00:00 – If you follow us on social media you know that we’ve been waiting for a big announcement. Today I’m talking to Alan wolf
00:05 – about a huge urinary microbiome study that will be the first of its kind. This groundbreaking work will be taking place in the US.
00:12 – But research will have implications for researchers clinicians and patients worldwide.
00:29 – Today I’m with Alan wolf professor of Microbiology and Immunology at Loyola University Chicago Street School of Medicine.
00:36 – And co-founder and co-director of the Loyola Urinary Education and Research Collaborative
00:41 – also known as LUERC. Thanks so much for joining me today for our chat.
00:46 – Alan Wolfe: Quite welcome. I’m looking for our conversation. Melissa: It’s quite a big day for our respective teams
00:52 – because we’re officially announcing our collaboration on a groundbreaking study into the urinary microbiome.
00:57 – But before we jump into discussing that can you tell us what is already known about the urobiome?
01:04 – Alan Wolfe: Sure. Maybe I could restate the question, which would be:
01:10 – How in the world did you ever get involved in urobiome research? And the reason I say that is because…
01:18 – I’m actually of microbial genalysist, my PhD is in genetics, I have a master’s degree in systems engineering,
01:25 – and for the first… Three decades of my career…
01:31 – The work that I did was to simply trying to figure out what the circuit board inside E. coli k12 look like.
01:39 – That’s the laboratory strain of the bacterium E coli.
01:44 – I simply wanted to know how does a cell, a bacterial cell,
01:51 – know how its feeling? How does it sense its environment and respond appropriately?
01:56 – It’s like one of those questions that falls under the category of, What is life? Right?
02:03 – So, hum… about sixteen or seventeen years ago
02:08 – I walked up to a World-renowned urogynecologist by the name of Linda Brubaker.
02:14 – I had no idea who she was, I had no idea how Influencial she was, but the chairman
02:20 – the chairperson of my departure, Katherine Knight, told me that I should introduce myself so I did
02:27 – I walked up I reached out my hand and I said: “Hi my name is Alan wolfe and we have to work in common.
02:32 – E. coli, you want to kill it, and I work on it.” She said “Let’s talk.”
02:40 – So we sat down for a series of one-hour conversations in her office and during one of those conversations, she said:
02:48 – “You know, some people think that the bladder is sterile.” And I said “no flipping way!” Have you seen the plumming?
02:55 – Because she is a plummer. That’s what gynecologist do, they fix the plummer. As a microbiologist,
03:01 – I could imagine how any part of the human body that has a hole to the outside
03:06 – could be sterile. I said: “If the bladder is sterile I want to patent it
03:11 – because something really special must be going on. It turns out that it’s not sterile.
03:17 – And I’ll tell you how we know that the moment. But something is special going on, because particularly in women
03:24 – it’s right next door to one of the most highly canonized natures, right? The vagina.
03:30 – And the difference in the amount of bacteria in the bladder and in the vagina is huge.
03:39 – So anyway. Then what I decided to do was to…
03:47 – Withdraw urine directly from the bladder this is when I learned about something called superpubic asperate
03:53 – when you stick a needle in the lower abdomen into the bladder. Mind you these for patients going in for your gynaecological surgeries
04:02 – the way I put it is this is the least worst thing that’s gonna happen Hum, they did- you know
04:09 – they weren’t gonna feel it they were already out. But we took skin swabs,
04:14 – and a shame needle stick that went through the abdomen at the same place but didn’t go in the bladder.
04:21 – We took cathet- we took urine by a transurethral catheter. We did specimens and vaginal swamps
04:28 – and then we did something called 16s ribosomal RNA sequencing. there’s a gene in all bacteria
04:36 – that is quite conserved so it’s very similar in all organisms just different enough
04:43 – that you can tell one species of bacterium from another by sequencing them
04:49 – the DNA in that gene. So we did this what’s called 16s ribosomal RNA gene sequencing
04:56 – on urines that had been… well on these samples
05:03 – and their urine had been sent to the clean lab and they come back as no gross, so these were culture-negative urines.
05:11 – What we found was DNA evidence of bacteria in culture-negative urine We also found that the…
05:18 – The catheterized urine and the suprapubic asperated urine looked very similar to each other.
05:25 – The aspirate- The rawl of aspiration bypasses vulval vaginal contamination
05:32 – we knew that we were looking at Bacteria that were in bladder urine. Right? So the skin swab and the same middle stick controls
05:41 – and the urine didn’t look like those controls as well
05:47 – And interestingly and importantly, the voided urine looked too much like the vaginal swab.
05:53 – Too often. Right? So we published that work just about eleven years ago
06:00 – and about what the sequencing couldn’t tell us is whether or not the bacteria detected by sequencing were alive.
06:08 – Because you can sequence DNA from dead bacteria.
06:14 – So the next step was to see if we could crew the bacteria And another member of our team,
06:20 – Paul Schwakenburger, was the director of our clinical microbiology lab. And I sort of chided him, I kept bogging him and said:
06:28 – “Paul! I’m looking at this, the taxo- the types of bacteria that we were sequencing,
06:35 – these are non unculturable they just don’t grow under the standard urine culture conditions.
06:40 – Can you develop an approach that will allow us to grow these bacterias.
06:48 – He invented what he called “Expanded quantitative urine culture” or “EQUC”.
06:54 – That rhymes with duck. And, hum… It’s an enhance culture method,
07:01 – it includes- we use a larger volume of urine many different growth media,
07:08 – different atmospheric conditions. not just ambient…
07:14 – You know, the air that we breathe but anaerobic conditions where there’s no oxygen at all.
07:20 – Conditions where you put a little bit of carbon dioxide into a chamber
07:27 – And that allowed us to grow a lot of the bacteria that we could sequence. And so now we know that there were bacteria in the bladder.
07:36 – And the question was… Did the bacteria in the bladder of individuals
07:43 – with different health statuses differ? So we looked at individuals with urgency urinary incontinence,
07:53 – stress urinary incontinence, interstitial cystitis painful bladder syndrome,
08:00 – individuals with urinary tract infection and recurrent UTIs, hum…
08:07 – People with kidney stones, and on, and on. What we found is that in many cases, but not all,
08:14 – that the communities of bacteria that we saw in people with lower urinary tract symptoms of some sort or another,
08:24 – differed in important ways from individuals that were presumably asymptomatic.
08:31 – So now that we know that there are bacteria in the bladder that they were alive and may in fact
08:38 – be associated with health and disorder, The question was, who was good who was bad?
08:45 – How do they interact with each other? And totally interact with the host or hostess in fact, most of the work we done
08:53 – has been with women. One of the nice things and scientifically very important thing is that others
08:59 – had joined in the fray and started to report similar findings to ours.
09:06 – And we’ve grown as a community We now have our own conference which we started back in 2019.
09:14 – Had another one in 2020 and then the pandemic hit We’re gonna have our first urobiome meeting in March 2023
09:23 – but we’re gonna all get together again and try not to get covid on our hair. Hum, so…
09:31 – To a large extent we and others are still looking at how did the communities affect the urobiome
09:41 – differ between individuals with different health statuses different demographics,
09:46 – different whatever you want, right? we’re moving, and how does the…
09:54 – the microbiome of the bladder differ from the urethra
10:00 – and the periurethra. in the vagina from rectal swabs
10:05 – and we were really trying to understand the all ecology in the system. That where we’re headed, we’re headed towards ecology.
10:12 – Right? You know, it’s a niche, it’s a ecological niche. The question is “who should be there?”
10:20 – In a given niche, mine is just different than yours. My, my urobiome…
10:27 – Should look a little bit different from your. You probably have lactobacillus. As a male, I shouldn’t lactobacillus
10:35 – I have no idea because one of the things I haven’t done is donating my own urine. Melissa: What?
10:40 – Alan Wolfe: I haven’t done it and we could do it. Melissa: It feels like it’s something you should do someday.
10:46 – Alan Wolfe: It is, but I just haven’t. Maybe I just don’t wanna know what’s in there.
10:51 – Melissa: I can understand that too. Alan Wolfe: Yeah! But in any case, hum…
10:57 – a lot of what we’re doing in my group now is to try to understand who’s good and who’s bad.
11:04 – We know that some E coli are pathogens We know that…
11:10 – Organisms like klebsiella and pretius can be pathogenic. Same thing with enterococcus faecalis.
11:17 – But there’s a whole bunch of organism that you well, you may have heard of now, but most of…
11:25 – Hum your… Your community may not.
11:31 – Many organisms that are difficult to pronounce clinicians haven’t even heard of these.
11:37 – The question is: “are these emerging uropathogens?” Are these uropathogens that have always been there?
11:43 – But we’re now beginning to realise that they’re pathogenic. Big part of my group now
11:50 – is attempting to characterise the organisms
11:56 – that huh… Show up in case reports like those are one of clinicians found some organism in an abscess
12:04 – or in a urinary tract infection or something. And they reported it. but it’s not science, it’s anecdotal. Melissa: Yeah.
12:11 – Alan Wolfe: Well, so now what were trying to do is ask is there any basis to the truth of those anecdotes
12:18 – or is that trully there me there because it was causing symptoms or was it just an innocent bystandard.
12:24 – That’s a non-trivial problem to solve because no one’s ever worked with an organism you don’t know how to work with it. Melissa: Right.
12:32 – Alan Wolfe: We’re starting from scratch and… Many these organisms are difficult to grow
12:39 – they don’t want to behave they’re not model organisms that researchers have worked on for years.
12:45 – So that’s where the community is right now it’s a great foundation for the study that were about to launch.
12:52 – Melissa: So going back to that study can you explain why it’s so significant and why the bladder was not included
12:58 – in previous research published around projects like the Human microbiome Project Alan wolfe: Right. So…
13:05 – Yeah, let’s go back to the Human microbiome Project. I’ve heard the second hand Ok.
13:11 – Not third-hand, it is second-hand. There’s only one person in between me and one of the members of the original HMB
13:19 – HMP, the Human Microbiome Project. In fact, voided urine was included.
13:26 – But it wasn’t included in the final manuscripts. Because the reviewers all claimed that
13:32 – what they had discovered must be contamination because the bladder is sterile, or urine is sterile.
13:38 – That’s what I’ve been told indirectly, and it rings true.
13:46 – So, hum… The reason that people
13:54 – thought that urine was sterile and the bladder was sterile. is it does back actually about a hundred years.
14:02 – No, a hundred and sixty years. I can take it back in time, a little bit of history.
14:07 – Those who remember in either High School or college or mayby for those who were in a progressive school district
14:17 – right, in Middle School, you remember back when you were learning about how
14:22 – there was this debate about spontaneous generation, right? Could… hum
14:28 – Life… Come from inorganic…
14:33 – You know, hum… Could it spring up without having been born from something else, right?
14:40 – And after they figured out that, you know, maggots in meat
14:46 – were simply the larvee of flies, and if you cover it, it didn’t get maggots.
14:53 – Then they went to smaller items, smaller things. And at some point
14:58 – they had completely narrow it down and the only thing that could spontaneously generate
15:04 – would be these little microbes and germs, right? So, hum…
15:09 – One of the key experiments was done by Louis Pasteur who’s essentially the founder of modern microbiology.
15:18 – And he did this experiment where we had flasks that he left open
15:23 – liquid in flasks he left up in the air and others that have a long gooseneck
15:29 – where you could get air in there but if anything was heavier than air it would fall down and it couldn’t get into the liquid.
15:36 – And he found that, you know, all the various liquids that he put in the flask with the Gooseneck
15:43 – after sterilising it, remain sterile. No growth. Ok? If he left it open,
15:50 – things could fall out of the sky it would turn cloudy and get turbid. Erm, one of the liquids…
15:58 – that he tested was urine from someone who was presumably healthy.
16:03 – And… The flask… that was not really open to the air
16:08 – remained clear. The flask that was open erm, was cloudy.
16:17 – What Pasteur said… was that this disproves spontaneous generation.
16:24 – But about fifteen years later, a very influential paper was written by godly name of Roberts
16:31 – who said that normal healthy urine is sterile, that was his first sentence.
16:37 – I have no idea how he came to that conclusion Melissa: Haha, yeah. Alan wolfe: Ok? But…
16:43 – Here’s what I think happened. And that is since we now know a couple of things.
16:48 – One, Bacteria are very very tiny.
16:53 – Ok? And you can have bacteria in urine.
16:58 – Up to… Over… About 10 million bacteria…
17:05 – For a mililiter. Below that level,
17:11 – that liquid weither it’s urine or growth medium, right,
17:16 – will be crystal clear. Below 10 million
17:22 – so that’s ten of the seventh colony-forming unit per ml. Way above the threshold for the standard urine culture test
17:29 – which is ten of the five, right? That’s a hundred thousand colony-forming unit per ml
17:35 – or bacteria per ml. So, first of all, a liquid with lots of bacteria in it can still look clear.
17:46 – The second thing is the most of the bacteria that we find in urine don’t grow…
17:52 – in ambiant conditions, they don’t grow in air. they like a little bit of CO2,
17:59 – they like not having any oxygen at all. And you need very specific growth medium.
18:06 – And urines are pretty poor growth medium. And so, I think the initial conclusion, the interpretation
18:16 – was a misinterpretation of the data. Melissa: Yeah. Alan wolfe: And then you step forward to the nineteen fifties and sixties
18:24 – when Ed Kass, a brilliant man who was an infection disease Doc
18:29 – er, er, at Harvard the Hospital System associated with Harvard
18:37 – was looking for a way to tell whether or not somebody had Pa
18:42 – and he came off with what was called the standard urine culture test. and it worked great for
18:51 – But it was, somewhere along the line it was transferred to trying to diagnose cystitis
18:58 – And I can tell you it doesn’t work very well because no one’s been able to agree on a threshold.
19:05 – So if you look in the litterature, you have clinicians and clinical microbiologists are going back and forth
19:11 – over whether they should use ten of the five, ten of the four, ten of the two, ten of the… I mean, and they’re usually talking about E. coli.
19:19 – We now know that there’s all these organisms Melissa: Yeah. Alan Wolfe: Right? So I think the reason that people thought that the bladder was sterile
19:29 – was the use of this test, the all history, right?
19:36 – Erm, and… When a clinician gets a report from a clinical microlab that says “no growth”…
19:45 – That got translated into sterlie. And then, that gets taught to the medical students.
19:52 – But in fact, if you know how a microlab works, “no growth” doesn’t mean no growth,
19:59 – it means no growth of what they’re looking for, aka known uropathogens. E. coli, klebsiella, and so on.
20:06 – So I just think it’s a comedy of errors. Also a lack of…
20:13 – Thinking, Thinking outside the box. Melissa: Yeah. Alan Wolfe: Which, as a microbiologist coming in from the outside, I went…
20:22 – “No.” Haha! We have to re-evaluate this.
20:27 – Melissa: That’s what we’re about to do this study which is great. It’s quite a big study,
20:32 – so we’re looking to recruit a thousand and fifteen participants, which is huge. And in that number, we’ll be looking at
20:39 – the urinary microbiome in people who do experience UTI, as well as people who do not.
20:44 – Can you explain why it’s so important that we have the comparison in this study? Alan Wolfe: Right, erm…
20:52 – Well actually, we’re going to be getting two samples from the people with recurrent UTIs
20:57 – one while they’re having a symptomatic episode and one they’re not. And we’re going to compare
21:03 – the community of bacteria, actually, the community of microbes,
21:09 – so bacteria and viruses and fungi, everything that’s in there.
21:14 – In the same woman, when she’s having symptoms or she isn’t
21:20 – and see whether or not the communities differ. Right? So you can imagine that, erm,
21:26 – you know, the reason that a woman might be having an episode
21:31 – a symptomatic episode is because for some whatever reason,
21:37 – a pathogen that’s part of the community blooms and now there’s a lot of them, and that’s causing symptoms.
21:47 – The controls, the people who are unaffected by recurrent UTIs
21:53 – would be used as the… Well I use the term “control”. In science, you need controls,
21:59 – I used that term when I told you about the very first study, right? We controled for the suprapubic aspirate
22:06 – by having a skin swab and a cham middle stick we controlled for, erm,
22:13 – the voided urine by having a vaginal swap because the voiding urine could be
22:19 – only urine from the urinary tract but it could be contaminated with vaginal or vulva vaginal
22:25 – microbe, which in fact it often is. So in science to do science you need negative control
22:34 – You need them. Because you need a comparator. Right? If you don’t have a control,
22:40 – Now what you have is anecdotal evidence. Right? You don’t have science.
22:47 – Ok, so we need the controls to know… Whether there’s any difference between individuals
22:54 – with recurrent UTIs, a history of recurrent UTIs and women who don’t.
23:00 – And we need the symptom vs non symptom sample
23:05 – to determine whether or not there is any reason to believe that the microbiome changes,
23:11 – and that change has something to do with symptoms. Whether those changes are a cause of the symptoms
23:20 – or a consequence of the symptoms is another story. Which is something we won’t be able to determine from the study.
23:29 – The study should give us some modern information as to where we should set our sight.
23:35 – Melissa: hu-hum. Alan Wolfe: For future studies. Melissa: Yeah it’s so exciting. We’ll have three hundred controls in this study
23:42 – and seven hundred people with recurrent UTI. We’re also hoping to recruit fifteen people
23:48 – that will send us a urine sample for everyday for forty days, which is quite a bit of urine samples.
23:54 – Can you explain what we’re hoping to learn from those people and why you choose forty days?
24:00 – Alan Wolfe: Right, right, erm… To be honest, that, to me, is the most exciting part of the study.
24:07 – Melissa: Haha, yeah. Alan Wolfe: So someone please volunteer! Melissa: Haha, yeah please! Alan Wolfe: Haha, please! Erm, it, it…
24:15 – Here’s why. So I got to take you back in time a few years, I had a graduate student by the name of Travis Price.
24:24 – Travis and I went to a conference in Seattle when he was just trying to decide,
24:31 – he was transitioning from being a master’s student in my lab to being a PhD student, and he was thinking about what his PhD dissertation project would be
24:40 – And I remember we played hockey the last day of the conference and we took the ferry,
24:47 – across the harbour, we literally just went across, Turn around got in the line and came back
24:54 – it was nice to do. It was a cold day I do remember that, and he was telling me
25:00 – about this crazy idea that he had, he was going to recruit a whole bunch of nursing students to give samples every
25:07 – so he could follow whether not the microbiome changed,
25:13 – Erm, weather… Anything that they did in their lives like you know,
25:20 – change the microbiome because he knew that have been a study like that done on the gut microbiome, by the way,
25:27 – with just two people one was senior one was junior. We figured that the first author was the student,
25:33 – the second author was the mentor. Haha! But it was a really fascinating,
25:39 – relatively early microbiome study. where they sampled themselves, basically everything for…
25:46 – Months. So in any case, he prepared… I said “Ok! Got for it!”
25:54 – So he prepared for that erm, by sampling himself everyday.
26:02 – And, erm and a female master’s student sampled herself everyday.
26:10 – And two things that we thought that again this is anecdotal because it’s one of, right?
26:16 – Melissa: Yeah. Alan Wolfe: One of the things besides learning how to do it, and how not to do it, and finding out that it was feasible,
26:22 – but what we found out from him is that…
26:29 – He finished his big comprehensive exams and took several weeks off and went to Thailand with his partner
26:36 – and he thought “that’s great”, I’m going to be eating different food, be in a different place I’m gonna come back, my urninary microbiome will be different.
26:44 – First day back, no different whatsoever. Second day, very different.
26:49 – Melissa: Hu-hum. Alan Wolfe: Third day, in the hospital in pneumonia Melissa: Oh, no. Alan Wolfe: So what we saw,
26:55 – was that his urinary microbiome changed because he got pneumonia and he could have known if something was up the day before.
27:03 – Except that We didn’t get the results for like three or four days later.
27:08 – Melissa: Right. Alan Wolfe: His partner in crime was actually, erm… Doing the analysis,
27:15 – and he was selling himself everyday even though he was sick. We also got to see the antibiotics work, which was kinda cool.
27:22 – Melissa: Yeah, that is cool. Alan Wolfe: The other thing we saw was that we saw… Actually I mispoke,
27:29 – they also did a little study with I think seven or eight young women for thirty days.
27:35 – We actually saw one woman getting UTI. Melissa: Oh, Yeah. Alan Wolfe: The very last day,
27:41 – she walked into the clinic and started to have UTI symptoms. We could have told her a week earlier. we couldn’t because we weren’t allowed to.
27:48 – over anything, right? But we could see the E. coli working its way from the periurethra, which is the…
27:55 – The skin around the opening of the urethra, into her bladder, and the numbers growing
28:02 – With no idea what happened after. Melissa: Yeah. Alan wolfe: The other thing that we learnt from this small preliminary studies
28:09 – was that, erm, haha ! We think that binge drinking affect the urinary microbiome.
28:17 – Melissa: That’s not that surprising. Alan Wolfe: No it isn’t, but here’s what happened. This was a master’s student,
28:24 – and she had started sampling herself pretty much every day, sometimes she was sampling herself in the morning and the afternoon
28:30 – to see if… Different times of the day would matter. And we got to the end of the semester,
28:38 – what a graduate students do at the end of the semester? They celebrate! So she looked at her samples and went “Well, something changed!”
28:47 – And she was astude enought to think that maybe it was because… I had done a lot of drinking over the weekend.
28:54 – So we set up a small study to test that, and, erm, the
29:00 – the commitee decides whether or not you can do a study on human being
29:05 – It’s called the RIB. We learnt that the IRB won’t let you
29:10 – say that, erm, you should drink on the weekends. But you can tell him not to drink in the week.
29:19 – Haha! So we set up a small study to see whether or not there was anything going on with binge drinking.
29:26 – We don’t have enough controls and enough data.
29:31 – Anecdotally, I think that binge drinking probably affects some of the microbes.
29:37 – Erm, in er… In the bladder. But, Now!
29:43 – Now Travis had the opportunity to set up a real, well designed study.
29:48 – And so so he recruited eight young women. All…
29:53 – In their twenties and thirties. All were students or employees of Loyola
29:59 – because we needed them to drop their samples off everyday, In our buildings so they had to be able to have access.
30:10 – They sampled themselves every day for… two months and then once a week,
30:17 – for the last third month. He asked them,
30:22 – everyday they had to fill out a questionnaire which was incredibly invasive. Melissa: Hu-hum.
30:27 – Alan Wolfe: they were asked about what they ate. any drugs that they had taken, prescription drugs or whatever.
30:34 – Whether they bathed, whether they swam, whatever they did, right?
30:39 – And all sort of invasive things about sex. Contraception, and so on and so forth.
30:47 – Erm, and, erm… What he found was…
30:54 – Really quite striking. We kept going back and forth when looking at the data and he would say:
31:00 – “It’s not stable at all.” And I was saying “No, no, it is stable.” he’d go “No it’s not stable!” I said “Yes, it is!”
31:08 – Finally I realised that, you know, I don’t know how many of your… Audience members of this podcast remember Esope’s Stables,
31:16 – fables, Esope’s fables. Erm, you know the lion and the elephant.
31:22 – We were tapping on the elephant from different directions. He was playing with the trunk and I was
31:29 – Is cider is years or something So I eventually came up with a way of describing
31:38 – what we were seeing, which is: If I knew what your microbiome looked like last week, and I know what it looks like this week,
31:46 – I can predict what it’ll look like next week. Here’s what I can predict.
31:51 – What it’ll look like tomorrow. Because what was going on is that they were essential, in most cases,
31:58 – two different communities that were changing places with each other. So you’d have community A,
32:04 – and that get replaced by community B and then community A, B, A, B. And the duration of either A or B
32:12 – could be two days, or five days, or three days, you just could never project the next day.
32:18 – But you know that in a couple of days, if you’re in state A you’re going to be in state B surely.
32:25 – With a few exceptions. This is really intriguing because
32:31 – One of the exceptions, and it was… Without exception.
32:37 – Menstruation caused a massive change in each individual’s microbiome.
32:43 – So there was one woman who was not on contraception, she was menstruating every month.
32:52 – There were some that were on… Contraception that, erm…
32:59 – Where they… They went through the cycle every month, and there was some that were on this three-month cycle…
33:06 – Contraception. The community… The change in the community structure
33:13 – was the same for each woman. So when a woman had…
33:20 – Menstruated each month, the change was essentially the same. But each woman’s change was different.
33:27 – Melissa: Hu-hum. Alan Wolfe: Right? So there was a uniqueness. Now we only had eight women
33:32 – so, you know, maybe there’s like a handful of… Of, erm…
33:38 – States that all women go into, maybe there’s eight of them, ten of them,
33:45 – eighty of them, I don’t know. But… So menstruation had this big effect. And the other thing that had a big effect was vaginal sex.
33:54 – And it didn’t have anything to do with male. Because whether a male
33:59 – wore a condom or didn’t wear a condom, there was always a disruption the day after.
34:05 – Or almost always. And it was a particular… Erm, it was a particular type of bacteria
34:13 – that would show up. A bacterium called Streptococcus. Melissa: Hu-hum. Alan Wolfe: It would last for a day or two or three, and it would
34:20 – Disappear or at least diminuish. So we think it has to do with sort of
34:25 – the physical activity of vaginal sex. The streptococcus is innate to
34:32 – the young woman. And, erm, having sex was causing a disruption.
34:39 – Now the thing is, is that… So where what he did was to take a…
34:47 – He reapted one of the women who’s having the most sex so we had the most data points.
34:54 – And we recruited her male partner. And they swapped various parts of their bodies
35:00 – and gave us samples. And… It was very clear that, that-
35:07 – Literally every time she had vaginal sex Streptococcus showed up,
35:12 – and it was a particular species of Streptococcus That we managed to identify.
35:18 – And I thought, initially, that he was…
35:23 – Inoculating her with this Streptococcus. But it turned out that
35:29 – the Streptococcus was resident in her… Urogenital tract.
35:35 – Melissa: Hu-hum. Alan Wolfe: So, erm… So here’s the thing: We…
35:41 – I have a hypothesis that we’ve not been able to test. Which is that, erm…
35:48 – That maybe, that the urinary tract infections
35:54 – that come from… Erm…
35:59 – that are often associated or thought to be associated with…
36:05 – Risky behaviours. May in fact simply be that
36:10 – when you’re drinking and you have sex You got two things that are reducing the protective microbiome.
36:21 – And allowing the blooming of non-protective bacteria. And if you’re exposed to a pathogen like E. coli or Proteus,
36:31 – you’re now more at risk. And I’d love to be able to test that.
36:36 – But it was it requires that I get money that I don’t have to set up a rather large study.
36:43 – So back to our study. Why is this every day for forty days important?
36:49 – Well forty days is we need enough data points to be able to tell whether we’re seeing a pattern,
36:55 – the reason that we were able to detect a pattern in the original study was because we had-
37:02 – we were getting- we got something along the lines of seventy samples.
37:08 – From eight women. So we’re able to clearly see these patterns, and when something happened,
37:14 – they changed the pattern. You could see, if we only had a week, we wouldn’t know whether we were seeing a random occurrence
37:21 – of weather was actually indication of some pattern that we might be able to see if we have more samples.
37:26 – So forty days is important. What the question is… Are women with recurrent UTIs-
37:34 – UTIs are their microbiomes as stable and dynamic
37:40 – in the way that we saw for young women who were presumably healthy. Right?
37:47 – It could be that people with recurrent UTIs have a very different pattern.
37:53 – first of all, I expect to see different bacteria. But are we seeing, you know,
37:58 – fluctuations: A B A B? Or is it just like A the whole way and then all the sudden you see B?
38:06 – And you have symptoms. Ok? So hopefully some of the people who are donating everyday
38:13 – I know that sounds bad, but getting episodes, so we can see. Right?
38:18 – But it’ll be random, I mean. You know, hopefully for their sake then I’ll get symptoms. Melissa: exactly.
38:25 – Alan Wolfe: But from the scientific point of view, we’d like to see a couple, two or three of them
38:30 – get symptoms, so we can use that information to design the next study.
38:35 – But, yeah. The problem with most of these studies, Two,
38:41 – two problems with the studies that have been done. One: They’re way too small. Melissa: Hu-hum. Alan Wolfe: Ok?
38:48 – So all the work has been done with recurrent UTIs or UTIs in general have been
38:53 – on the smaller side. So, erm, You don’t have a lot of power, statistical power
39:01 – Er, so… Your interpretation is: “Well, we think we might have a pattern here.”
39:07 – We might, you know, we have to sort of- if you’re going to be rigorous scientifically,
39:13 – you need to sort of be a little… Cautious about your conclusions and interpretations.
39:22 – Erm, but, erm… The other is the most of them are cross-sectional.
39:31 – And they are one time point. So you’re looking at people that are presumably healthy
39:37 – and people who have chronic kidney disease. You look at them and you go:
39:42 – “Well… This group looks different from that group.” That’s all you can say.
39:49 – But if we’re getting samples everyday from these individuals, then you could determine
39:56 – how did they become. For example I would love to be able to get somebody…
40:02 – Who’s going to get a UTI. Ok? And start sampling them,
40:07 – a month before they get the UTI. Let’s say we could predict you’re going to get a UTI on March 1st.
40:12 – I’d say “Ok great!” Let’s start sampling you every day, starting on February 1st.
40:18 – You’re going to get a UTI on March 1st You’ll get treated and we’re going to watch the treatment work and not work.
40:23 – and then we’re gonna wait, You know, after the treatment, we’re going to wait another month to see if anything changes.
40:32 – So, You know, that’s ideal. Because then you can really tell
40:38 – what’s happening and from that information you can then begin To determine, well
40:45 – is there anything- Do we understand the process? If we understand the process, then maybe we can intervene.
40:52 – Maybe, at least we can predict. Like wouldn’t it be great
40:57 – if you could take a test every morning, you know when you’re-
41:03 – Before or after you brush your teeth or whatever. and looking and go “Ok”,
41:08 – “Today, tomorrow, the day after I’ll be fine.” but you look down and you go “Ah”
41:13 – I’ve got a biomarker, a marker here, right? I’m going to have a UTI tomorrow.
41:19 – Perhaps you could do something about it. Melissa: That would be ideal. Alan Wolfe: I would love that, right?
41:24 – We can’t. We don’t know what those biomarkers are, we don’t even know whether you can tell the day before,
41:30 – althought we suspect that you can, based upon that anecdotal data that I told you about.
41:37 – Melissa: Yeah. Alan wolfe: So, the everyday sampling is really critical,
41:43 – for us to get a first look at what ideal microbiome looks like
41:49 – in women that have a history of recurent UTIs. Melissa: Yeah, it would be interesting for us.
41:55 – Alongside the urine samples, our team has developed some very in-depth survey which mimic a bit what you explain earlier,
42:02 – where we’ll be collecting information about all sorts of things that could impact the urinary microbiome.
42:08 – So what kind of associations are you anticipating that we might see between the survey data and the urine sample data?
42:16 – Alan Wolfe: Erm… Age.
42:21 – Melissa: Hu-hum. Alan Wolfe: Clearly… Recurrent UTI vs controls.
42:30 – Symptoms vs asymptomatic. Episodes.
42:37 – We… Maybe location, geography,
42:43 – I mean, I don’t know. Most of the work that’s been done has been on women from either Chicago, or
42:51 – Portland, Santiago, little bit from Providence. Some work in, erm…
42:59 – North Carolina, a few other places, some work has been done in China, A little bit of work was done in…
43:07 – Certain part of Europe. You know, I would presume…
43:14 – That, erm… That women in North America might be generally similar.
43:22 – Who the heck knows? Haha! Melissa: I hope we’ll find out. Alan Wolfe: We’ll know whether certain…
43:33 – Certain medications that are allowed to be included in the study
43:39 – have an effect. Maybe if we get on a large enough sample size of individual’s on
43:46 – you know, medication A versus B versus not at all.
43:57 – Jezz, almost anything! Melissa: Haha, yeah! Alan wolfe: The point is, no one’s ever done this.
44:04 – So predicting the pattern outside of the obvious
44:10 – is almost impossible. So like I said, the obvious is I fully expect that symptomatic episodes, non-symptomatic
44:19 – Episodes vs none and women with UTI versus you know, the controls.
44:25 – I expect differences, I expect that on average young women with recurrent UTIs
44:31 – or controls with- that are younger will look different from the women that are older
44:37 – particularly premenopausal vs postmenopausal. We already know that that’s true,
44:43 – but this will be the biggest study where we can simply ask that question. Ok? Erm…
44:50 – But outside, and like I said, the obvious things, It’s hard to know. But I know, I’ve seen your questionnaire
44:57 – at least it’s in a draft of it, and it asked a lot of questions. Melissa: Yeah, we’re excited to see what happens.
45:04 – Alan wolfe: I think that the majority of questions, you know… Will illicite “No pattern” whatsoever.
45:11 – But I guarantee that there’ll be some- that we’ll see pattern, and I think that
45:17 – I’m expecting at least one or two surprises. Melissa: I hope so. and with the information that we’ll be collecting
45:23 – what information can participants expect to receive after we finished with the data collection and analysis?
45:29 – Alan wolfe: Well, you and I have been talking about this, right? I mean I’m not there yet, so we’re not exactly sure.
45:37 – But one thing that we’ve tossed around is the idea of… Regular updates.
45:45 – You know, erm, where we can talk about how many individuals have we recruited
45:50 – how many other samples have been sequenced and sort of generally what was seeing that specifically.
45:58 – Maybe. And then at the end, there will be a survey,
46:04 – a very deidentified summary report where, erm, participants could take a look at…
46:14 – Sort of what the… Generally, what we found from the entire study.
46:21 – And then, we will ultimately take all of our data,
46:26 – analyse it, process it, turn it into a manuscript. So individuals certainly,
46:33 – not just participants but everybody you know, can get access.
46:38 – And we should be able to put our publications up on your website.
46:46 – Whether we do an open source, so that we can put up immediately we’ll have to pay for that, right?
46:52 – Or you know, after, I don’t know, a year’s embargo, but those manuscripts will be available.
46:59 – And, erm… Our task will be to try to write these papers so the general public can understand what we’re talking about!
47:07 – Melissa: Yeah. Alan Wolfe: I tried very hard to write in simple English, even when… Writing to other scientists.
47:14 – But it’s not easy. So, Yeah, it’s not like your- the participants and samples are going to go into the ether,
47:23 – or in through the mail and you’ll never get to see what came of it. We planned to make this available to
47:31 – the general public. Melissa: It’s definitely our goal to share the information as much as we can.
47:37 – they’re important to our patients community to see what comes out of this study. The study itself will be-
47:43 – because of logistics, will be recruiting from us mainland only. But the findings of the research will likely to have implications
47:50 – globally, so, How do you think this study might benefit researchers clinicians and patients in the future?
48:01 – Alan Wolfe: It’s information. It’s, like I said, the biggest study to date.
48:10 – It is big enough that it will have statistic power for a number of different-
48:16 – a hypothesis that we will, erm… Propose.
48:23 – And since we will be making the information available to everybody ultimately,
48:29 – it means, at the very least, that clinicians…
48:37 – who take the opportunity to read may open their minds and make them think differently.
48:44 – For researchers, it will be a wealth of data To develop their own hypotheses and design their own studies.
48:52 – The goal of course is to get where we’re at,
48:58 – to where we need to be, to be able to… Propose.
49:07 – More accurate hypotheses for how- for the underlying mechanisms that cause symptoms
49:15 – of things like recurrent UTI or urgency, urinary incontinence, all sorts of lower urinary tract symptoms that…
49:23 – Millions of people, particularly women, suffer from.
49:29 – The, erm If you understand the process then you can begin to
49:35 – figure out ways to diagnose more problem more accurately.
49:41 – We know that the standard urine culture test well…
49:47 – It is what it sounds like. Erm, and, They are better diagnostics, the problem is that…
49:57 – Like I said, we don’t really know who’s good and who’s bad outside and the few that have always been thought to be
50:05 – Pathogen we’re working on that we have some pretty good ideas.
50:11 – But we need better diagnostics that can, erm…
50:17 – Give an accurate assessment of what the ecology of an individual’s bladder
50:22 – or entire urinary tract looks like. Then with some algorithm treatment
50:28 – algorithm that takes into account not just the bad guy, Right? The E. coli,
50:34 – But the rest of the ecology. So for example, it’s an analogy that I use,
50:42 – suppose you didn’t know what the concept of the lion was You’ve never seen a lion, you have no idea what a lion was.
50:49 – And your friend said: “oh you want to see a lion” “well there’s a lion in the zoo down the road there”
50:55 – It’s a pretty loud housing zoo. The lion’s in a cage on ciment, and every once in awhile
51:01 – they throw raw meat at it, that’s a lion. Or, Your friend can say “hey you book a ticket to Nairobi or somewhere else”
51:10 – You know, in the appropriate parts of Africa, and go on a safari and go out into the Savannah
51:18 – and realised that lions, actually, whether males or females, they live in prides
51:24 – families named prides, they spent most of the day living, lying in the shade under trees
51:29 – every once in a while the whole group gets up in the wildebeest or a gazelle
51:34 – and the gazelle or the wildebeest is there because there’s a waterwhole and the Savannah is grasseling.
51:41 – You’re looking at the ecology. We’re still living in the ninteeth century
51:47 – where it was important to a clinician to be able to say: “Oh! That’s Cholera, I can identify Cholera and I can kill it.”
51:55 – Or, you know, that’s salmonella Or that’s Tuberculosis, that’s the bo-
52:04 – that causes Tuberculosis. Those are truly invasive, true pathogens.
52:10 – But in most cases what we’re dealing with now are not true pathogens or true invaders.
52:16 – They’re not like Covid which is not something that normally lives within us it’s an invader from the outside.
52:22 – That’s a true pathogen. We’re talking about organisms that normally we live with.
52:27 – And normally that kept under control, but something happened. You get some sort of dysbiosis, a disruption of your ecology
52:36 – and now you get symptoms. So you need to understand what the ecology is supposed to look like.
52:42 – And that includes not just the potential pathogen, it includes the rest of the urinary microbiome,
52:48 – and it includes the host or the hostess, right? I mean, righ? The Savannah! Haha!
52:56 – And my hope is that, erm… Scientists, clinicians, clinical microbiologists,
53:02 – that everybody begins to start thinking about… Well let’s think about
53:07 – you know, urinary tract infections, and other sorts of Chronic diseases.
53:14 – Not just in the urinary tract, As disruptions or dysbiosis
53:20 – all the niche where the symptoms are occurring. And then,
53:26 – having algorithm treatment algorithms that allow us to try to restore
53:32 – what would be a healthy microbiome. would be considered a healthy microbiome with that individual.
53:38 – That’s a pipe dream. In a sizing here, but I think that ultimately
53:44 – we can get there. But we can get there, unless we do studies like the one we’re about to embark on.
53:50 – We need the data. So we need the- we need people to volunteer to participate.
53:56 – Melissa: I hope they will too. We’ll be relying on our community a lot for recuitment for this study so hope anyone watching this video shares it.
54:04 – I also look forward to chatting to you during the study so we can share updates and do some life events for people can ask you questions
54:11 – about how it’s going. Alan Wolfe: Sure, why not. Melissa: Thanks so much for joining me today, it was great to chat!
54:19 – Alan Wolfe: Absolutely, it’s always a pleasure. Anyone interested in participating in a study can find a link to the screening questionnaire in the description.
54:27 – The questionnaire will allow our potential participants to tell us about themselves, so we can allocate them to the right group
54:33 – if they meet the inclusion criteria. We’re excited about this research, and need the support of our whole community
54:39 – to recruit the participants we need so please share this video, subscribe to our channel and tick the bell.