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J Thomas Lamont MD grand rounds BIDMC

BIDMC Grand Rounds: J. Thomas Lamont, M.D. on Major Advances in Gastroenterology & Hepatology

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J Thomas Lamont MD grand rounds BIDMCIn January 2020, J. Thomas Lamont, M.D. (author of C. Diff In 30 Minutes) gave a grand rounds presentation at the Sherman Auditorium, Beth Israel Deaconess Medical Center, Boston. He was looking back at Major Advances in Gastroenterology & Hepatology over a 50+ year period, which actually stretched back to a much earlier age of scientific and medical discovery. From the introduction by Nezam H. Afdhal, MD, the current Chief of the Division of Gastroenterology, Hepatology and Nutrition at BIDMC:

[Lamont] published a paper that was the cover of Nature that illustrated why the stomach does not digest itself due to the interactions of mucins and the effect of acid on the mucin structure within the stomach. At BIDMC he and his research team worked on the mechanism of action of the toxins for C. difficile. These are just some of his scientific advances. He is a clinician, still sees patients today, and is a well sought after teacher, and has educated innumerable fellows and faculty. He’s been a mentor to many. He’s been a great friend to the GI division here at BIDMC. His lecture this morning is going to be a look back at what has happened in the 50 years of Tom’s career in gastroenterology.

Here is the full presentation with audio, about 45 minutes long:

Some selected quotes by Lamont follow. You can view a full transcript of the Lamont’s Grand Rounds presentation here.

On incremental progress vs. paradigm shifts:

I used to think, and a lot of people believe that discoveries are incremental, that knowledge is added like bricks to a wall which you gradually build. But in fact scientific discoveries are primarily revolutionary not incremental. There’s a paradigm shift which is a radical change in the way we do things. It’s often disruptive, a word borrowed from technology, where the new discovery or invention blows up whatever was there before. Later in the talk I’ll show you some examples of disruptive discoveries and inventions in the field of Gastroenterology.

On convincing the scientific establishment:

A major feature in the field of scientific discovery is resistance from the establishment. I can tell you that Boston has a very powerful medical establishment, and the resistance to some of what I’m going to show you was quite robust. So, if you’re interested in this topic, there’s a very important small book, about 100 pages long, by Thomas Kuhn called “The Structure of Scientific Revolutions”. Kuhn championed the concept of paradigm shift, in which scientists have to move away from something that has been accepted for a long, long time. And the new paradigm replaces the original paradigm, which eventually fades away.

On technology transfer from other fields:

Kapany and colleagues then had the idea that extremely thin flexible glass fibers could transmit endoscopic images. This was picked up by Basil Hirschowitz, a native of South Africa, who in 1953 was a GI fellow at the University of Michigan. He was already trained in endoscopy in England before he went to Michigan. Hirschowitz was trained in the Schindler type of endoscopy that I showed you earlier, but he realized that this older technology was difficult and dangerous because of the rigidity of the Schindler scope.

On the impact of endoscopy:

The impact of fiberoptic endoscopy on practice was massive. Currently about 100-million endoscopies performed a year in the United States, about two thirds of them by GI doctors. Flexible fiberoptic endoscopy has had important impact worldwide in many medical and surgical fields.

On the discovery of the cause of ulcers:

Barry Marshall wrote in his note cards and some of his later publication “Everyone was against me, but I knew I was right.” So who was against him? The acid mafia, a powerful group of senior investigators who championed the idea that hydrochloric acid was the key to formation of stomach ulcers. When we were residents and fellows we had to know a lot about gastric hydrochloric acid secretion. So those who believed in the primacy of stomach acid were definitely strongly opposed to these Australian upstarts, Marshall and Warren. … Marshall and Warren were finally justified in 2005 when they won the Nobel Prize for Medicine. A couple of blokes from Australia who had not done a lot of research at all, with very little support. they used equipment and tools that were right at hand. This seems to be a study that could have been performed by almost anyone. But they were the first, and their persistence in the face of heavy opposition payed off.

 

 

C. diff in babies: an unsolved mystery

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The following article was excerpted from C. Diff In 30 Minutes: A guide to Clostridium difficile for patients and families by Dr. J. Thomas Lamont, M.D.

C. diff was originally discovered in healthy babies, who seem to tolerate this nasty bug in their stools without getting sick. About 70% of infants during the first year of life carry C. diff. Why they don’t show signs of disease like diarrhea or fever remains a mystery.

Can babies get C. diff - clostridium difficile in infantsOne theory is that the infant’s bowel doesn’t “recognize” Clostridium difficile or its toxins. C. diff toxins cause diarrhea by hooking on to a special toxin receptor, much like a key opens a lock. Once the toxin (the key) hooks on to its receptor (the lock), it opens the floodgates of diarrhea and causes fever, cramps, and other signs of acute infection. Healthy infants lack this receptor, so they don’t get sick even though they are carrying enough C. diff to cause severe diarrhea in an adult. After the first year of life, babies develop the receptor and can develop C. diff just like adults. So, finding C. diff in the stool of an infant is not worrisome. Eventually, C. diff will disappear from the intestinal tract when the infant reaches 10-12 months.

Can babies make other people sick with C. diff?

Can babies spread C. diff to other family members, babysitters, or health-care workers? The answer is yes, but in practice it’s very rare. Sometimes mothers of newborn babies have to take antibiotics for a urinary tract infection. The antibiotics can damage the protective stool barrier allowing C. diff to get in and cause infection. I have treated a few moms who probably caught C. diff from their newborns. I have also treated a neonatologist (a pediatric specialist in newborn diseases) who probably picked up C. diff at work from one of her sick newborns.

Even though babies can carry C. diff, we don’t recommend any special precautions to mothers or other family members. Catching C. diff from a baby is so rare that enforcing special precautions is probably not necessary. Wearing rubber gloves when diapering, or hand washing after changing diapers, is always recommended, especially if the person changing the diaper is taking an antibiotic.

Being a carrier of C. diff is beneficial to the baby. Healthy babies who are carriers develop an immune reaction to C. diff toxins that results in the formation of antibodies that protect against C. diff infection. Immunity to C. diff developing during the first year of life can last a lifetime and protect patients who later come in contact with C. diff. Those who have antibodies become “carriers” with no diarrhea, while those with no antibody can develop full-blown C. diff. Since about 70% of babies are carriers, this implies that they will likely never get C. diff when they grow up!

To learn more about C. diff, download or purchase a copy of C. Diff In 30 Minutes: A guide to Clostridium difficile for patients and families by Dr. J. Thomas Lamont, M.D.

C. diff fecal transplants: What the research says

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The following excerpt about C. diff fecal transplants is from the journal article “Fecal Transplantation for Recurrent Clostridium difficile Infection in Older Adults: A Review,” from the August 2013 edition of the Journal of the American Geriatrics Society. It was authored by Kristin E. Burke, MD, and J. Thomas Lamont, MD. Used with permission.

C. diff fecal transplants

Recurrent Clostridium difficile infection (CDI) is a common nosocomial infection that has a large effect on morbidity and quality of life in older adults in hospitals and long-term care facilities. Because antibiotics are often unsuccessful in curing this disease, fecal transplantation has emerged as a second-line therapy for treatment of recurrent CDI.

A comprehensive literature search of PubMed, Embase, and Web of Science regarding fecal transplantation for CDI was performed to further evaluate the efficacy and side effects of this promising therapy in older adults. Data were extracted from 10 published articles from 1984 to the present that met inclusion criteria, including nine open-label reports and one randomized controlled trial.

Baseline characteristics and outcomes of individuals undergoing fecal transplantation and effects of fecal transplantation on the fecal microflora were reviewed. Methods of fecal transplantation and donor selection were reviewed. Fecal transplantation was performed in 115 individuals aged 60 to 101, with a female predominance.

CDI cure was achieved in 103 (89.6%) individuals over a follow-up period of 2 months to 5 years (mean 5.9 months). There was no significant difference in cure rate between older and younger participants in included studies. Most failed transplantation occurred in individuals infected with the aggressive NAP1/027 strain of C. difficile.

Microbiological studies of fecal biodiversity before and after fecal transplantation demonstrated greater bacterial diversity and shift in flora species to resemble donor flora after transplantation that correlated with clinical remission. Fecal transplantation provides a safe and durable cure for older adults with recurrent CDI. J Am Geriatr Soc 61:1394–1398, 2013.

Keywords: fecal transplantation; recurrent C. difficile infection; fecal microflora

colonoscope used for c. diff fecal transplants or c diff stool transplants - shutterstock image used under license

Colonoscopes are used for C. diff fecal transplants (Shutterstock)

C diff. slides by J. Thomas Lamont, M.D., of the Harvard Medical School

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The following C diff. slides were created by J. Thomas Lamont, M.D., a professor and researcher at Harvard Medical School and the author of C. Diff In 30 Minutes: A guide to Clostridium difficile for patients and families. The slides were part of a 2013 presentation given to doctors and researchers:

If you are interested in learning more about C. diff, check out the many resources listed on this website.

DISCLAIMER: Nothing in this presentation is intended to constitute medical advice, a clinical diagnosis, or treatment. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions.