stem cells were kind of the hot thing. You know, Dario's work had started earlier on all kinds of things, exciting things about amniotic stem cells. So it just was IPS cells were a thing. So it was about the time that I also moved to UC Davis, which I said had the vet school and I had already been driving from San Francisco to Davis to do experiments at the time. And it started seeing ridiculous to drive all that time. Although in retrospect, one thing about being at the animal lab was no one could get me. It was definitely way too far to go back and take care of patients. So in retrospect, it was really a good thing. It was like being at surgery camp. But anyway, at the time, the original idea we thought that I thought that no mother would allow someone else's cells in their baby. I mean, I just thought that was completely unacceptable. So I thought we needed an autologous source of cells. We originally had done early work on maybe biopsying the fetus and using fetal skin to create IPS cells. But that's doing investigation with fetal tissue, which also started to be not appropriate from a society point of view at the time. But the placenta, as you know, is essentially fetal, a source of fetal drive cells. So I thought we could use CVS sampling, which was what was used at the time before cell free DNA to be a source of cells. And that's really how we landed on the placenta. So fast forward many years. And I can't remember if this is the slide. Oh, yeah. So I took out all the slides of the things that didn't work. So I didn't retrospect for this crowd. Those are probably the most important slides. And I do tease my, now junior partner, Piam Sudai, because I realized he's the author of almost all the experiments that didn't work. So he's like really famous in my mind. But we did try IPS cells. We did try nanopipers scaffolds. We did try amnion. We tried a bunch of things of which he is the first author. So, but the thing that was cool about placental mizankimals stem cells was from my point of view. This is all very practical and very translational. They doubled in time fast enough and much faster than bone marrow derived cells fast enough for it to be possible to get enough cells between when you would do the CVS sampling and when you would have to do fetal surgery. So everything we did in the lab at the time was really focused on the translational end. What would it take to actually do this? So that was a really interesting different approach than my basic science colleagues and working together with my basic science colleagues. I could say, well, that's a great idea, but it's never going to work. We're not going down that path. We're going on this path. I sort of describe it as the play the winner approach. I think that's a gambling thing, which I don't really know, but somehow I heard that somewhere. But that's what we did. And then it turned out they were really cool. So this is also somewhat controversial, but there's the embryonic stem cell, which has a whole lot of anxiety and concern for creating teratomas and other things because it, as you all know, can form all the lineages, endodermal, ectodermal, mesodermal. Mizzankomal stem cells are farther down that sort of tree you all remember, sort of terminally differentiated. But we were able to coax our placental derived mizzankomal stem cells into two sets of lineages, mizzankomal and ectodermal. Now, you know, what is that good for? Again, at the time we thought we needed neurocress stem cells, but mostly it says something about these cells being a little bit more intermediate, if you will, which I think is something that's also interesting about them. But then they create all kinds of stuff, which I call the magic stem cell juice, when I'm trying to explain this to patients. And we were able to demonstrate in a, in vitro model, a cell-based model that they could protect neurons from damage. So in a study looking at creating a poptosis, so poisoning, S-Y-5Y cells, neuroblastoma cells, which by the way is what I started out working in the lab when I was doing cancer way back when. So I knew that S-Y-5Y cells existed. If you added the juice, the supernatant from our stem cells cultured in kind of a neurogenic pathway, we could rescue, we could protect, we could get more branching this thing, then we would if we didn't have cells. So, okay, that was interesting. So again, the secretory profile had stuff that we thought was important for the development of neurons. And why did we think or know that partly because my partner in all of this now, a bioengineer from Berkeley, whom I met because he was working with the spinal cord injury guys at San Francisco General, who I went to talk to to say, I got to learn something about the spinal cord, because I did, right? My pediatric surgeon, I don't know anything about the spinal cord. So he was working, he was collaborating with them. He was a postdoc at Berkeley, and mostly I realized he was the guy that did all the work, not his boss, but him. So I said, that's the guy I want, and I hired him when I came to San Francisco. I'm going to come to Davis. But we went back and took the typical Spina Bifida model. We tweaked it a little bit to focus more on just distal neurologic function and not on spinal cord injury. So a little bit of different sort of changed the model a little bit for the questions you're asking. But it tested the question, ultimately, if we added stem cells, would it make a difference? Same model. Oh, here's Dr. Siddai, the famous guy. It's really interesting that if you haven't seen any of the sheep models, and I know you guys do some of this work here, but how similar it really does look, even though it is a surgically created model for which there is criticism appropriately. It's not really a true recapitulation of the disease, but we simply just expose the spinal cord. We just take off all the bony elements and the dura, but it looks very similar to a human Spina Bifida model. The spinal cord is exposed. This is how we do it. It's really sort of gross. Good morning. You take off the skin, you take off the paraspinal muscles, then you take off the lamina, then you can kind of see the shiny stuff here. That's the dura. You open and strip the dura so that you get an exposed spinal cord. And then we do the same defect, except this time we added the cells. Oh, yeah. This is the stuff that didn't work. I said, I said, I'm fine. This is the secret. This is part of why we have the trainees be the first authors. So couple of, you know, so we actually, I wanted a hydrogel. I still want a hydrogel because, and I said to my bioengineering colleague, I need toothpaste. I need something I can squeeze in because if you just squirt the cells in media, they're going to all fall away by the time you can actually do the repair. But it turns out all hydrogel these days is made out of rat tail collagen. And for some reason, you cannot get rat tail stuff, hence the FDA. So in fact, my little disclosure side is bio prime. We actually created a hydrogel out of amnion. And someone else licensed that and they're making face cream in China. By the way, I think it works great. But the, so we still, I still, I think, I'm going to say, I'm going to say, I'm going to say, I'm going to say, I'm going to say, I'm going to say, I'm going to say, I'm going still, I still need, and now there are some FDA approved hydrogels. Although they're not that good yet. I mean, we still need that. So we just went again. We played the winter, OK, we can't do hydrogel as we can't get through the FDA. Let's try something else. And we found a matrix that it turned out the cells really liked. Again, we sort of got lucky. OK, the thing I am most famous for, my most sighted paper is the, heat locomotor rating score. And Aaron Brown was the first author in that. So you know, you do take a risk, right? She's more famous. But the because there's a mouse rating score for, you know, how mouse, how mice move and the BBB, it's very famous. So we actually contacted Brian Henan-Bady and said, teach us how to make a mouse walking score for sheep. So there we were in a sheep lab walking, you know, they have what's an ankle, what's it's different, right? They, they're backwards. So we had to learn how to score sheep. This is highly cited now. More important, like the most important thing, it's ridiculous. So here it is. But so then the day, and I'll never forget it because I was sitting in Shriners at a meeting, not they're always scoring, but just sometimes boring. And I got the call from my buddies in the sheep lab. The first set of twins was born. So the aunts, we got again, usually their twin pregnancies in sheep. So the only difference, it was the same mother, same uterus, two different uterine horns. But the one lamb got the matrix only and the other lamb, fetal lamb got the matrix for cells. That was it. That was the only difference. And I screamed in the middle of this meeting because, and you can see that these are newborn lambs. You can see the little scars on their back. The one that got the cells walked like a normal lamb. I mean, everybody went back and said, you know, what did we do? And the other one, and again, this is, if human babies were born like this, everyone goes, oh, it's so sad that baby lamb came off. Is this where human babies? Someone would have cured this disease a long time ago. Because it's heartbreaking, right? The lambs have to be able to stay in so that they can nurse. So anyway, the good one is, you know, not as dramatic. But it's amazing. All right. So, like good scientists, if it's too good to be true, it's probably not true. So we did it again, and again, and again. And then we thought, okay, maybe it's just this line of cells. So we did another, we did another line of cells because we, you know, we just get placentas from the delivery room. You know, they stick the sticky placentas in the refrigerator. We would just take them. And that's how we got sources of cells. So we did it again with different donors, and then we did it again with different concentrations of cells because we didn't know that. And consistently, it's not perfect, but consistently, if you got cells compared to just matrix alone, the animals did better on our little BBB score. And then we asked the question, okay, how does it work? Because people want to know that. And interestingly, it does not completely reform the spinal cord. We didn't know exactly what we needed to do in the early days. That's why we looked at neurocressels. Did we need to actually make more cells? Did we just need to repair the ones that were there? And it doesn't. They still look. So this is what a normal spine in cross-section looks like of a fetal lamb. And these are our treated lambs. And we would then looked at the most squished place to see. So this is just vehicle alone. It still looks squished. And so it's not completely recapitulating an enemy, which has other questions of relevance in terms of how you repair this spinal cord is important to have dorsal and nerve. And eventual orientation is that important for nerve growth and development, don't know. But anyway, what we, so the top is a normal. This is completely untreated in our experimental model. This is just with the ECM. And then this is with our ECM plus cells. And the biggest difference was the increase in the density of motor neurons. Now we can't actually call them motor neurons because we don't. So no, for sure. So they are large neurons, but they're most likely motor neurons. Just a technical thing. So then again, different cells, different donors, different things over the years. And each one of these, you know, 10 is a lamb. This is a lot of sheep gave their lives for this study. So then word of at school. We find out because one of the kids in my lab who came in because they were pre-med, a college kid, they wanted to go to medical school. I felt like a complete failure because by the time he had been in the lab for a couple years, he decided he wanted to be a veterinarian, not a medical student, not all that. So no good. Plus he wanted to study snakes. I thought, remember what have I done? So also though, thank you very much for the great, you know, history of all the people I've mentored. I should probably have that, you know, just like the failed experience. These are the ones that didn't do so well. But actually, he's a great snake veterinarian now working in a zoo. But he turned us on to the fact that there is a naturally occurring model of spinobifida that baby bulldogs, English bulldogs in particular, get spinobifida. Now the breeders don't want you to know this. That for, you know, it takes like 10, maybe bulldogs to or one out of 10 has a spinobifida defect, spinobifida. And some of them, so if it's an open defect, they're euthanized right away. But if it's skin covered, they might, you know, still be delivered and kind of survived, resuscitated. And then only later do they discover, you know, a couple of days that the dog has spinobifida. And often they are still euthanized. But there are little baby rescue farms for, and people who adopt these handicapped dogs, so to speak. And these dogs are the cutest thing ever. Not only are bulldogs cute, which is why everyone buys them. And is they have like human faces, which by the way make them very expensive and they have bad airway problems. So they're also looked at the E&T guys work on baby bulldogs. But they have little baby wheelchairs and little baby bulldog diapers. And they are the cutest things. And there's this family that actually the bulldog adoptee also works at the Shrine or Hospital. So there were all these reasons that we were able to connect with them. So we started studying the bulldogs just as proof of principle. So we met with the veterinarians who never operated on these bulldogs before. And we taught them how we operated on fetal lambs. And we are now doing a clinical trial of bulldogs with stem cells because the first studies that we did and I will show you aren't perfect. Now I had to learn about how dogs walk. So you can see this. So this is an un-the-free treated. And they kind of walk on their hawks, the whole ankle a little bit. And they're kind of discoordinated. You can see how they're flatter. I mean it's not terrible, right? But then, so this is a postnatal bulldog. And they usually get worse. See how he's more up on the pads, his toes, and more coordinated. And usually as they get more weight in their hind limbs, they get worse. They don't naturally get better. The natural history is that they get worse. This takes a little. And we had pads, pressure pads that the dogs walk down like we do for mice to sort of help evaluate them. And now my partner is actually running a real clinical trial in the bulldog model. But okay, so now we had enough preliminary data that was like, oh my gosh, we maybe are on the something. And the bulldogs were kind of proof of principle. But not as rigorous data as we had with the sheet. So again, just like you being in California's SIRM, the California Institute for Regenerative Medicine funded essentially all this work. This is when the federal government stopped doing stem cell research. California taxpayers put money into stem cell research with the idea that it would become a hub for stem cell research. People would come to California to work, move, bring their labs. It would bring industry and money. That was the investment that taxpayers were making to California. So we got the first, what's called preclinical development award. And now these words start to get relevant because I was learning how to deal with the FDA. So you have to have preclinical data to first show that you might, whatever you're trying to make might actually work. So and then we got the money to develop clinical grade cells. So at the present time, these were just the cells were just made from placentas that were discarded and we got from the delivery room. So now we actually had to get donors that you would consent and you would get a history from them. So they had no infections. They had no history of all kinds of diseases. So this process now of generating clinical grade cells. So the details of this don't matter, but basically you get the cells, you culture them if they're infected, if cultures get used contamination, you know, we discard those and go on. So we basically got started with 17 donor placentas that we collected five were cultured in the lab and at used contamination eight past. And then we had to test for viral infections. Interestingly, this was post-Zika, but free COVID-19. So this was, so they were all screened for all these viruses and it came down to two lines of cells. And one mother had been exposed to CMV. The cells were not CMV positive. They were all negative, but mother had a history of having CMV and the other line, they were exactly the same in terms of their secretory profiles and everything, but she had no evidence of previous CMV exposure. So I figured I would just pick the safest one, the least risk of anything because the FDA was pretty nervous about this. You're putting stem cells in the spinal and the central nervous system of a fetus, which obviously hadn't been done before. So then all the other safety studies, the big thing they're concerned about for stem cell therapy is tumor development. So the mouse is the classic study for, and this is all kind of boring, it took us a while to figure out where to put. So you take an immunodeficient mouse and you see if it's going to grow tumors. This is how all the cancer drugs are done, this stem cell work, so that it's the most permissive model. We first put them under the belly and it turns out the mice can figure out how to eat all the cells, et cetera. So we finally had to do this enough and figure out that the top of the neck was the only place they couldn't get at them. And also looking to see if there was any evidence of human DNA in the mice later on because the other advantage of a masoncule cell, unlike a hematoportic cell, we're not looking for engraffment. We don't want it to stay forever. We're not trying, we don't need it, we need it to fix repair whatever damage was in the spinal cord and then theory, then you're born with a normal spinal cord. You don't need to keep giving it all the time, like you do for if you want to treat sickle cell anemia as return over cells all the time. So you need to have a gene therapy or an engrafting cell that that's the work that M on flake has worked on for a long time. Anyway, blah blah blah. The mouse studies were fine. Then they wanted us to put it in a sheep, our sheep model. So we had to go back and do more sheep. Again, the same thing looking at, you know, did we get any age and putting cells interfere with the good effect of fetal surgery so that it prevent hindrane herniation, did it, and did we get any tumor development, which we did not. We had to figure out how to do sheep, fetal sheep MRIs. Again, this is the virtue of having a veterinary school. We could take the lambs over to the vet school. I just think they're kind of cool studies. And then the FDA didn't care about efficacy. They carried much more about safety, but SIRM before they would give us any more money wanted us to do an efficacy study with the exact cell line that we had that we were going to propose to put in humans because they wanted to know that that cell line actually worked before they were going to give us more money because now we were talking about serious money. The first couple of grants were like one or two million dollars typical kind of NIH level grants. This is now five million dollars. So they made us do an efficacy study. We did 10 more patients. Speed is the same thing. And the same thing they worked. So the end goal of that grant was to submit an IND and investigational new drug application to the FDA. So we had pre-IND meetings with the FDA by Zoom. You can't record it. It's all interesting. I had my whole lab there so everybody could take notes and that between like 20 people taking notes we could write down practically everything the FDA had said because I never never dealt with the FDA before. They and we had to use the clinical trial was really easy. I did exactly the same clinical trial that we did in the mom's trial. And even though there are a lot of new things going on in spina bifida, the most rigorous data that we have is really from the mom's trial because those patients were independently evaluated. They had standard radiologic examinations done. So that is the most rigorous. And so the statistics were done. I'm trying to show that we could get a 20% improvement in the amount, the degree of neurologic functioning of, you know, so if you're an L2, do you become an L4 or more? So and that was what the comparison is too. So even though we offer like fetoscopic surgery at our place for this particular trial, we're doing it exactly the same way we did the mom's trial because that's really the only way we can compare it. You know, is it is it the cells that makes a difference? So now we're talking real money. This was $9 million to do the first phase one trial. So a phase one trial that's phase one two and three trials phase one are purely safety. And the FDA insisted that we this one I had my spiky here. The that we go very slowly that we wait until the mother delivers so that we could be absolutely sure that there were no, we weren't going to get tumors or aliens or who knows what something that we'd never heard about from putting not only regular bone marrow cells but plus tenfold derived cells into a fetus. So you know, all trials need a fancy acronym. Someone in the lab came up with this. She's now finishing her pediatric surgery fellowship in New York. Cellular therapy for in-eater repair and then we can plug in, you know, what we need in myelomin acetyl diaphragm and macronutrient, you know, specificity, optimistic days. So the it's a phase one to a normally a phase one is done on healthy volunteers. You're obviously not going to do healthy volunteers and not going to have fetal surgery. So it's this is what makes it a combined trials. It's done on a patient with the disease. Phase one trials and drug arts are also used then for dose development. Obviously we're not going to give different doses. We did that in the sheet model. And you combine preliminary efficacy. You keep that information to look at efficacy because so that's the combined phase one to a. So the first six patients we have completed and the answer was that there are no there was no evidence of adverse effects essentially. This has not been published yet. But there's a little side note for fun. So we are in California. Here is the team that is actually generating the cells in the GMP facility. Here is where we made a tactical error from the lab to what you might do in humans in the long run. This is a four day cell prep process. So the cells are thawed. So we do have a bank of cells. The cells are thawed. They sort of come to life in culture media. Then you change the culture media after 24 hours and you then seed them on the end you send them for stability testing. Then end identity testing. Then you see them on the matrix for another 24 hours. So the whole thing takes about four days. My techs have to sleep in the lab because some of you have you know after 24 hours you have to change the media and when this 24 hours happen, etc. So it's completely impractical for you know regular use. So at some point that has to get work done. But this is what we had done. So this is what got approved. And this is what we have to do for the purpose of answering the questions for the FDA. But so here are the guys in the GMP facility which it's just so happened that little old UC Davis had the only GMP facility in northern California at the time. I have no idea why. And believe me, my UCSF friends were like what is this about? You know how does Davis competition is great? You know I mean the main contribution I think I will have made to the world of Spina Bifida will be looking at the increase in the number of publications. From like 19, there's nothing from 1950 to 1980. No one cared. I mean frankly Martin Muley started this in San Francisco. But after that it's just ssh lots of papers, lots of people are studying Spina Bifida. No one cared about this disease before. But anyway here they are. So these these were our techs in our lab who then had to get trained how to work in a GMP facility. Looks like a little NASA in there. Oh this looks like your wife's B outfit. I just realized that but I saw last night. It's exactly now I know why it looks so familiar. So this is the team. Then you're going to this is how we transport the cells into the hospital. Anybody know what these are? Come on there's someone in this room from California. I should. What is that? Yes. Who said it? Wine bags. So two bottles of wine. We have ourselves in there in this little cylinder that we had to temperature control because you have to make sure that there's you know the temperature is steady between leading the lab and getting through the operating room and then they so we can keep them temperature controlled for about six hours at the present time in in the wine bags. We are actually upgrading the technology for that they now have things. Oh and you're going to love this. The operating room would not let us keep a refrigerator there. Are you kidding me? So I guess because you have to you know to be used in the operating room you have to have a then you have to be sure the refrigerator works you have to test it etc etc so they wouldn't let us store our refrigerator. So we bring a refrigerator we put a fancy label on it so it looked official. From the lab every day every time we do an operation over to the main hospital so that we can put a backup set of cells in the refrigerator in case one of us moronic surgeon drops them in the operating room. Right. You really only have one shot at this. So we actually take three we create three different cell products you know on the matrix that we take to lab and two we bring in and one we put in the refrigerator that we schlep across every time. So it's Chris Pavelli who is our great lab. Here's the now we're taking our precious in the lab people you know carry these drops and then the surgeons mess with them she just goes crazy. I wish I'd never put the video on like you can handle them like that. Oh sorry. So again this is not published yet but the first three patients these are the pre-op photos of their hindram so they had this we have we're using the same criteria for the mom's trial so they've got to have a carry malformation. Again we're not testing the carry malformation but we want to make sure that what we're doing doesn't interfere with that doesn't make what was good about fetal surgery worse. So these are the pre-op fetal MRIs the fetal the appearance of the myelamine ingressials are all different. So unlike our tightly controlled animal models where the defect looks the same exactly because it's a surgical model human beings are different so it's really hard to predict how much is going to work. We use the same criteria operate about 25 weeks here's just the interoperative photos and how different the appearance of all these defects is and then here's here's the you know now 20 million dollar product looks like a piece of wet toilet paper it is like ridiculous that this is all this has gone into that and these are the three these are interoperative photos it looks ridiculous and when we just put it on but importantly again we have to wait three months till the baby's born we had no infections we had no failure to repair there's a lot of anti-inflammatory effects of the central drive cells amniotic cells often so we were actually concerned that there it might not heal as well when we used the amniotic membrane alone in that sheet model paper number three by applying sedate the skin didn't heal over in in all these animal models the skin heals almost no matter what that's that's why you have to make such a big defect otherwise the defect will heal by itself so so we were a little concerned about that no CSF leaks no evidence of tumor and we had reversal of the carium alformation so it did not interfere with the reversal of the carium alformation and it improvement in ventricular migway so no evidence of tumor by the way scarless fetal surgery is a myth if you're doing fetal surgery you know in mid second trimester oh now we also we're developing the poop scale for newborns so the Bristol we're scale people because we're hoping that we not only get improvement in distal neurologic function but we can improve the bowel and bladder function because a little known secret the major cause of death now for children with spine abbypida is menophalia kidney transplant you probably have kidney transplant spine abbypida patients in your hospital so but the scars look terrible um and we did poop and pee evaluation on our sheep so these are the fellows that really feel like they got the you know the short straw they have to go watch and record how do sheep urinate and how what does the sheep poop look like but we have score anyway it has taken a huge village over the years to get this far we are now approved by the FDA to do the second half the phase two which really just allows us to enroll patients at the pace that they come I mean frankly we can't do more than one kind of every other week because the team can't do four days of nights what you have to pay overtime and all this kind of stuff you know and um you can make fellows work as hard as you want you can't make real employees to fat and lots of things you learn um actually fellows are getting smart about that too I mean in California but um they still miss half the cases though um but so we can only really do two patients a month it just because it's too labor intensive so it's not a practical thing right now but the whole point of this is to see if it actually works in a very rigorous way and this is the team that has worked on this um the core team in the bottom and isian Wang I will say is the bioengineer who did all the work at Berkeley who got the stinky placenta jobs when I was first collaborating with them who's been my scientific partner ever since and it I just have to say it is such a magnificent relationship I feel like we're one human being but we have been able to accelerate I think from a real translational point of view because I was always able to say well that's a great idea but it's not going to be practical no surgeon could do out we couldn't and so we stayed very focused so the basic scientists are frustrated with this this is not a basic science project we don't actually know how this stuff works neither does anyone know how Aspen works by the way just for the record um but it was it's a very translational approach all along and he's now off doing all kinds of other things in addition um from a bioengineering point of view and we are already thinking this is old technology so I have a great appreciation for well not a great appreciation a greater appreciation for when drug companies say you know we've invested millions of dollars in this and it took us 20 years like oh guess what we have invested millions of dollars in this the taxpayers and we're at 15 years I would say now since we really started down thus them can we do it better paths it was 2011 when the monstrile was published and that's really what prompted looking for a way to improve it so it does take a long time and it is already outdated right because we want something that probably could be delivered fetuscopically we want something that would be easier um we don't want a four-day cell processing technology that we again we're not thinking we were never thinking about how would this get disseminated when we were first doing the lab stuff we just did we optimized growing conditions and we optimized you know what was normal lab activity so you know I would be better at this the second time that now I've told Dr. Sidai he's going to have to up his game because he probably have to take this over because I may not live long enough to sort of see it all to the finish line but I do think I'll live long enough to see this trial to the finish line so we have done six patients we have 29 more to do and I do think our data safety monitoring board has recommended we do a interim analysis at 10 patients and 10 patients who reach a year the primary out convertible is same with the moms it's two and a half years that's when 90% of children would have met the milestone of walking the FDA also doesn't want to have to wait two and a half years so they have asked us to do earlier analyses but it has just been you know it does feel like surgery camp all the time so the first was my lab team the second is the fetal treatment center team which is really now all run by Shin Hirosi and then we had to teach the lab I mean the OR little UC Davis which function in County Hospital to do fetal surgery which was sort of amazing and it is it is true that none of this is rocket science right you can you can train teams particularly if you're enthusiastic and they think they're doing something fun it is amazing how supportive they are and it's it's totally doable anywhere and we did get lots of support from lots of people so thank you and have four minutes of questions well Diana it's a great thrill to have you here for this lecture and for our entire academic day and then I'm sure everybody and many more by the way had a huge you have a huge zoom following at the moment many more this evening this room will be full and we really look forward to learning more from you it's a great honor that you would take time from this work to and all of your meetings which I know all about to spend a couple days with us so we're grateful and that clock is actually a couple minutes fast so we do have some time for questions and great followers has a question hi Sammy hey hey doing incredible talk thank you very much and I love your sense of humor when that listens to your talks two questions one related to the fetal and one related non related the first thing is the metrics that you're making can you fold these metrics or roll it and I'm thinking about you know if you want to do phytoscopy can you roll it and then push it inside or that's that's a tough thing to do so great question um I think the answer is no we are already working on that's what I might comment about the technology in a way is already out of date because obviously you'd want to deliver this phytoscopically there is a group in Italy that has an automatic unrolling matrix that they've created so we're working on the material transfer agreements to get that stuff over here to test it in our sheet model to see if you could A to see if the cells like it be if they attach to it and could we um could you roll it and then have it automatically unroll it's it's sort of a temperature related thing so when it gets into to you know 98 degrees it just unrolls all by itself so there would be less messing if you will with the with the cells right now I think and we haven't done all the testing on it that if we rolled it and unrolled it most of the cells would be gone by the time we got them there but clearly this is you know not as up to date if you will and we'd want you would want to be able to do this phytoscopically it is interesting just a little side note the even the mom's trial the actual technique of the spinal closure so if you talk to neurosurgeons was not well controlled at all the trial was mostly designed the mom's trial to prove that fetal surgery was bad the fetal surgery was bad for mothers that fetal surgery it there was very much sort of a hostile and and Sammy knows all about the sort of competition if you will between MFM's and um pediatric surgeons which actually has been healthy for the field in many respects because the MFM that there was a fair amount of bias early that this was bad for moms and it is true that open-futual surgery is associated with increased risk of placenta accretia I mean you can actually get it with fetoscopic work too but we think that the risk is higher so there's lots of things that are not ideal but the so the controlling in the mom's trial actually how you did the repair it was not well done I do know that so there were three original groups UCSF Vanderbilt and Chop at UCSF we did a three-layer repair we reading it was in a relation we retubularized the spinal cord this is the north south dorsal ventral thinking that that was important then close the dura then close the skin other places did a two-layer repair some used a microscope some didn't use a microscope so that was not very well controlled and it's even less well controlled today because if you you can do anything you want without approval from the FDA if it's not a new drug in theory if you're using a device that hasn't been used for this indication you have to go to the FDA and so there's some so there's great work being done using desalularized freeze-dried amni um um um umbilical cord just putting the umbilical cord on top and sewing it to the side nothing else but again that's just one of I would probably say 10 different ways the back repair is done and none of that is really also involving rigorous post-op follow-up because in advantage of fetal fetoscopic myelominemic acid repair is that you can go home you can deliver vaginally wherever you come from well it's really hard to get rigorous post-op follow-up for two and a half years on all those patients that so nobody really knows what the outcomes are and by the way all the mothers say their kid is great you know the the other thing I will say for me that's interesting running a trial in the era of uh social media all these mothers so I am very careful not to really feel any data we're not going to open the data set until it's the first you know interim analysis time but the mothers are all out there talking to each other talking to everybody videoing pictures of their kid I'm like oh my god so there's a Facebook thing which I have not on but so it's a brave new world I shouldn't if the FDA has all these videos just weird right you got the you the second question is you know on your wonderful um you know model that you have as a bull like and you do the post-nature repair what about the cord injury in adult that means why that path is not going to that outside instead of going coming to the fetal yeah so if I we the I think that we could do better repairs on babies when they're born we are also asking the question the obvious question was well gosh if this works for congenital spinal cord injury would it work for adult spinal cord injury there's a lot of work that's been done on bone marrow and was the Enchamel stem cells for spinal cord injury which has not been very promising I think based on the mechanism of anti-apoptosis the things that we know you would it would only work I don't think you could repair a spinal cord that's been injured for 20 years I think it would only work if it did at all on an acute spinal cord injury I think it might be able to ameliorate the effects of that the secondary damage that comes from swelling and inflammation and stuff so you'd have to figure out how to know in advance the patient would come in you know make the cells it but we are we are looking at that in mouse models and we'll be interested to see what the bulldogs really do when it's they've also we're controlling for having the surgery bulldogs never those patients the bulldogs that you saw have surgery and cells at the same time so we're now I said and that doesn't prove anything you got to go back and do some that just have surgery maybe it's just the effect of the surgery and add the cells so that's what's going on there then it's very refreshing to see a surgeon leading the way on cell based therapies and to congratulate you is another statement thank you for being here have a very very basic question the timing of ultrasound diagnosis and how fast these cells grow which has also been our experience to grow very fast would in principle allow you to do this without all of the cells you do a CVS you grow them and you create your your patch and you're using bank cells has has there been any thought about using an autologous version yes so I I thought we'd have to use it autologously in the very beginning that's how I got started on placenta because you guys you know it's what do you have you guys had good access to to amniotic cells and we had better access to placental cells it's just funny how things work but obviously followed your great work closely and took a lot of advice from the the things you worked out in advance so thank you the now the problem with doing autologous cells is you it would be another procedure and every procedure even every needle based procedure and everyone knows that there are women who miscarry after after amniocentesis or after certainly after CVS so this avoids having to have another procedure that might put the pregnancy at risk and then you have the diagnostic procedure or the cell extraction procedure followed by another procedure so that's why we kept down the path of something off the show I don't know if it'd be better but it would certainly have reduced the anxiety the FDA when you mentioned bringing something you knew how to do very well from San Francisco to a place where it hadn't been done and had to teach everybody at Davis I I could feel shami's heart palpitating because he's been living through that for the last couple years and this is just overcoming the same hurt hurdles been there's incredible enthusiasm you can do it he is he has we are now at time we are so appreciative of all of the work you've done over the decades the mentorship as Patrick mentioned of people around the world who have benefited from your mentorship is unending and we're thrilled to have you today to do some more of it so I really pleased to join our academic activities and we look forward to seeing upstairs thank you so much thank you