WEBVTT 1 00:00:00.240 --> 00:00:02.879 Here we go. Hi, and welcome. 2 00:00:02.879 --> 00:00:06.899 I'm Siobhan Sarna, founder of Chronic Condition Rescue and the author of Healing SIBO. 3 00:00:07.200 --> 00:00:11.200 I have my new podcast, The Siobhan Show, launching 06/20/2026, 4 00:00:11.200 --> 00:00:13.155 Health, Wealth, Wisdom. Come check it out. 5 00:00:13.315 --> 00:00:18.215 My very first guest on that podcast is my cohost today, doctor Allison Sebecker, 6 00:00:18.675 --> 00:00:19.414 a true 7 00:00:19.875 --> 00:00:23.575 SIBO specialist. Hi, doctor Sebecker. Hello. Welcome, everybody. 8 00:00:23.955 --> 00:00:27.015 And Marcus Welcome. Welcome, doctor Pimentel. 9 00:00:27.400 --> 00:00:28.140 Our superstar 10 00:00:28.440 --> 00:00:31.180 of the day is the incredible doctor Mark Pimentel. 11 00:00:31.240 --> 00:00:36.940 And as I always say, no pressure, doctor, but he is going to be the one with his team to cure SIBO. 12 00:00:37.720 --> 00:00:40.700 So, yeah, I know. Your mission. Right? Pressure. No pressure. 13 00:00:41.239 --> 00:00:45.895 No question. I love that. So today's a message of hope, information, transformation, 14 00:00:46.754 --> 00:00:47.254 and 15 00:00:47.635 --> 00:00:57.655 a way to help you all move forward with the knowledge that we're gonna be sharing with you from doctor Pimentel and to take that knowledge and turn it into thinking so you can make the proper decisions going forward. 16 00:00:58.390 --> 00:00:59.130 Share this 17 00:00:59.510 --> 00:01:00.810 replay with your practitioners. 18 00:01:01.190 --> 00:01:07.050 Right? Share the love because so many of them don't have the bandwidth to get this kind of training, 19 00:01:07.430 --> 00:01:11.534 and they will no doubt be thankful for it. And if they're not, find a new practitioner. 20 00:01:12.314 --> 00:01:14.814 Okay. So doctor Pimentel is also 21 00:01:15.674 --> 00:01:17.935 here right now at, Cedars Sinai. 22 00:01:18.155 --> 00:01:25.454 He is the leader of the mass program there where they are working with a variety of different approaches to very difficult, 23 00:01:26.080 --> 00:01:27.700 obnoxious medical conditions 24 00:01:28.560 --> 00:01:30.180 that's not in his bio officially. 25 00:01:30.480 --> 00:01:36.180 And we're gonna hand things over to him so he can share with you the latest updates from the Digestive Disease Week, 26 00:01:36.640 --> 00:01:37.140 big 27 00:01:37.520 --> 00:01:42.685 convention that just happened in May 2026, but also what they're doing, additionally 28 00:01:43.305 --> 00:01:47.784 at the lab. Hi, doctor Pimentel. I'm handing things over. Doctor Sebecker and I will hide ourselves. 29 00:01:47.784 --> 00:01:51.405 We're not going anywhere. We're on our edge of our seats just like everybody else. 30 00:01:52.690 --> 00:01:57.970 Well, thank you for that introduction. It's great to be here. I don't know if you see my slides. 31 00:01:57.970 --> 00:02:03.030 That's weird. I don't know what that is. There we go. There we go. Something came up. Zoom came up. 32 00:02:04.130 --> 00:02:06.630 Thank you again. It's a pleasure to be here. 33 00:02:06.770 --> 00:02:11.224 I'm always happy to help people help people or help people to help people. 34 00:02:11.224 --> 00:02:12.845 How do you however you wanna say it, 35 00:02:13.784 --> 00:02:16.204 and help people directly. And so, 36 00:02:17.385 --> 00:02:20.765 I'm gonna try and take you through some of the updates from from DDW. 37 00:02:21.920 --> 00:02:31.860 If you've heard me speak before, you're gonna see some of these slides are familiar initially because it's all context and then how the new science fits into these contexts and how, 38 00:02:32.560 --> 00:02:37.305 you know, we're expanding, how where where we're going with this. And I always promise 39 00:02:38.005 --> 00:02:40.245 that things are coming, things are coming, and they're coming. 40 00:02:40.245 --> 00:02:46.825 And that's where why DDW is so important is because they're upon us, and we're super excited about that. 41 00:02:49.220 --> 00:02:54.980 What I will try to do is I love this slide from my lab as this highlight that my lab is amazing. 42 00:02:54.980 --> 00:03:03.885 We got 25 amazing people, 10 PhD scientists here, literally 25 people in this whole program here that are just doing this stuff. 43 00:03:04.525 --> 00:03:06.784 And and one of the ironies of this is 44 00:03:07.165 --> 00:03:15.584 that, you know, this research this research on IBS and SIBO and all of that never gets the right amount of credibility and funding 45 00:03:16.045 --> 00:03:17.245 from because it's 46 00:03:17.965 --> 00:03:20.760 you know, maybe it's not inflammatory bowel disease or Crohn's disease. 47 00:03:20.760 --> 00:03:23.099 You can't see stuff, and it's all microscopic. 48 00:03:23.879 --> 00:03:24.360 But, 49 00:03:25.159 --> 00:03:29.659 we're doing okay. We're getting some funding, and we're trying to make a big push for a bigger 50 00:03:29.959 --> 00:03:30.459 expansion 51 00:03:30.920 --> 00:03:37.475 because we've got such big good ideas that we think we can accelerate the drug development with an expansion. 52 00:03:38.335 --> 00:03:39.155 I'll leave that, 53 00:03:39.935 --> 00:03:42.115 out there floating. And our big, 54 00:03:42.975 --> 00:03:45.635 sort of flagship study is the reimagine study. 55 00:03:45.935 --> 00:03:49.940 You've probably heard this reimagine, reimagine, reimagine, but it is bearing so much fruit. 56 00:03:49.940 --> 00:03:51.560 Everybody has focused on stool, 57 00:03:52.180 --> 00:03:54.520 and we said let's focus on the small intestine. 58 00:03:54.820 --> 00:04:00.920 It's the absorbing surface, the stuff the bacteria produce in this area of the gut, the small intestine get can get absorbed. 59 00:04:01.205 --> 00:04:03.945 So it can affect you more directly than stool. 60 00:04:04.405 --> 00:04:07.605 And, wow, did have we ever found some stuff? So, 61 00:04:08.165 --> 00:04:11.945 and we're doing a whole plethora of things in the small intestine 62 00:04:12.405 --> 00:04:19.789 and new directions of microbiome research and new techniques that nobody's ever done, which I will talk about because they're actually 63 00:04:20.169 --> 00:04:21.149 bearing fruit. 64 00:04:23.130 --> 00:04:28.830 I put this slide up upfront now because we're starting to think of the diseases 65 00:04:29.210 --> 00:04:31.070 that are associated with the microbiome 66 00:04:32.235 --> 00:04:32.975 as overgrowth 67 00:04:33.755 --> 00:04:35.935 diseases or overgrowth syndromes. 68 00:04:36.395 --> 00:04:37.695 And h pylori, 69 00:04:38.155 --> 00:04:40.975 which you know causes ulcers, is really an overgrowth. 70 00:04:41.595 --> 00:04:42.815 So it's not an infection. 71 00:04:42.955 --> 00:04:46.650 It doesn't get into your bloodstream and make you have a fever or anything like that. 72 00:04:46.729 --> 00:04:47.630 It's a colonization. 73 00:04:48.330 --> 00:04:51.470 Each pylori overgrows, and when it overgrows, you get an ulcer. 74 00:04:52.169 --> 00:04:56.650 C. Diff, if you checked a 100 people on the street, 50 might have C. 75 00:04:56.650 --> 00:04:59.789 Diff detectable in small quantities in your colon. 76 00:05:00.075 --> 00:05:04.015 But when it overgrows, you get pseudomembranous colitis or c diff infection. 77 00:05:05.115 --> 00:05:09.135 Candida isn't present in many people's gut, and then you get an immunodeficiency 78 00:05:09.515 --> 00:05:11.135 or on steroids, you have HIV, 79 00:05:11.515 --> 00:05:14.895 and all of a sudden, Candida overgrows, and then you get esophagitis, 80 00:05:15.275 --> 00:05:17.720 thrush, and other problems. And so 81 00:05:18.340 --> 00:05:19.960 what we're talking about with overgrowth 82 00:05:20.500 --> 00:05:26.520 SIBO, overgrowth of methanogens, overgrowth of hydrogen sulfide is is basically just 83 00:05:26.900 --> 00:05:31.755 plug and play of the same story we've been studying on other diseases for 84 00:05:33.835 --> 00:05:34.235 decades. 85 00:05:34.795 --> 00:05:42.335 What I want to now as we transition to SIBO, what I wanna start with is I always want you to understand whether you're a patient or a doctor, 86 00:05:43.515 --> 00:05:46.735 that it isn't as simple as saying, oh, you have SIBO. 87 00:05:46.990 --> 00:05:50.849 And and we try in our practice, in our in our in our clinic 88 00:05:51.310 --> 00:05:54.050 to say, yes. You have SIBO, but why? 89 00:05:54.509 --> 00:05:58.050 And and it's really important to ask the but why, 90 00:05:58.430 --> 00:06:03.264 and you don't have to rush to find out why. You can go ahead and treat the SIBO if you detected it. 91 00:06:03.405 --> 00:06:08.044 But you have to think because maybe it's a tumor in the small bowel blocking the small bowel. 92 00:06:08.044 --> 00:06:10.625 Maybe it's a a torsion or an intersuception 93 00:06:11.565 --> 00:06:16.770 or a a medication the patient's taking like morphine or other narcotics, which will slow the gut down. 94 00:06:17.870 --> 00:06:21.629 Obviously the most common thing we see is irritable bowel syndrome. 95 00:06:21.629 --> 00:06:25.150 And the most, most common association with SIBO is IBS. 96 00:06:25.150 --> 00:06:27.330 So that's the one you're gonna see most often, 97 00:06:27.710 --> 00:06:28.975 but don't forget 98 00:06:29.355 --> 00:06:33.775 about other things that could be serious. And so I just want to put this up just for reference. 99 00:06:35.514 --> 00:06:37.695 Speaking of irritable bowel syndrome, though, 100 00:06:38.315 --> 00:06:43.055 we have you know, the one of the things that happened at DUW was the launch of Rome five. 101 00:06:45.060 --> 00:06:45.800 I'm kinda 102 00:06:46.260 --> 00:06:46.760 personally 103 00:06:47.220 --> 00:06:54.760 tired of the Rome versions because they tend to be a little bit redundant and and without much evidence to change the criteria. 104 00:06:55.940 --> 00:07:01.065 And also if Rome five takes IBS back to Room 3 because Room 4 was too strict. 105 00:07:01.065 --> 00:07:04.264 So there's just this back and forth, which is a little frustrating. 106 00:07:04.264 --> 00:07:06.365 But one one of the things that comes out 107 00:07:06.745 --> 00:07:09.165 of this last twelve months is that 108 00:07:09.865 --> 00:07:11.645 we really have to start moving away 109 00:07:12.104 --> 00:07:12.925 from just 110 00:07:13.370 --> 00:07:14.590 saying you have IBS, 111 00:07:14.970 --> 00:07:15.710 but rather 112 00:07:16.090 --> 00:07:16.909 to compartmentalize 113 00:07:17.210 --> 00:07:21.229 IBS and say, okay, but what is causing your IBS biomarkers? 114 00:07:21.770 --> 00:07:25.550 And so this is a very nice paper, up top by Mauricio Jin 115 00:07:26.044 --> 00:07:27.025 And then below, 116 00:07:27.565 --> 00:07:31.665 from UCLA, Lynn Chang's group saying, you know, we need biomarkers. 117 00:07:31.805 --> 00:07:36.625 And, of course, they mentioned CDTV and Vinculin in their abstract as you can see on the slide here. 118 00:07:36.925 --> 00:07:40.625 Up top, they mentioned Vinculin as well, CDTV and Vinculin antibodies 119 00:07:41.085 --> 00:07:41.585 also. 120 00:07:42.960 --> 00:07:46.500 And then this very nice paper from the Mayo Clinic, Michael Camilleri, John Damiano. 121 00:07:46.640 --> 00:07:50.660 Some of you may know him on social media, a very up and coming researcher 122 00:07:50.960 --> 00:07:55.700 in SIBO as well. Now going to the Cleveland Clinic, little, shout out to John. 123 00:07:56.155 --> 00:07:58.095 Congratulations on that. He'll be there. 124 00:07:58.475 --> 00:07:58.975 But, 125 00:07:59.675 --> 00:08:00.415 you know, 126 00:08:01.115 --> 00:08:03.375 talking about small intestinal microbial 127 00:08:04.395 --> 00:08:04.895 dysbiosis, 128 00:08:05.275 --> 00:08:08.095 that's what they're they wanna try and change the name to. 129 00:08:08.155 --> 00:08:13.900 I think we're gonna keep it probably SIBO, EMo, ESO, but maybe this is an umbrella term for all these syndromes. 130 00:08:14.280 --> 00:08:15.100 But, again, 131 00:08:15.800 --> 00:08:17.020 identifying these 132 00:08:17.400 --> 00:08:18.139 and then 133 00:08:18.919 --> 00:08:23.180 treating IBS based on the identify the identification of these biomarkers. 134 00:08:23.505 --> 00:08:24.725 That's where we're going. 135 00:08:26.625 --> 00:08:29.825 So I show this slide first of all, I'm very proud. 136 00:08:29.825 --> 00:08:35.445 I made this slide from AI, and it kinda looks nice. But secondly, it kinda illustrates a point. 137 00:08:35.745 --> 00:08:37.045 IBS is the manifestation 138 00:08:38.000 --> 00:08:39.940 of things that are happening in your body. 139 00:08:40.959 --> 00:08:43.839 And the question is, what is the root cause of IBS? 140 00:08:43.839 --> 00:08:48.100 And so we we're gonna talk a lot about SIBO, ESO, and emo preferentially. 141 00:08:49.200 --> 00:08:49.700 But 142 00:08:50.154 --> 00:08:55.115 what is causing SIBO, EMONISO? That's the other thing. So we we gotta get down to the true root. 143 00:08:55.115 --> 00:08:57.775 And to some extent, the Vinculin and anti CDT antibodies 144 00:08:58.235 --> 00:09:00.495 are really important in that context. 145 00:09:01.755 --> 00:09:03.135 So with that context, 146 00:09:04.589 --> 00:09:08.769 one of the things I said at, an advisory board I I attended at DDW 147 00:09:09.070 --> 00:09:13.890 was and it was a group of inflammatory bowel disease people. And here I am, the I one 148 00:09:14.350 --> 00:09:17.730 not solo, but me and one other person where the IBS 149 00:09:18.425 --> 00:09:20.285 representatives in a sea of 40 150 00:09:20.665 --> 00:09:25.725 IBD representatives. And I said, we know more about the cause of IBS than IBD, 151 00:09:26.824 --> 00:09:27.324 considering 152 00:09:27.865 --> 00:09:29.885 IBD gets a lot of resources. 153 00:09:30.660 --> 00:09:31.779 And it's because of this. 154 00:09:31.779 --> 00:09:36.839 It's because of papers like this, which show that food poisoning triggers irritable bowel syndrome. 155 00:09:37.140 --> 00:09:39.240 We don't know what triggers I Crohn's. 156 00:09:39.540 --> 00:09:45.160 You know, you're 40 year old woman, all of a sudden, healthy your whole life, now you have Crohn's disease. 157 00:09:45.745 --> 00:09:47.605 What caused that? How did that suddenly 158 00:09:48.225 --> 00:09:48.965 crop up? 159 00:09:49.665 --> 00:09:50.885 Whereas with IBS, 160 00:09:51.745 --> 00:09:58.325 in a lot of instances, I would say sixty percent of IBS d, we can say you had food poisoning and then you developed IBS. 161 00:09:58.930 --> 00:10:01.430 Some people don't remember, some people do remember, 162 00:10:01.810 --> 00:10:08.870 but the data here from these outbreaks shows that one in seven people who get food poisoning will develop IBS. 163 00:10:10.370 --> 00:10:12.230 But gets even crazier with campylobacter, 164 00:10:13.265 --> 00:10:14.965 one in five. So 165 00:10:15.425 --> 00:10:19.525 if if a hundred people at a wedding got campylobacter from the buffet, 166 00:10:21.345 --> 00:10:27.125 one in five, twenty of those people would develop IBS for an indefinite period of time. 167 00:10:27.540 --> 00:10:30.500 That's a lot. So we know more about that step. 168 00:10:30.500 --> 00:10:34.420 First event, the first event to the development of irritable bowel syndrome. 169 00:10:34.420 --> 00:10:37.320 And so we're gonna take it from there. A lot we know a lot now. 170 00:10:37.940 --> 00:10:41.640 But it leads to the antibodies to Vinculin and CDT b because 171 00:10:42.695 --> 00:10:43.355 the campylobacter, 172 00:10:43.655 --> 00:10:45.415 the salmonella, the shigella, the E. 173 00:10:45.415 --> 00:10:49.515 Coli that cause food poisoning, the classic four food poisoning bacteria, 174 00:10:50.135 --> 00:10:53.515 they have one toxin in common and that's called CDT B. 175 00:10:53.975 --> 00:10:54.475 Cytolethal 176 00:10:54.775 --> 00:10:57.995 distending toxin b, CDT B for short. 177 00:10:58.720 --> 00:10:59.540 And what CDTV 178 00:11:00.560 --> 00:11:03.540 does is it it's a it's a protein sequence, 179 00:11:04.240 --> 00:11:07.540 and part of that protein sequence looks like you, 180 00:11:08.080 --> 00:11:09.220 the protein vinculin. 181 00:11:09.680 --> 00:11:11.700 And so when you form antibodies 182 00:11:12.080 --> 00:11:12.740 to CDTV, 183 00:11:13.755 --> 00:11:14.495 you accidentally 184 00:11:14.955 --> 00:11:16.895 also form antibodies to vinculin. 185 00:11:17.035 --> 00:11:21.775 Turns out vinculin is super important for the nerves and the cells of the gut to connect. 186 00:11:22.395 --> 00:11:28.095 And therefore, you get a disconnected nerve network of the gut, and that's what leads to SIBO, we believe. 187 00:11:28.589 --> 00:11:33.310 And so it kind of works like this, CDTV toxin. You get exposed to it. You got food poisoning. 188 00:11:33.310 --> 00:11:34.529 You form these antibodies. 189 00:11:34.910 --> 00:11:36.449 One of them looks like vinculin, 190 00:11:36.829 --> 00:11:39.569 and then you get this autoimmunity 191 00:11:40.110 --> 00:11:43.410 or what we call molecular mimicry. The CDTV toxin 192 00:11:44.065 --> 00:11:45.605 mimics the sequence 193 00:11:45.985 --> 00:11:48.485 of you, the human vinculin protein. 194 00:11:50.225 --> 00:11:55.665 So over years, we, studying this, and I can't show you all the data because there's so many papers. 195 00:11:55.665 --> 00:12:00.480 It would take an hour just to show you the sequence of papers to get to this point. 196 00:12:00.860 --> 00:12:04.560 And this point right here is that if you measure these antibodies 197 00:12:05.180 --> 00:12:10.320 and use a specific threshold, but if you measure these antibodies in the blood of an IBS patient 198 00:12:10.700 --> 00:12:13.920 versus the blood of a Crohn's or ulcerative colitis patient, 199 00:12:14.255 --> 00:12:19.714 they separate. So for the first time, we're able to say you have IBS, 200 00:12:21.055 --> 00:12:25.714 not Crohn's or ulcerative colitis in the patient who comes to us in our clinic with diarrhea. 201 00:12:26.790 --> 00:12:28.090 And that's really important 202 00:12:28.470 --> 00:12:31.529 because it means that we legitimize IBS patients 203 00:12:32.070 --> 00:12:37.770 and that IBS is an organic disease. And I and I, I'll explain a little bit more on that later. 204 00:12:38.985 --> 00:12:45.645 The post test probability of having irritable bowel syndrome, if one or both of these antibodies is positive, 205 00:12:46.185 --> 00:12:49.305 meets medical certainty. Eighty percent is medical certainty. 206 00:12:49.305 --> 00:12:51.805 There is no test that meets medical certainty 207 00:12:52.990 --> 00:12:56.769 like, the IBS smart test when compared to Crohn's disease. 208 00:12:57.070 --> 00:12:59.810 If you use wrong criteria in Crohn's disease, 209 00:13:00.190 --> 00:13:05.010 sixty to eighty percent of of Crohn's patients would meet wrong criteria. 210 00:13:05.709 --> 00:13:06.769 That's not certainty. 211 00:13:07.894 --> 00:13:08.394 Now 212 00:13:08.855 --> 00:13:12.714 sensitivity is really important. So we talk about specificity of a test. 213 00:13:13.255 --> 00:13:15.995 The test has it ninety, ninety three percent. 214 00:13:16.454 --> 00:13:19.595 Specificity is 56 and people say, well, that's very low specificity. 215 00:13:20.320 --> 00:13:23.139 And the answer is no. It's not because we're this 216 00:13:23.440 --> 00:13:23.940 slide 217 00:13:24.320 --> 00:13:25.860 talks about diagnosing 218 00:13:26.639 --> 00:13:27.139 IBS, 219 00:13:28.240 --> 00:13:32.740 but only sixty percent of IBS we think comes from food poisoning. 220 00:13:33.345 --> 00:13:39.045 So the best sensitivity you can get for overall IBS is sixty, and we got fifty six. 221 00:13:39.345 --> 00:13:45.204 So when the test is positive, what I'm trying to say is it's identifying IBS with certainty 222 00:13:45.665 --> 00:13:47.524 and identifying that that IBS 223 00:13:47.940 --> 00:13:49.400 came from food poisoning 224 00:13:49.940 --> 00:13:50.760 with certainty. 225 00:13:51.300 --> 00:13:53.800 So that's the that's the real, 226 00:13:54.420 --> 00:13:55.320 gist of that. 227 00:13:56.500 --> 00:14:00.440 So then we said, well, can we make IBS occur in rats? 228 00:14:00.815 --> 00:14:05.075 And we can do this in multiple ways. But but more recent ways, we inject the CDTV 229 00:14:05.615 --> 00:14:07.394 toxin into their skin. 230 00:14:08.095 --> 00:14:11.454 And then they just get an immune reaction. So you're not putting it in the gut. 231 00:14:11.454 --> 00:14:14.790 You're not the toxin's not damaging the gut directly. 232 00:14:15.250 --> 00:14:19.910 You're forming antibodies to the CTB, which is the first panel on on the left. 233 00:14:20.850 --> 00:14:25.750 And then the rats get diarrhea. And the diarrhea is higher the more the antibodies are higher. 234 00:14:26.290 --> 00:14:26.790 So 235 00:14:27.635 --> 00:14:30.455 CDT B toxin causes IBS, 236 00:14:31.155 --> 00:14:34.215 and it does this by changing the gut microbiome. 237 00:14:34.355 --> 00:14:37.335 So and I've said this on many of my previous lectures. 238 00:14:38.035 --> 00:14:40.295 Imagine you gave a toxin in the skin, 239 00:14:41.270 --> 00:14:46.010 and it changed the microbiome of your gut. Didn't put it in the gut, put it in the skin. 240 00:14:46.390 --> 00:14:52.410 And so these antibodies are are affecting the function of the gut, and that leads to overgrowth. 241 00:14:53.030 --> 00:14:54.170 And in rats, 242 00:14:54.705 --> 00:15:01.365 they will get one of two types of overgrowth, the blue dots, which is e coli, which produces hydrogen, 243 00:15:01.985 --> 00:15:07.445 and that's part of a hydrogen breath test in humans, or the purple dots going up, and that's 244 00:15:07.820 --> 00:15:08.320 desulfovibrio 245 00:15:08.860 --> 00:15:13.360 in rats, and that's hydrogen sulfide producer. That's a hydrogen sulfide producer. 246 00:15:13.740 --> 00:15:15.040 So my point is 247 00:15:15.500 --> 00:15:20.640 we're seeing hydrogen and hydrogen sulfide in a rat model of IBS using CDTV. 248 00:15:21.335 --> 00:15:25.435 And as you'll see later, hydrogen sulfide is now becoming the most more important gas 249 00:15:25.815 --> 00:15:27.035 in breath testing. 250 00:15:28.295 --> 00:15:33.195 Now we're gonna get into some of the DDW stuff that even takes this to the next level. 251 00:15:33.335 --> 00:15:35.355 So this is anti vinculin antibodies 252 00:15:36.560 --> 00:15:39.440 and tracking them over time. This was not part of the DW. 253 00:15:39.440 --> 00:15:46.899 We we just published this recently, but it's getting a lot of attention because if we make these antibodies go down, whether it's spontaneously 254 00:15:47.200 --> 00:15:47.940 over time 255 00:15:48.475 --> 00:15:54.895 or IVIG, which is a therapy for reducing antibodies, or plasmapheresis, which is a way to filter out antibodies. 256 00:15:55.435 --> 00:16:02.655 If you make the anti vinculin antibody normal, seventy five percent of those patients now have a relief of symptoms, 257 00:16:03.910 --> 00:16:07.610 which tells us that these antibodies are causing IBS. 258 00:16:08.150 --> 00:16:10.490 And if we can get rid of them, maybe, 259 00:16:11.190 --> 00:16:13.690 we have to prove it, we can cure IBS. 260 00:16:15.430 --> 00:16:15.930 So 261 00:16:16.755 --> 00:16:21.015 we also know that these antibodies now from DDW now this is DDW. 262 00:16:21.795 --> 00:16:23.815 You say, well, in the rat study, 263 00:16:24.515 --> 00:16:25.255 the CDTV 264 00:16:25.715 --> 00:16:29.015 toxin is this and antibodies are associated with overgrowth. 265 00:16:29.620 --> 00:16:34.420 So in the reimagine study, we looked at anti CDT b, and the higher that is, the higher the E. 266 00:16:34.420 --> 00:16:35.399 Coli levels 267 00:16:36.259 --> 00:16:39.560 are in the gut. And CDT b goes along more with E. Coli. 268 00:16:40.100 --> 00:16:43.240 Vinculin, though, goes along more with klebsiella 269 00:16:43.779 --> 00:16:48.545 and E. Coli, and that they're higher when vinculin antibodies are present. 270 00:16:49.005 --> 00:16:49.985 So these antibodies 271 00:16:50.365 --> 00:16:51.105 are actually, 272 00:16:52.605 --> 00:16:53.105 predicting 273 00:16:53.644 --> 00:16:55.825 or being associated with SIBO, 274 00:16:56.445 --> 00:16:58.305 which is what we saw in the rats. 275 00:17:00.120 --> 00:17:01.820 Another interesting thing from DEW, 276 00:17:02.360 --> 00:17:02.860 because 277 00:17:03.160 --> 00:17:05.980 we talk about food poisoning being a cause of IBS. 278 00:17:06.520 --> 00:17:09.820 What about travel? You get sick when you travel. I had a diarrhea 279 00:17:10.280 --> 00:17:14.540 event when you went to Hawaii, and ever since then, you have IBS, 280 00:17:15.755 --> 00:17:18.015 stuff like that. So we looked at recent 281 00:17:18.954 --> 00:17:19.454 international 282 00:17:19.835 --> 00:17:20.335 travel, 283 00:17:20.714 --> 00:17:24.894 not asking about whether they got food poisoning, but you're saying you got recent international travel. 284 00:17:25.355 --> 00:17:28.095 Anybody with recent international travel had 285 00:17:28.669 --> 00:17:32.610 higher h two s producers and higher e coli in their gut 286 00:17:33.230 --> 00:17:33.730 and 287 00:17:34.270 --> 00:17:37.090 more often had anti vinculin antibodies. 288 00:17:38.110 --> 00:17:38.610 So 289 00:17:39.710 --> 00:17:41.789 so, obviously, some of those people went away. 290 00:17:41.789 --> 00:17:46.825 They got something, and they came back, and now they have overgrowth, and now they have these anti vinculin antibodies. 291 00:17:47.445 --> 00:17:52.265 So proving in a in a way that travel can be associated with this development. 292 00:17:54.805 --> 00:17:59.190 So I wanted to give a little bit of a a shout out to what we're doing for vinculin 293 00:17:59.490 --> 00:18:03.670 drug antibody drug development. Because if we can get the antibody out of the bloodstream, 294 00:18:04.130 --> 00:18:05.430 could we cure IBS? 295 00:18:06.610 --> 00:18:09.510 This is an extremely complicated set of slides. 296 00:18:09.555 --> 00:18:13.095 I'm not gonna dumb it down, but I will try to simplify the explanation. 297 00:18:14.435 --> 00:18:16.535 So we took 10 people, 298 00:18:16.995 --> 00:18:19.555 and you're gonna say, well, it's only ten in three patients. 299 00:18:19.555 --> 00:18:23.575 Three normal, no normal people, no IBS, and no anti vinculin, 300 00:18:24.490 --> 00:18:27.309 and ten people who have IBS who have anti vinculin. 301 00:18:28.570 --> 00:18:29.309 But we 302 00:18:29.690 --> 00:18:32.510 sequenced every single antibody to vinculin 303 00:18:32.890 --> 00:18:33.630 in these 304 00:18:34.169 --> 00:18:34.669 humans. 305 00:18:35.690 --> 00:18:37.309 So this is a very 306 00:18:38.655 --> 00:18:39.155 extensive, 307 00:18:39.855 --> 00:18:40.835 very difficult, 308 00:18:41.295 --> 00:18:42.275 very complicated 309 00:18:42.735 --> 00:18:43.635 set of, 310 00:18:44.495 --> 00:18:45.475 a set of work. 311 00:18:45.775 --> 00:18:54.929 And we're able to identify the sequences in the vinculin that are binding to the vinculin that are binding to the CDTB because they came from CDTB 312 00:18:55.710 --> 00:18:56.690 and to understand 313 00:18:57.070 --> 00:18:57.889 these proteins. 314 00:18:58.190 --> 00:19:00.610 We now know the full antibody 315 00:19:01.389 --> 00:19:02.929 amino acid sequences 316 00:19:04.184 --> 00:19:06.044 of these antibodies that cause 317 00:19:06.424 --> 00:19:08.524 IBS or are associated with IBS. 318 00:19:08.904 --> 00:19:12.684 Because of this, what we've done the last year and presented at DDW. 319 00:19:14.585 --> 00:19:17.404 As a result of this, we're able to see 320 00:19:17.865 --> 00:19:19.005 whether these antibodies 321 00:19:20.500 --> 00:19:21.559 are more competitive. 322 00:19:21.940 --> 00:19:26.340 They go in and they attack vinculin and stay on it and get everything else off. 323 00:19:26.340 --> 00:19:28.200 So those are the more aggressive ones 324 00:19:28.580 --> 00:19:32.760 or the less aggressive ones. It's because we're looking for the more aggressive ones. 325 00:19:33.220 --> 00:19:36.965 And we're able to see sort of families of these antibodies 326 00:19:37.425 --> 00:19:40.645 and identify the ones that tend to be more aggressive. 327 00:19:42.225 --> 00:19:45.925 And what we boiled it down to is a set of five antibodies 328 00:19:46.940 --> 00:19:50.640 that are probably the most sinister of the antibodies to vinculin, 329 00:19:51.179 --> 00:19:54.000 and now we're targeting these for drug development 330 00:19:54.540 --> 00:19:57.040 to try to get the antibody out of these 331 00:19:57.420 --> 00:19:59.360 specific antibodies out of the bloodstream 332 00:19:59.975 --> 00:20:04.215 and cure IBS. That's the next twelve months. So we've come a long way. 333 00:20:04.215 --> 00:20:07.355 We now know which of the antibodies are are sinister. 334 00:20:09.495 --> 00:20:09.995 So 335 00:20:10.535 --> 00:20:16.410 I'm super excited about that because that's going to be one of the one of the big moments if we can get that to work. 336 00:20:16.410 --> 00:20:18.170 But it's coming, and and it's doable. 337 00:20:20.410 --> 00:20:25.470 Takes money. That's all. We were trying to raise money to get that done. IBS Smart, 338 00:20:26.145 --> 00:20:29.365 therefore, measuring anti CDTV and anti vinculin 339 00:20:30.785 --> 00:20:31.285 is 340 00:20:31.825 --> 00:20:35.445 really the first test telling you you have IBS. 341 00:20:35.985 --> 00:20:40.000 So you're legit. You're not just it's not in your head 342 00:20:40.620 --> 00:20:44.480 telling you what caused your IBS. It's food poisoning that caused your IBS. 343 00:20:45.899 --> 00:20:52.320 The antibody appears to cause IBS because we put the CDTV toxin in the rats, so they get IBS and SIBO. 344 00:20:53.025 --> 00:20:56.005 We see the same association now with humans as of DDW. 345 00:20:57.585 --> 00:20:59.925 In my experience, it predicts a poor response. 346 00:20:59.985 --> 00:21:05.125 So what I mean is the antibodies don't predict the poor response, but if the antibodies are super high, 347 00:21:05.505 --> 00:21:08.485 those patients are the tougher are the toughest to treat. 348 00:21:09.720 --> 00:21:12.060 If a patient of mine has antibodies positive, 349 00:21:12.680 --> 00:21:14.860 I'd be very careful with them on traveling. 350 00:21:15.000 --> 00:21:20.700 I even give them prevention therapies for food poisoning because every time you get food poisoning, just like with any antibody, 351 00:21:21.075 --> 00:21:23.815 it goes higher. It goes higher. It goes higher. 352 00:21:23.875 --> 00:21:30.514 And we've seen that in our clinic on patients who travel and then get sick while traveling and then measure the antibody again, and there it is up higher. 353 00:21:30.514 --> 00:21:32.455 And now they're more difficult to treat. 354 00:21:32.835 --> 00:21:35.975 Everything we're trying to do centers around this antibody 355 00:21:36.450 --> 00:21:43.510 or these two antibodies and preventing them from going up and giving them the opportunity to slowly go down over time. 356 00:21:43.570 --> 00:21:45.990 So we we're we focus on this in clinic. 357 00:21:47.330 --> 00:21:50.175 If we can force them down, we can make this better. 358 00:21:50.335 --> 00:21:53.155 And and and that's what we're working on in the clinic. 359 00:21:54.015 --> 00:21:55.875 Okay. Now we move to breath testing 360 00:21:56.175 --> 00:21:57.875 because this has changed a lot. 361 00:21:58.655 --> 00:22:01.875 What's so amazing is that people still say, 362 00:22:02.655 --> 00:22:05.715 is breath testing important? Is breath testing accurate? 363 00:22:06.390 --> 00:22:09.850 And and and to me, it's kinda it's a little weird because 364 00:22:10.310 --> 00:22:13.130 you've got a tremendous amount of data. 365 00:22:13.190 --> 00:22:20.570 This is 25 studies that when you summarize them together, confirm that IBS patients have higher breath test positivity. 366 00:22:21.515 --> 00:22:28.175 Not only that, of these 25 patients, if you look at the bottom left corner, it says star, 15 were considered high quality studies. 367 00:22:28.235 --> 00:22:31.135 This isn't our our study. This is a study from Australia. 368 00:22:31.595 --> 00:22:34.955 These aren't our studies. Only one study there is ours. 369 00:22:34.955 --> 00:22:38.860 So you can see it half partway through the top, and they spell my name wrong. 370 00:22:39.000 --> 00:22:43.160 So clearly not our study we did because I wouldn't have spelled my own name wrong. And, 371 00:22:43.800 --> 00:22:44.860 but they 372 00:22:45.960 --> 00:22:48.395 they just summarize the the 373 00:22:48.695 --> 00:22:51.755 the data. And and sure enough, the breath test is abnormally 374 00:22:52.455 --> 00:22:53.435 in in IBS. 375 00:22:54.375 --> 00:22:58.395 Now there's a new meta analysis that just came out in March of this year. 376 00:22:58.455 --> 00:22:59.995 And, again, it says exactly 377 00:23:00.375 --> 00:23:01.355 the same thing. 378 00:23:01.655 --> 00:23:02.955 No matter if you do lactulose 379 00:23:03.470 --> 00:23:04.290 or glucose, 380 00:23:04.750 --> 00:23:06.350 you're gonna see that, 381 00:23:08.350 --> 00:23:11.810 it's positive. It's more often positive in IBS versus healthy. 382 00:23:12.750 --> 00:23:17.090 They do a really cute thing on the right side. It's called the leave one out analysis. 383 00:23:17.950 --> 00:23:18.450 So 384 00:23:18.875 --> 00:23:19.375 it, 385 00:23:19.835 --> 00:23:23.515 you know, you omit one study, repeat the analysis, omit another study, repeat. 386 00:23:23.515 --> 00:23:30.095 It it tests the strength of the data, and doing the leave one out analysis makes the data even stronger. 387 00:23:30.475 --> 00:23:34.960 So it suggests that no matter what you do to this data, it's right. 388 00:23:36.300 --> 00:23:40.240 And then there are people who still think the breath test is measuring transit. 389 00:23:41.500 --> 00:23:48.480 So, of course, everything slowly gets through the gut or over time gets through the gastrointestinal tract and eventually gets to the colon. 390 00:23:48.695 --> 00:23:52.934 If the lactulose gets to the colon, you're gonna get some hydrogen produced. 391 00:23:52.934 --> 00:23:56.054 And so they're saying, well, that's where the hydrogen comes from. 392 00:23:56.054 --> 00:23:57.995 I'm gonna show you data that's not true. 393 00:23:58.054 --> 00:24:01.355 I'm also showing you this paper where they measured transit. 394 00:24:02.110 --> 00:24:05.789 It's not true. And by eighty minutes, it's not in the colon. 395 00:24:05.789 --> 00:24:11.169 And if it's a twenty part per million rise, those are the patients that respond to antibiotic therapy. 396 00:24:11.789 --> 00:24:16.605 This was I I encourage you to read this paper because this paper really finally puts a pin in it. 397 00:24:16.605 --> 00:24:19.085 They did it right. They did the transit studies right. 398 00:24:19.085 --> 00:24:25.985 They gave antibiotics to everybody even if they were positive or negative on breath test, and only those that are positive on breath test responded. 399 00:24:26.445 --> 00:24:30.625 So a very brilliantly done study proving the point that it's not transit. 400 00:24:32.070 --> 00:24:33.289 Even culture studies 401 00:24:33.830 --> 00:24:34.330 show 402 00:24:34.870 --> 00:24:36.570 the the orange is IBS, 403 00:24:37.110 --> 00:24:39.450 the gray is not IBS, and 404 00:24:39.750 --> 00:24:42.409 more people are positive on culture for SIBO. 405 00:24:42.950 --> 00:24:47.049 The study on the right really hammers home that sixty percent number. 406 00:24:47.524 --> 00:24:51.945 So we think sixty percent of IBS came from food poisoning, sixty percent of IBS 407 00:24:52.404 --> 00:24:58.664 because it comes from food poisoning, probably is SIBO, and this shows sixty percent of IBS d is SIBO. 408 00:25:00.650 --> 00:25:03.309 This is what I was saying about it's not transit. 409 00:25:04.250 --> 00:25:09.230 So going back to that comment again, but I'll get to to the point I'm trying to make on that. 410 00:25:09.690 --> 00:25:11.870 The breath test using lactulose, 411 00:25:12.730 --> 00:25:13.870 just using hydrogen, 412 00:25:14.745 --> 00:25:15.485 just measuring 413 00:25:16.025 --> 00:25:17.565 SIBO by culture, 414 00:25:18.105 --> 00:25:19.145 it's 84% 415 00:25:19.145 --> 00:25:19.645 specific 416 00:25:20.025 --> 00:25:22.925 using the 20 part per million by 90 with lactulose. 417 00:25:24.025 --> 00:25:27.645 And then we measure the bugs that produce hydrogen and, of course, they correlate. 418 00:25:28.265 --> 00:25:28.765 But 419 00:25:29.320 --> 00:25:31.500 the last column gets sometimes 420 00:25:31.800 --> 00:25:32.780 glossed over. 421 00:25:33.560 --> 00:25:34.620 But we can actually 422 00:25:34.920 --> 00:25:36.380 through sequencing assess 423 00:25:37.480 --> 00:25:39.340 the production capacity 424 00:25:39.720 --> 00:25:40.380 of hydrogen 425 00:25:41.475 --> 00:25:47.174 by hydrogen enzymes that are found in that mixture in the small bowel. And they correlated, 426 00:25:47.715 --> 00:25:48.215 meaning 427 00:25:48.515 --> 00:25:50.535 small bowel hydrogen enzymes 428 00:25:51.875 --> 00:25:55.975 are proportionally higher to the amount of hydrogen on the breath test. 429 00:25:56.059 --> 00:25:59.280 So this isn't coming from the colon. It's coming from the small intestine. 430 00:25:59.660 --> 00:26:01.840 And, you know, let's put this to bed now. 431 00:26:04.540 --> 00:26:07.040 This study was the first study in history 432 00:26:07.419 --> 00:26:07.919 doing 433 00:26:08.220 --> 00:26:09.440 shotgun sequencing 434 00:26:10.245 --> 00:26:11.945 of the human small intestine, 435 00:26:12.405 --> 00:26:13.705 and in this case, particularly, 436 00:26:14.085 --> 00:26:15.945 small intestinal bacterial overgrowth. 437 00:26:17.045 --> 00:26:21.945 So everybody up until this point was doing sixteen s sequencing, 438 00:26:23.010 --> 00:26:26.790 which tells you about the ribosomal RNA sequence of a bacteria. 439 00:26:27.810 --> 00:26:30.150 But now we're sequencing the genome, 440 00:26:30.610 --> 00:26:36.070 so we're able to get down to the strain level of bacteria present in the small intestine. 441 00:26:37.330 --> 00:26:37.830 And, 442 00:26:38.535 --> 00:26:42.395 again, as I've said in previous lectures, this is not something new at DDW. 443 00:26:42.615 --> 00:26:45.035 We've we published this in 2024. 444 00:26:45.815 --> 00:26:51.275 SIBO really is two characters, klebsiella in humans, klebsiella and E. Coli. That's it. 445 00:26:51.720 --> 00:26:53.340 If you put these two together, 446 00:26:53.640 --> 00:26:55.320 that's 46%. 447 00:26:55.320 --> 00:26:56.299 So if you imagine 448 00:26:57.080 --> 00:26:58.700 your small bowel contains 449 00:26:59.160 --> 00:27:00.620 a thousand different species. 450 00:27:01.240 --> 00:27:03.100 Now I'm telling you, you have SIBO, 451 00:27:03.400 --> 00:27:04.919 and 46% 452 00:27:04.919 --> 00:27:06.780 of everything in that sample 453 00:27:07.105 --> 00:27:08.404 is e coli and klebsiella. 454 00:27:09.105 --> 00:27:13.764 That's a lot. So it's they're basically taking over, and they're so aggressive 455 00:27:14.384 --> 00:27:19.365 that they squash everything else out and destroy the rest of the microbiome by being there. 456 00:27:20.850 --> 00:27:22.470 And they're super fermenters. 457 00:27:22.850 --> 00:27:26.790 So they can ferment glucose 63 times faster 458 00:27:27.250 --> 00:27:28.710 than if you didn't have SIBO. 459 00:27:29.010 --> 00:27:32.470 So those patients who say that they blow ten minutes after eating, 460 00:27:33.245 --> 00:27:37.165 SIBO is just so aggressive in that in that way, and they produce hydrogen. 461 00:27:37.165 --> 00:27:40.305 We also saw hydrogen sulfide elevated in that analysis. 462 00:27:42.365 --> 00:27:45.985 Because of all this data that's emerging, 2018, 463 00:27:46.045 --> 00:27:46.785 we decided 464 00:27:47.560 --> 00:27:50.060 with a group of from all across North America 465 00:27:51.240 --> 00:27:55.320 to say, look. We have to have standardized ways of interpreting breath test. 466 00:27:55.320 --> 00:27:57.660 There's too many different this and that, analyses. 467 00:27:58.280 --> 00:28:03.135 You can do what you want, but you gotta do the standard way and then prove that the other your way is better. 468 00:28:03.455 --> 00:28:08.975 And the standard way has held the test of time because now we have the European guidelines in 2021, 469 00:28:08.975 --> 00:28:14.755 2022, the Asia Pacific, including Australia as part of this. Those guidelines came out. Brazil 470 00:28:15.055 --> 00:28:15.795 came out. 471 00:28:16.170 --> 00:28:20.890 Argentina just came out a couple of months ago, and they all say basically the same thing. 472 00:28:20.890 --> 00:28:22.990 They agree on the criteria for SIBO. 473 00:28:23.370 --> 00:28:24.750 They agree on the substrates, 474 00:28:25.290 --> 00:28:31.435 and they mostly agree that SIBO and IBS are interrelated, which is fantastic, which is what we're talking about today. 475 00:28:32.775 --> 00:28:39.335 Here's where things are evolving, and that is that there are three gases that are produced in the gut. 476 00:28:39.335 --> 00:28:40.955 And traditional breath testing 477 00:28:41.940 --> 00:28:43.559 initially only measured hydrogen, 478 00:28:43.860 --> 00:28:45.399 then hydrogen and methane, 479 00:28:45.779 --> 00:28:47.080 and now there's hydrogen 480 00:28:47.460 --> 00:28:47.960 sulfide. 481 00:28:48.659 --> 00:28:55.240 And why is hydrogen sulfide important? Because hydrogen never core when it's up, you have diarrhea. 482 00:28:55.654 --> 00:29:01.595 Hydrogen I mean. But it's not proportional. So your hydrogen could be a 100 or 50 both abnormal 483 00:29:02.054 --> 00:29:03.755 at 20 at ninety minutes. 484 00:29:03.894 --> 00:29:09.115 They're both greater than 20 but the patient with a 100 is not sicker than the patient with 50. 485 00:29:09.790 --> 00:29:14.690 Because the hydrogen gas is being used to make methane or hydrogen sulfide in a person. 486 00:29:14.750 --> 00:29:16.130 It's the hydrogen sulfide, 487 00:29:16.830 --> 00:29:21.010 that level, that determines diarrhea, pain, and urgency, 488 00:29:21.310 --> 00:29:23.570 and other and other symptoms. And methane 489 00:29:24.135 --> 00:29:25.195 determines constipation 490 00:29:25.575 --> 00:29:28.555 because the more methane you have, the more constipated you are. 491 00:29:30.295 --> 00:29:36.955 So now we have three gases, and so we've given them names. SIBO is the traditional hydrogen only. 492 00:29:37.630 --> 00:29:39.809 IMO is intestinal methanogen 493 00:29:40.110 --> 00:29:43.570 overgrowth, but it's not just in the small intestine, but also the colon, 494 00:29:43.870 --> 00:29:45.890 which is why it's not small intestinal. 495 00:29:46.669 --> 00:29:52.905 And it's not small intestinal sulfide overproduction because it also can occur in the small intestine and the colon or both. 496 00:29:53.385 --> 00:29:54.125 And so 497 00:29:54.425 --> 00:29:59.165 we have these new terminologies. But when you have three, you can have a combination 498 00:29:59.545 --> 00:30:02.045 like you see on the right in the Venn diagram, 499 00:30:02.505 --> 00:30:05.305 which can complicate how you treat patients. 500 00:30:05.305 --> 00:30:08.285 And so it's important to know all three to know how to do it. 501 00:30:09.440 --> 00:30:14.340 So TRiO smart breath testing is the only breath test that actually can, 502 00:30:15.040 --> 00:30:16.420 measure all three gases. 503 00:30:17.360 --> 00:30:17.860 And 504 00:30:18.160 --> 00:30:20.895 it's been completely validated as you'll see. 505 00:30:20.975 --> 00:30:27.795 And it it's validated for home testing or in office testing if you want to have the patient do it in front of a technologist. 506 00:30:28.575 --> 00:30:31.555 And it holds all three gases for up to ten days. 507 00:30:32.655 --> 00:30:33.155 And 508 00:30:34.120 --> 00:30:39.820 I'll show you in a moment, we validated it against sequencing from the human small intestine. 509 00:30:40.520 --> 00:30:45.580 No breath test. And I mean no breath test in history has done breath samples 510 00:30:47.605 --> 00:30:51.465 and shotgun sequencing of the small bowel to prove that the breath 511 00:30:52.165 --> 00:30:54.825 findings with that instrument, with that technology 512 00:30:55.125 --> 00:30:55.625 matches 513 00:30:56.085 --> 00:30:57.945 what's going on in the small intestine. 514 00:30:58.325 --> 00:31:00.825 And then I'll show you the 6,000 patient study 515 00:31:01.290 --> 00:31:03.550 and other things that we've presented at DDW. 516 00:31:03.850 --> 00:31:07.070 But this is the most validated breath test in history, 517 00:31:07.610 --> 00:31:08.350 the TrioSmart, 518 00:31:08.810 --> 00:31:13.610 because it's validated against the actual bugs, and it's proportional to the bugs. 519 00:31:13.610 --> 00:31:14.670 So I'll show you that. 520 00:31:15.965 --> 00:31:20.865 This is one of the first studies we did showing that hydrogen and methane are proportional 521 00:31:21.165 --> 00:31:25.805 to the bugs in the gut. This is an IBS study. So an IBS d study, IBS c study. 522 00:31:25.805 --> 00:31:30.145 Everybody had a breath test. We didn't pick them for SIBO or EMO or any of that stuff. 523 00:31:30.260 --> 00:31:32.120 They just were IBS patients. 524 00:31:32.580 --> 00:31:35.000 And if you're methane, you're constipated. 525 00:31:35.460 --> 00:31:39.700 But IBS d patients, almost none. You can see that down here, the blue line. 526 00:31:39.700 --> 00:31:42.360 Almost none of them had methane. 527 00:31:42.900 --> 00:31:47.925 But about sixty percent of constipated patients had methane, and that's the red line. 528 00:31:49.105 --> 00:31:52.625 Hydrogen, on the other hand, was really only seen in the d patients. 529 00:31:52.625 --> 00:31:57.505 And this is the breath test, what it looked like. Ninety with a rise of twenty is a positive test. 530 00:31:57.505 --> 00:32:00.809 And this is the average of all the patients in this study. 531 00:32:01.110 --> 00:32:04.809 And you can see it's elevated on average, which means they had SIBO. 532 00:32:05.909 --> 00:32:12.250 Hydrogen sulfide was measured for the first time in this kind of a study, and hydrogen sulfide was associated with diarrhea. 533 00:32:14.515 --> 00:32:16.695 But this is really important, and and 534 00:32:16.995 --> 00:32:19.095 I sometimes I present this very 535 00:32:19.395 --> 00:32:21.575 quickly and just move on. But I think 536 00:32:21.875 --> 00:32:22.615 more recently, 537 00:32:22.915 --> 00:32:24.455 I've been getting some questions 538 00:32:24.755 --> 00:32:27.655 about accuracy and sensitivity and specificity 539 00:32:28.035 --> 00:32:30.390 and those sorts of things for these gases. 540 00:32:31.170 --> 00:32:31.670 But 541 00:32:32.050 --> 00:32:34.230 you have the gas on the breath 542 00:32:34.690 --> 00:32:38.310 and it correlates with high p look at the p values here. 543 00:32:39.170 --> 00:32:42.310 With the actual level of m smithii 544 00:32:42.690 --> 00:32:46.575 in the gut. K. So there's sensitivity and specificity, 545 00:32:46.875 --> 00:32:52.975 which is you're trying to diagnose a disease. Do you have lupus or not? It's a 2 x 2 table. 546 00:32:53.595 --> 00:32:59.135 But then when you're talking about breath testing, you're talking about it goes beyond sensitivity and specificity. 547 00:32:59.674 --> 00:33:01.250 It goes to accuracy. 548 00:33:01.630 --> 00:33:02.130 So 549 00:33:02.670 --> 00:33:08.370 is the breath test telling you how many of these characters m smithy are in the gut? 550 00:33:08.430 --> 00:33:12.930 The answer is yes. It's proportional. This is a good correlation coefficient 551 00:33:13.405 --> 00:33:15.025 and a very strong p value. 552 00:33:15.405 --> 00:33:20.385 So the levels on the breath tell you how many of these bugs are in the intestine. 553 00:33:20.925 --> 00:33:21.425 Accuracy. 554 00:33:23.245 --> 00:33:25.585 The same is true for the small bowel. 555 00:33:26.470 --> 00:33:28.890 We did breath methane right now, 556 00:33:29.190 --> 00:33:33.850 took them right into the GI lab, scoped the patient, took juice, and measured methanogens 557 00:33:34.870 --> 00:33:35.370 accuracy. 558 00:33:35.750 --> 00:33:38.250 The methane on the breath correlated with methanogens 559 00:33:38.710 --> 00:33:40.655 in in the gut and particularly 560 00:33:41.035 --> 00:33:41.935 with methanobrevibacter 561 00:33:42.715 --> 00:33:44.655 smithii. This paper is now published. 562 00:33:46.155 --> 00:33:48.655 Methane slows the gut down. So methane 563 00:33:48.955 --> 00:33:50.655 is the agent, the biological 564 00:33:50.955 --> 00:33:52.015 agent that's causing 565 00:33:53.730 --> 00:33:57.510 infuse in 2,006 methane into the intestinal tract, it gets slowing of transit 566 00:33:58.290 --> 00:34:02.070 in all the animals. And it doesn't do it by paralyzing the gut. 567 00:34:02.130 --> 00:34:05.670 It does it by causing the gut to squeeze and tighten 568 00:34:06.205 --> 00:34:09.985 to prevent things from moving, and that's panel b on the right side. 569 00:34:11.085 --> 00:34:12.925 Okay. So now there's meta analysis. 570 00:34:12.925 --> 00:34:16.945 This is kinda getting old because there's a lot of studies since here since this study. 571 00:34:17.005 --> 00:34:21.505 But when you have methane, you have constipation, and you have less diarrhea. 572 00:34:22.359 --> 00:34:27.739 More methane is the left panel, less diarrhea is the right panel, which is basically two sides of the same coin. 573 00:34:28.760 --> 00:34:33.739 Beautiful study by Talamentis from Stanford. If you did a smart pill or a wireless, 574 00:34:34.679 --> 00:34:36.139 capsule measuring transit, 575 00:34:36.520 --> 00:34:37.339 if you're methane, 576 00:34:37.655 --> 00:34:42.635 your gut's moving slower and sort of goes along with all the things we've been saying. 577 00:34:43.734 --> 00:34:46.234 We also did the same thing for hydrogen sulfide. 578 00:34:47.335 --> 00:34:48.395 Measure the breath. 579 00:34:48.695 --> 00:34:50.795 Measure the hydrogen sulfide in the breath. 580 00:34:51.680 --> 00:34:55.780 Immediately take the person, the patient to the GI lab, scope them, get the juice, 581 00:34:56.240 --> 00:34:56.980 and compare. 582 00:34:57.520 --> 00:34:58.900 And there's a correlation 583 00:34:59.200 --> 00:35:01.460 between the bugs that produce hydrogen sulfide 584 00:35:02.240 --> 00:35:03.940 and the breath. So accuracy. 585 00:35:04.240 --> 00:35:13.005 It's accurately telling you about the microbiome and where the microbiome is sitting with reference to the bugs that produce the gas that you're measuring. 586 00:35:14.425 --> 00:35:20.765 So now I'm gonna talk to you a little bit about the 6,000 breath test study because this this is really important because 587 00:35:21.460 --> 00:35:24.200 it's one of the biggest studies ever done in breath testing. 588 00:35:25.060 --> 00:35:26.360 These are breath tests 589 00:35:26.660 --> 00:35:27.940 using the Trio Smart system. 590 00:35:27.940 --> 00:35:32.280 These are breath tests done at home by people just sitting in their living room. 591 00:35:33.220 --> 00:35:34.440 Some of them did glucose. 592 00:35:35.085 --> 00:35:36.385 Some of them did lactulose. 593 00:35:37.005 --> 00:35:42.224 And to show, does it work? Meaning, are we getting the same kind of signals 594 00:35:42.765 --> 00:35:47.744 as we would get if we had the patient sitting in our office doing a breath test like old school? 595 00:35:48.560 --> 00:35:50.820 First of all, I'll tell you that if you do glucose 596 00:35:51.680 --> 00:35:56.020 or lactulose, it doesn't matter for methane, and it doesn't matter much 597 00:35:56.320 --> 00:36:00.015 for hydrogen sulfide because they're either there or they're not there. 598 00:36:00.575 --> 00:36:04.434 But for hydrogen, you miss a lot of people by doing glucose. 599 00:36:04.894 --> 00:36:08.755 And you're gonna say, well, are you missing people, or are you over calling 600 00:36:10.015 --> 00:36:11.474 SIBO by doing lactulose? 601 00:36:12.400 --> 00:36:16.980 And the way I rationalize this is the people in the study, we show this data, 602 00:36:17.440 --> 00:36:20.180 the people in this 6,000 breath test study 603 00:36:20.560 --> 00:36:22.660 who did a breath test using glucose 604 00:36:23.360 --> 00:36:25.300 but were negative on glucose 605 00:36:25.920 --> 00:36:27.140 had more diarrhea 606 00:36:28.525 --> 00:36:30.145 than the people who 607 00:36:30.445 --> 00:36:32.145 were negative on lactulose. 608 00:36:33.325 --> 00:36:34.925 Why do I why is that important? 609 00:36:34.925 --> 00:36:41.185 It means that the lactulose is picking up more of the sick people and categorizing them as SIBO. 610 00:36:41.530 --> 00:36:43.290 Glucose is missing people. 611 00:36:43.290 --> 00:36:48.190 But we've known this because glucose breath testing is about twenty five percent of IBS patients. 612 00:36:48.490 --> 00:36:51.070 And rifaximin works in forty four percent. 613 00:36:51.450 --> 00:36:52.830 So clearly, we're missing, 614 00:36:53.290 --> 00:36:56.750 you know, nineteen percent just based on that basis alone. 615 00:36:57.165 --> 00:37:01.265 So we know glucose misses people who could benefit from treatment. 616 00:37:01.965 --> 00:37:04.865 Again, the argument I'm making is I like lactulose. 617 00:37:06.125 --> 00:37:08.065 But in this real world study, 618 00:37:09.005 --> 00:37:11.425 all these patients out there doing it at home, 619 00:37:12.650 --> 00:37:17.790 You have severe diarrhea, you have more hydrogen sulfide. If you have severe constipation, 620 00:37:18.090 --> 00:37:19.230 you have more methane. 621 00:37:19.690 --> 00:37:21.690 This radar plot puts it all together. 622 00:37:21.690 --> 00:37:28.445 So this is complicated because now we're talking about SIBO, SIBO and Eso, Eso and emo, and all these different 623 00:37:29.385 --> 00:37:33.245 things. But what we found here is that elevated hydrogen sulfide 624 00:37:34.025 --> 00:37:37.565 is a very strong signal for producing diarrhea 625 00:37:38.025 --> 00:37:40.205 even if you have EMO. 626 00:37:41.190 --> 00:37:43.930 So hydrogen sulfide I used to say emo wins. 627 00:37:44.869 --> 00:37:49.530 According to the 6,000 breath test study, which is the gold standard now, it's the biggest study, 628 00:37:50.310 --> 00:37:53.210 hydrogen sulfide wins. If it's present, if it's elevated, 629 00:37:53.590 --> 00:37:55.930 you have diarrhea even if you have methane. 630 00:37:57.245 --> 00:38:01.905 So hydrogen sulfide really is associated with urgency. You can see here, urgency, 631 00:38:02.605 --> 00:38:03.105 diarrhea, 632 00:38:04.125 --> 00:38:04.625 pain, 633 00:38:05.085 --> 00:38:08.945 and the overall severity of the person's illness, whereas 634 00:38:09.565 --> 00:38:11.105 the blue is emo 635 00:38:11.550 --> 00:38:12.290 is constipation. 636 00:38:13.230 --> 00:38:14.450 So hydrogen sulfide 637 00:38:14.750 --> 00:38:21.250 turns out maybe the most important of all three gases because it dictates the severity of everything, 638 00:38:22.270 --> 00:38:23.250 except constipation. 639 00:38:25.935 --> 00:38:33.235 This is a very interesting study, and and we're working on the paper to fully publish this, but we presented it at DDW so I can share it with you now. 640 00:38:33.535 --> 00:38:34.835 We took the breath 641 00:38:35.615 --> 00:38:37.475 hydrogen sulfide or methane, 642 00:38:38.700 --> 00:38:42.880 took them to the GI lab right away, scoped them, and sucked the gas 643 00:38:43.580 --> 00:38:44.320 in the duodenum 644 00:38:45.020 --> 00:38:46.400 and tested that. 645 00:38:47.339 --> 00:38:47.839 And 646 00:38:48.300 --> 00:38:51.520 if you have hydrant hydrogen sulfide on the breath 647 00:38:51.885 --> 00:38:55.665 correlates with the hydrogen sulfide in the gas of the duodenum 648 00:38:56.125 --> 00:38:58.545 and the same was true for methane. So 649 00:38:59.405 --> 00:39:02.065 the point I'm trying to make is we are measuring 650 00:39:02.365 --> 00:39:07.025 in our breath in these breath tests the gases that are produced in the duodenum. 651 00:39:10.260 --> 00:39:10.760 This 652 00:39:11.860 --> 00:39:17.540 is now accepted for publication, so I'm gonna have to change the slide as of two or three days ago. 653 00:39:17.540 --> 00:39:20.840 So I didn't have chance to change this, but it was presented at DDW 654 00:39:21.140 --> 00:39:21.880 last year. 655 00:39:22.725 --> 00:39:23.865 Hydrogen sulfide 656 00:39:24.485 --> 00:39:27.145 does more things bad to your intestine 657 00:39:27.525 --> 00:39:30.265 than any of the other gases when it's present. 658 00:39:30.725 --> 00:39:33.145 So these bugs that produce hydrogen sulfide 659 00:39:33.525 --> 00:39:34.745 cause visceral hyperalgesia 660 00:39:35.205 --> 00:39:36.745 signals to go up, serotonin 661 00:39:37.125 --> 00:39:37.785 to change, 662 00:39:38.220 --> 00:39:38.720 aquaporins 663 00:39:39.020 --> 00:39:46.560 to change, which are what drives the wateriness to the diarrhea, and your defensins go up because you're trying to get rid of these characters 664 00:39:47.340 --> 00:39:48.640 and your mitochondria 665 00:39:49.100 --> 00:39:50.800 in the gut are dysfunctional. 666 00:39:51.895 --> 00:39:55.435 If the hydrogen sulfide is high enough, the cells of the intestine 667 00:39:55.815 --> 00:39:56.875 literally die. 668 00:39:57.895 --> 00:39:58.395 Pharaohptosis 669 00:39:58.855 --> 00:40:01.995 happens. Phptosis means the cell is contracting and dying. 670 00:40:02.615 --> 00:40:03.355 And so 671 00:40:04.080 --> 00:40:07.860 this h two s thing is is quite a big deal. 672 00:40:09.200 --> 00:40:15.860 And so what we did was we looked at the human pathways that we found in the intestinal lining using transcriptomics 673 00:40:16.875 --> 00:40:22.975 and then compared it to animals that we gave them. We gave them these hydrogen sulfide producers. 674 00:40:23.355 --> 00:40:28.655 And the animals pathways that were augmented were the same similar pathways as the humans. 675 00:40:28.920 --> 00:40:30.440 So we know these are the bugs. 676 00:40:30.440 --> 00:40:34.700 We know those are the ones that make hydrogen sulfide, and we know they're causing this. 677 00:40:35.960 --> 00:40:37.020 So IBS 678 00:40:38.200 --> 00:40:39.099 is a microbial 679 00:40:39.400 --> 00:40:39.900 disease 680 00:40:40.200 --> 00:40:41.980 in about sixty percent of cases. 681 00:40:42.765 --> 00:40:46.224 We now have three categories. We have intestinal sulfide overproduction. 682 00:40:46.525 --> 00:40:48.684 These are the bugs that do that. We have, 683 00:40:49.244 --> 00:40:52.285 traditional SIBO, e coli, klebsiella. We talked about that. 684 00:40:52.285 --> 00:40:54.464 And then we have intestinal methanogen overgrowth 685 00:40:54.765 --> 00:40:55.585 with the methanogens 686 00:40:55.885 --> 00:40:57.744 in both the small bowel and the colon. 687 00:40:58.204 --> 00:41:01.630 So it gives us an opportunity to try and think about treatments. 688 00:41:02.250 --> 00:41:03.230 But we have 689 00:41:03.849 --> 00:41:05.150 new data from DDW, 690 00:41:05.450 --> 00:41:06.990 and I wanna take you through 691 00:41:07.369 --> 00:41:09.390 what what I'm trying to get at here. 692 00:41:10.329 --> 00:41:10.829 Everything 693 00:41:11.130 --> 00:41:11.869 all the 694 00:41:12.420 --> 00:41:12.920 literally 695 00:41:14.345 --> 00:41:17.325 hundreds of thousands. I think it's 212,000 696 00:41:17.464 --> 00:41:19.484 papers on the human microbiome. 697 00:41:20.184 --> 00:41:22.924 The majority of them look at what's called relative 698 00:41:23.224 --> 00:41:23.724 abundance. 699 00:41:24.105 --> 00:41:29.484 So if you look at the slide on the right, there's bees and beetles and and butterflies to try and give you context. 700 00:41:30.320 --> 00:41:31.300 And so 701 00:41:32.080 --> 00:41:38.340 if you have a sample from the small bowel and there are three bees, let's say the bees are e coli. 702 00:41:38.480 --> 00:41:40.260 There are three bees on the left, 703 00:41:40.560 --> 00:41:42.480 and they make up 25% 704 00:41:42.480 --> 00:41:47.245 of the bacteria there. How much can three bees do? How much can they really do? 705 00:41:47.245 --> 00:41:48.785 It's only three bees. Right? 706 00:41:49.565 --> 00:41:52.945 Or five. I think it's five is the actual number. So 25%. 707 00:41:54.205 --> 00:41:59.585 But if you look at the panel on the right it's still 25% 708 00:42:00.180 --> 00:42:01.400 but it's fifty bees. 709 00:42:01.859 --> 00:42:06.760 50 bees can produce a lot more chemicals that can make you messed up than five bees. 710 00:42:07.060 --> 00:42:08.920 And so absolute abundance 711 00:42:09.460 --> 00:42:11.240 is so much more important 712 00:42:11.619 --> 00:42:12.920 than relative abundance. 713 00:42:13.455 --> 00:42:14.595 And one of our geniuses, 714 00:42:15.055 --> 00:42:19.475 genius PhDs here and another genius PhD collaborating together 715 00:42:19.855 --> 00:42:23.395 have gotten a a way to take the samples and calculate 716 00:42:24.495 --> 00:42:25.715 through, an algorithm 717 00:42:26.095 --> 00:42:27.235 absolute abundance. 718 00:42:27.810 --> 00:42:30.870 And this is a new advancement in in sequencing. 719 00:42:33.410 --> 00:42:36.230 I'll talk a little bit about what that means in a moment. 720 00:42:36.290 --> 00:42:38.630 But these are some of the more transcriptomic 721 00:42:39.010 --> 00:42:44.935 things that we're seeing in the duodenal microbiome of people with with SIBO, and we're seeing hydrogen pathways go up. 722 00:42:45.395 --> 00:42:47.975 This is the first human proteomics 723 00:42:48.755 --> 00:42:52.195 study of SIBO. Okay. Now we're getting into really advanced stuff. 724 00:42:52.195 --> 00:42:57.335 So we basically take the juice from the small intestine of a SIBO patient and a non SIBO patient. 725 00:42:58.040 --> 00:43:00.780 And we look at the stuff you're doing 726 00:43:01.720 --> 00:43:04.859 because SIBO is there. The stuff you're doing. 727 00:43:05.240 --> 00:43:07.080 You are and so it's proteome. 728 00:43:07.080 --> 00:43:11.740 So we're do we're putting this in a mass spec and doing the calculating all the proteins, characterizing 729 00:43:13.694 --> 00:43:17.075 shoved into the juice of the small intestine because you have SIBO. 730 00:43:17.694 --> 00:43:21.714 Your neutrophils are up. Your defensins are up. You're fighting these guys. 731 00:43:22.255 --> 00:43:23.234 And your immunoglobulins, 732 00:43:24.095 --> 00:43:27.645 you're sending out antibodies to get rid of all this e coli and klebsiella. 733 00:43:28.230 --> 00:43:29.210 You're fighting 734 00:43:29.670 --> 00:43:30.490 all the time. 735 00:43:30.950 --> 00:43:32.890 And this is the first demonstration 736 00:43:33.270 --> 00:43:34.890 of that using proteomics 737 00:43:35.270 --> 00:43:35.770 ever. 738 00:43:38.070 --> 00:43:40.250 And then what we did was we looked at, 739 00:43:41.295 --> 00:43:42.035 we cultured 740 00:43:42.494 --> 00:43:46.435 these patients, and we were able to look at seven seven patients 741 00:43:46.895 --> 00:43:49.555 who had varying degrees of SIBO. 742 00:43:50.335 --> 00:43:56.650 And we wanted to see, like, who were the actual E. Coli? Like, what strain are we talking about? 743 00:43:56.650 --> 00:43:58.829 So we took the culture results. 744 00:43:59.450 --> 00:44:02.430 We swab all the E. Coli from those plates, 745 00:44:02.809 --> 00:44:04.109 and then we sequenced 746 00:44:04.490 --> 00:44:05.789 the culture results 747 00:44:06.425 --> 00:44:07.805 to the deepest degree. 748 00:44:08.265 --> 00:44:08.765 And 749 00:44:09.224 --> 00:44:11.805 almost everybody has either e coli and klebsiella. 750 00:44:12.025 --> 00:44:15.484 We sort of know that, but then we map them genetically. 751 00:44:16.665 --> 00:44:22.205 And it turns out that the e coli in SIBO is a little different than almost 752 00:44:23.200 --> 00:44:25.540 any e coli we we can map, 753 00:44:25.840 --> 00:44:27.060 but it is a variation 754 00:44:27.600 --> 00:44:28.660 on k 12. 755 00:44:29.280 --> 00:44:33.440 So it maps very strongly, 98, 99% 756 00:44:33.440 --> 00:44:34.500 to k 12, 757 00:44:34.880 --> 00:44:36.260 but it has additional 758 00:44:38.315 --> 00:44:38.815 pathogenic 759 00:44:39.355 --> 00:44:41.535 traits that makes it more aggressive. 760 00:44:42.075 --> 00:44:46.395 So k 12 is a bad one to begin with, and then you add aggressive genes to it. 761 00:44:46.395 --> 00:44:48.815 So we're able to now determine that, 762 00:44:49.355 --> 00:44:52.174 and maybe that's why it hangs on so tightly. 763 00:44:52.980 --> 00:44:53.640 The klebsiella 764 00:44:53.940 --> 00:44:55.640 is close to klebsiella pneumonia, 765 00:44:56.740 --> 00:44:59.320 without too many of these sort of advancements. 766 00:44:59.700 --> 00:45:04.280 So it's pretty much straightforward klebsiella or at least to a greater or lesser degree. 767 00:45:04.660 --> 00:45:07.080 So this is just getting us down to 768 00:45:07.555 --> 00:45:10.915 what's going on. What is this exact e coli that we're talking about? 769 00:45:10.915 --> 00:45:12.835 Can we make better antibiotics for it? 770 00:45:12.835 --> 00:45:17.255 Can you know, to think about the future if other treatments fail for us. 771 00:45:18.755 --> 00:45:21.590 And then we did some other things to try and look. Siebel increases with age. 772 00:45:21.590 --> 00:45:23.910 As you get older, there's another DDW abstract. 773 00:45:23.910 --> 00:45:29.530 You have more Siebel, more Siebel, more Siebel, more e coli, more e coli, more e coli, more klebsiella, 774 00:45:29.830 --> 00:45:31.370 more klebsiella, more klebsiella 775 00:45:31.670 --> 00:45:32.970 as you get older and older. 776 00:45:33.505 --> 00:45:36.885 And, again, it's been known for fifty years or forty years that 777 00:45:37.345 --> 00:45:38.805 older people can get SIBO. 778 00:45:40.224 --> 00:45:41.365 Same thing with methanogens, 779 00:45:41.825 --> 00:45:46.244 higher with older age. We characterized all the methanogens in the gut, 780 00:45:46.690 --> 00:45:49.830 in the small intestine for the first time. And methanabrhebibacter 781 00:45:50.850 --> 00:45:54.390 is really the predominant methanogen, one of the more predominant 782 00:45:54.850 --> 00:45:58.150 methanogens, which we sort of knew, but it it's good to do this again. 783 00:45:59.405 --> 00:46:01.105 Then we looked at type two diabetes. 784 00:46:01.405 --> 00:46:08.145 So if you have if you don't have a diabetes and you have SIBO, it's different than if type two diabetes 785 00:46:08.445 --> 00:46:09.105 and SIBO. 786 00:46:09.565 --> 00:46:10.385 And so, 787 00:46:11.005 --> 00:46:16.660 like, if you have no type two diabetes, no SIBO, the diversity of your microbiome is here. 788 00:46:16.660 --> 00:46:18.200 If you have type two diabetes 789 00:46:19.140 --> 00:46:24.920 starting to go down, SIBO makes your diversity go down. But if they're both there, it's the lowest. 790 00:46:25.620 --> 00:46:31.535 But we're gonna focus in on that. I wanna go to this slide really because what we found was 791 00:46:32.075 --> 00:46:33.215 if you have 792 00:46:33.915 --> 00:46:35.215 type two diabetes 793 00:46:35.675 --> 00:46:38.175 and SIBO, you have the highest biomass 794 00:46:38.795 --> 00:46:39.695 of E. Coli. 795 00:46:40.955 --> 00:46:41.275 But 796 00:46:42.099 --> 00:46:43.320 so type two diabetes 797 00:46:43.700 --> 00:46:45.000 make SIBO worse 798 00:46:45.540 --> 00:46:46.040 or 799 00:46:47.060 --> 00:46:49.800 could SIBO make type two diabetes worse? 800 00:46:49.940 --> 00:46:57.079 And what we found was that the blood sugar of people with type two diabetes who had SIBO was higher. 801 00:46:57.855 --> 00:46:59.715 And some of the bugs that were 802 00:47:00.175 --> 00:47:04.435 correlating with higher blood sugar included the hydrogen sulfide producers. 803 00:47:05.055 --> 00:47:06.835 So there is a link between 804 00:47:07.615 --> 00:47:09.075 the severity of diabetes 805 00:47:09.650 --> 00:47:15.910 and some of the bacteria we're finding in SIBO and that SIBO and bacterial and and and diabetes go together. 806 00:47:16.130 --> 00:47:21.190 Maybe all that sugar around because of the diabetes is allowing these bacteria to grow more, 807 00:47:22.050 --> 00:47:23.270 or flourish more. 808 00:47:23.685 --> 00:47:26.505 But either way, we're we're dissecting that now. 809 00:47:27.525 --> 00:47:31.045 In methane, we we've dissected this in a in a lot of ways. 810 00:47:31.045 --> 00:47:34.905 We know a lot of things about methane on the far right. It's associated with obesity. 811 00:47:35.685 --> 00:47:36.185 Interestingly, 812 00:47:36.990 --> 00:47:40.450 methane is associated with obesity. There are papers that show that. 813 00:47:40.510 --> 00:47:44.750 And anorexia, there are papers that show that. And so you're saying, well, how can that be? 814 00:47:44.750 --> 00:47:45.650 How can you have 815 00:47:45.950 --> 00:47:46.450 both 816 00:47:46.990 --> 00:47:51.630 from methane? Methane slows the gut down. So you would imagine you could absorb more food. 817 00:47:51.630 --> 00:47:53.605 That's one thought for obesity. 818 00:47:54.785 --> 00:47:58.865 But if you're not eating food, maybe methanogens are good. 819 00:47:58.865 --> 00:48:02.625 Maybe they're trying to get you to absorb more food. They're slowing your gut down. 820 00:48:02.625 --> 00:48:05.605 Give more chance. Get more calories. Save your life. 821 00:48:06.039 --> 00:48:09.720 It's a very interesting thing with methanogens. So we studied this. 822 00:48:09.720 --> 00:48:12.140 We looked at people in the reimagine study 823 00:48:12.680 --> 00:48:16.059 who are healthy weight, and we looked at the level of the methanobrevibacter 824 00:48:16.920 --> 00:48:17.420 bacteria 825 00:48:18.305 --> 00:48:18.965 by absolute 826 00:48:19.665 --> 00:48:22.485 abundance. That's so important. I've mentioned that earlier. 827 00:48:23.105 --> 00:48:26.725 So if you're heavy or if you're healthy or overweight, this is methanogens. 828 00:48:27.265 --> 00:48:29.365 But if you're underweight or obese, 829 00:48:30.080 --> 00:48:34.180 this is the level. So it's a u shape. So it is happening 830 00:48:34.480 --> 00:48:39.060 that if you're underweight, the methanogens are going up. Are they trying to help you? 831 00:48:39.360 --> 00:48:41.780 We don't know. But if you overeat 832 00:48:42.795 --> 00:48:50.494 the types of food, the fatty foods, we think feed the methanogens and bring them up and then slow your gut down and then make you gain more weight, 833 00:48:50.795 --> 00:48:54.415 meaning you get more calories from smaller meals than a regular person. 834 00:48:55.880 --> 00:49:00.060 And then we did the same for breath methane. It was the same u shaped type phenomenon 835 00:49:00.760 --> 00:49:06.700 with the breath methane as you would expect because we know that methane gas in the breath correlates with the bugs in the gut. 836 00:49:07.665 --> 00:49:09.685 And then we looked at the TriNetX 837 00:49:09.985 --> 00:49:13.365 data because we were seeing in our reimagine study that 838 00:49:13.905 --> 00:49:16.725 rheumatoid arthritis patients also have a lot of SIBO. 839 00:49:17.265 --> 00:49:21.120 And over time, people with RA have more and more SIBO over time. 840 00:49:21.280 --> 00:49:25.140 And so SIBO and rheumatoid arthritis are now connected as well. 841 00:49:25.920 --> 00:49:27.300 Now let's jump to treatments. 842 00:49:27.680 --> 00:49:28.820 We treat Rifaximin 843 00:49:29.120 --> 00:49:29.920 or SIBO 844 00:49:30.320 --> 00:49:33.460 IBS with Rifaximin. It's FDA approved for IBS. 845 00:49:33.855 --> 00:49:38.355 On the premise that IBS is a microbiome disease, this was approved in 2015, 846 00:49:38.415 --> 00:49:41.075 but now we know so much more. And we know that 847 00:49:41.935 --> 00:49:46.435 if you have a positive breath test, you're much more likely to respond to Rifaximin. 848 00:49:46.655 --> 00:49:53.500 And if the breath test becomes negative, those are the patients who do the best if the Rifaximin makes the breath test negative. 849 00:49:54.120 --> 00:49:58.860 Now there's a meta analysis on Rifaximin for SIBO showing Rifaximin works for SIBO. 850 00:49:59.160 --> 00:49:59.660 And 851 00:49:59.960 --> 00:50:07.555 if you have IBS, if you do a breath test, it's a good predictor of who's gonna respond to this FDA approved drug for IBS. 852 00:50:09.215 --> 00:50:11.155 This is the newest meta analysis 853 00:50:11.455 --> 00:50:12.115 of rifaximin 854 00:50:12.494 --> 00:50:15.955 in IBS and basically in IBS with SIBO. 855 00:50:16.470 --> 00:50:16.970 So, 856 00:50:17.590 --> 00:50:25.609 again, telling you that if you have SIBO, if you have a breath test and you have IBS, it's gonna give you a a leg up that you're going to respond 857 00:50:25.910 --> 00:50:26.650 to Mirafaxmin. 858 00:50:27.830 --> 00:50:28.650 For methane, 859 00:50:29.109 --> 00:50:32.635 you know, I I I heard a comment just a couple of days ago. 860 00:50:32.935 --> 00:50:36.315 Oh, there's no studies on giving rifaximin and neomycin 861 00:50:36.615 --> 00:50:39.755 for methane. Well, there's a double blind study, this one. 862 00:50:39.974 --> 00:50:43.275 And then somebody says, well, neomycin can cause autotoxicity. 863 00:50:44.535 --> 00:50:46.260 Well, I've never seen it. 864 00:50:47.220 --> 00:50:47.720 Gentamicin 865 00:50:48.100 --> 00:50:49.000 can cause autotoxicity. 866 00:50:49.380 --> 00:50:53.560 Neomycin is related to gentamicin, but we don't give neomycin intravenously. 867 00:50:54.660 --> 00:50:55.160 So, 868 00:50:56.340 --> 00:50:58.440 and it's the intravenous venous glycosides 869 00:50:59.380 --> 00:51:00.440 that do that. 870 00:51:00.820 --> 00:51:01.320 So, 871 00:51:01.855 --> 00:51:03.215 anyway, it's it's, 872 00:51:03.535 --> 00:51:05.635 I hear comments, and then I just 873 00:51:06.015 --> 00:51:07.475 bring them out at these talks. 874 00:51:08.175 --> 00:51:12.595 But for hydrogen sulfide, this is where we need work. We know bismuth 875 00:51:12.975 --> 00:51:16.755 reduces these h two s producers from a study from 1998, 876 00:51:17.150 --> 00:51:17.650 And 877 00:51:18.110 --> 00:51:21.950 we're working on another product that I think could get rid of the h two s. 878 00:51:21.950 --> 00:51:23.330 I'll show you that in a moment. 879 00:51:23.710 --> 00:51:25.070 The other thing is elemental diet. 880 00:51:25.070 --> 00:51:30.590 We presented some more data on elemental diet, this meeting showing that it reduces methanogens in the gut. 881 00:51:30.590 --> 00:51:31.250 It reduces 882 00:51:31.895 --> 00:51:32.775 some of the, 883 00:51:33.095 --> 00:51:36.315 bacteria in the gut that are important to SIBO as well. 884 00:51:36.694 --> 00:51:40.474 But what you can see here is 30 patients before 885 00:51:41.015 --> 00:51:48.020 red line and after elemental diet, and this elemental diet is the palatal full elemental diet called ambiota. 886 00:51:48.559 --> 00:51:50.799 And now it's below threshold. 887 00:51:50.799 --> 00:51:57.839 So it got rid of the SIBO, and it made the IMO go away by the definition of 10 part per million for IMO. 888 00:51:57.839 --> 00:51:59.859 Now it's less than 10 after treatment. 889 00:52:00.305 --> 00:52:03.045 And the symptoms improved as you can see on this side. 890 00:52:04.545 --> 00:52:08.725 What we do after treating SIBO is we these the vinculin antibodies, 891 00:52:09.105 --> 00:52:13.170 we believe damage the nerves of the gut. So the gut doesn't have good cleaning waves. 892 00:52:13.410 --> 00:52:14.710 If you give a prokinetic 893 00:52:15.089 --> 00:52:16.869 after you get rid of the overgrowth, 894 00:52:17.809 --> 00:52:19.430 you can prolong the remission 895 00:52:20.210 --> 00:52:23.990 as compared to giving nothing. And tigasiride is a serotonin 896 00:52:24.290 --> 00:52:24.790 agonist 897 00:52:25.170 --> 00:52:26.390 similar to Motegriti 898 00:52:26.690 --> 00:52:27.430 or prucalopride. 899 00:52:28.455 --> 00:52:32.795 And so we don't have to gas route available anymore, but I use prucalopride 900 00:52:33.095 --> 00:52:33.755 or Motegriti. 901 00:52:35.975 --> 00:52:38.635 We're spending a lot of time on this drug, 902 00:52:39.015 --> 00:52:44.880 CSO six. So CSO six is a drug that binds to the MTD gene 903 00:52:45.580 --> 00:52:47.440 and blocks methane production 904 00:52:47.820 --> 00:52:48.880 in the methanogen 905 00:52:49.420 --> 00:52:50.080 m smithii. 906 00:52:51.100 --> 00:52:58.415 And I can't some things I can't tell you, some data I just got this morning, which would knock your socks off, I can't tell you, 907 00:52:58.955 --> 00:53:01.295 but I'm pretty excited about what I saw this morning. 908 00:53:03.435 --> 00:53:03.935 And 909 00:53:04.315 --> 00:53:07.135 but this study, which we presented at last year's DUW, 910 00:53:07.835 --> 00:53:10.655 if you give this drug to rats that have methane, 911 00:53:11.390 --> 00:53:18.690 their water content of their stool goes up, meaning they're less constipated, and the methane in their gut goes down, which is the signal on the right. 912 00:53:18.830 --> 00:53:22.050 Super excited about this. We hope to be in clinical trials 913 00:53:22.350 --> 00:53:23.170 next year. 914 00:53:24.545 --> 00:53:26.625 We are in clinical trials here. 915 00:53:26.625 --> 00:53:32.725 So one of the things that we know for rifaximin, I showed it earlier, forty four percent of people respond to rifaximin. 916 00:53:32.945 --> 00:53:33.925 Forty four percent. 917 00:53:34.785 --> 00:53:37.185 That's not good enough for me. I want I want higher. 918 00:53:37.185 --> 00:53:41.520 And part of the reason we don't get higher is because half of the half of the E. 919 00:53:41.520 --> 00:53:45.620 Coli and klebsiella in the gut are living in that mucus thick mucus. 920 00:53:46.320 --> 00:53:48.980 So we developed something to combine 921 00:53:49.440 --> 00:53:49.940 rifaximin 922 00:53:50.480 --> 00:53:52.660 with NAC in a particular way, 923 00:53:53.234 --> 00:53:55.575 and we did a study. This is rifaximin. 924 00:53:55.875 --> 00:54:00.454 You're giving plain rifaximin to patients. This is a randomized controlled trial pilot study, 925 00:54:00.994 --> 00:54:04.375 proof of concept study. Sorry. And, yeah, things are getting better. 926 00:54:04.434 --> 00:54:10.350 But if you put NAC with the with a smaller dose of rifaximin even, you're getting even better response. 927 00:54:11.450 --> 00:54:14.350 So right now, we're in the middle. We're doing it now, 928 00:54:14.970 --> 00:54:16.590 randomized controlled trial, 929 00:54:17.050 --> 00:54:17.790 two centers 930 00:54:18.250 --> 00:54:19.630 where we're giving rifaximin 931 00:54:20.090 --> 00:54:21.390 with the NAC in that 932 00:54:21.765 --> 00:54:22.265 special 933 00:54:22.805 --> 00:54:23.305 way. 934 00:54:24.005 --> 00:54:26.484 And two thirds of people get rifaximin and NAC. 935 00:54:26.484 --> 00:54:29.305 So that's a good thing in this trial, and one third gets placebo. 936 00:54:31.045 --> 00:54:35.145 So to sum up, you know, we now have three types of overgrowth. We have intestinal 937 00:54:35.490 --> 00:54:36.470 sulfide overproduction. 938 00:54:37.010 --> 00:54:38.290 We have SIBO, and we have, 939 00:54:38.850 --> 00:54:40.710 intestinal methanogenic overgrowth. 940 00:54:41.010 --> 00:54:41.990 For the sulfide, 941 00:54:42.369 --> 00:54:47.030 I personally this is what I do. As you can see in the title, I get rifaximin and Pepto Bismol. 942 00:54:47.170 --> 00:54:52.305 And I just had a patient this morning. She's doing great after the Rifaximin and Pepto 943 00:54:53.005 --> 00:54:57.265 or the elemental. The elemental can be used for any of the types of overgrowth. 944 00:54:57.645 --> 00:55:00.785 Rifaximin for SIBO and Rifaximin and neomycin 945 00:55:01.245 --> 00:55:02.785 for methanogen overgrowth. 946 00:55:03.420 --> 00:55:04.640 But we're developing 947 00:55:05.020 --> 00:55:13.359 this new drug for intestinal sulfide overproduction, which is the rifaximin plus NAC because h two s goes down with that drug 948 00:55:13.660 --> 00:55:14.720 and for SIBO. 949 00:55:15.305 --> 00:55:16.045 And then, 950 00:55:16.505 --> 00:55:19.965 for intestinal methanogen overgrowth, we have the CSO six drug. 951 00:55:21.465 --> 00:55:27.325 If you're interested in the study and you live in the LA area, I know there were a few people who live in the LA area, 952 00:55:27.950 --> 00:55:31.410 and you've had a colonoscopy in the last three years and you have the diarrhea type, 953 00:55:32.990 --> 00:55:36.210 click on our, just scan the QR code, and, 954 00:55:36.670 --> 00:55:39.809 we'd love to talk to you about the trial. And we're we're 955 00:55:40.109 --> 00:55:44.615 trying to recruit now so you can get this, new and emerging therapy. 956 00:55:44.675 --> 00:55:46.595 So I'll just pause there for a second. 957 00:55:46.595 --> 00:55:51.895 But it's really it's really important to do clinical trials so that we can get this stuff to patients. 958 00:55:54.320 --> 00:55:56.580 So in conclusion, IBS is a disease 959 00:55:56.880 --> 00:55:57.780 and autoimmunity. 960 00:55:58.080 --> 00:56:02.420 Those antibodies are what starts the whole thing. The IBS smart test diagnosis 961 00:56:03.040 --> 00:56:03.540 IBS 962 00:56:04.720 --> 00:56:09.300 from food poisoning and is a marker for the development of SIBO and 963 00:56:11.145 --> 00:56:14.685 and these elevations in e coli and klebsiella that we showed at DDW. 964 00:56:15.385 --> 00:56:18.765 TrioSmart is the most validated breath test in history. Hands down. 965 00:56:19.145 --> 00:56:23.085 Like, nobody's done sequencing of the small bowel with breath testing until this. 966 00:56:23.349 --> 00:56:27.030 H two s may be the most important gas in how it affects you. 967 00:56:27.030 --> 00:56:31.450 Hydrogen and methane don't affect your gut like h two s, not as profoundly. 968 00:56:32.310 --> 00:56:33.690 New therapies are coming. 969 00:56:35.375 --> 00:56:37.214 It's being found more commonly now. 970 00:56:37.214 --> 00:56:42.815 People are looking finally, and SIBO has a dramatic effect on the host, which we talked about with h two s. 971 00:56:42.815 --> 00:56:47.055 Well, I'm gonna stop there. I was given an hour. I finished two minutes early, Shavonn. 972 00:56:47.055 --> 00:56:50.275 Gonna be proud of you. I'm so proud of you. Flight on time. 973 00:56:50.750 --> 00:56:51.490 Thank you 974 00:56:51.950 --> 00:56:55.490 so much. Thank you so much. Alright. That was fantastic. 975 00:56:55.790 --> 00:57:02.130 Fantastic. Let's put some love into the chat and the icons there for doctor Pimentel. 976 00:57:02.765 --> 00:57:07.105 Take a sip of water and a break. Big breath, doctor Pimentel. That was amazing. Congratulations. 977 00:57:08.125 --> 00:57:10.205 Sincerely and just huge, huge 978 00:57:10.925 --> 00:57:20.000 Like I always say, if I could only tell you the newest stuff, you'd be so excited because every year, it's getting it's getting more and more interesting, but, also, 979 00:57:20.300 --> 00:57:24.480 we're getting so close to the finale, which is what I'm thrilled about. 980 00:57:24.780 --> 00:57:28.675 Are you still sharing your screen? Because I just see a black screen. Yeah. Yes. Oh, yes. I am. 981 00:57:28.675 --> 00:57:30.694 So I'm gonna stop that nonsense. Okay. 982 00:57:30.994 --> 00:57:34.035 Alright. Everyone take a big breath because that was a lot. 983 00:57:34.035 --> 00:57:37.255 I wanna help you reset your central nervous system right now and 984 00:57:38.115 --> 00:57:43.840 wow. That was a Data dump. Data dump. But, but it's important, you you know, to understand the role. 985 00:57:43.980 --> 00:57:45.120 Totally exciting. 986 00:57:45.500 --> 00:57:52.640 Also, everyone, you will be receiving the replay, so you can just watch it, and there will be transcription there for you. 987 00:57:52.780 --> 00:57:53.280 And 988 00:57:54.865 --> 00:57:56.785 so that's gonna be really nice. You can share this. 989 00:57:56.785 --> 00:58:01.605 It's gonna be on Cboe Info's YouTube channel and the Cboe SOS YouTube channel. 990 00:58:02.225 --> 00:58:03.025 Get it out there. 991 00:58:03.025 --> 00:58:11.260 Like, follow, subscribe because the more the algorithm picks up that people are interested in this, the more people organically receive this information, And we will send you an email 992 00:58:11.560 --> 00:58:12.460 tonight. Okay. 993 00:58:13.320 --> 00:58:15.560 Doctor Seabecker, I wanna ask you to go for it. 994 00:58:15.560 --> 00:58:18.040 You have some questions, and then we have a lot of questions. 995 00:58:18.040 --> 00:58:21.420 I've been trying to answer them, the ones that I absolutely know are 996 00:58:21.960 --> 00:58:24.940 answerable by me, because we will not get to everybody's, 997 00:58:25.240 --> 00:58:27.665 but hang in there. Okay. Go ahead, Doctor. Seabecker. 998 00:58:27.665 --> 00:58:33.345 And also put your questions in the Q and A box. In the Q and A box, not the chat. Thank you so much. 999 00:58:33.345 --> 00:58:33.845 Yes. 1000 00:58:34.465 --> 00:58:34.965 Okay. 1001 00:58:35.265 --> 00:58:35.505 Yeah. 1002 00:58:35.505 --> 00:58:43.010 Well, you know, Mark, the first thing I wanted to ask is when you were talking about funding, I saw some people were saying in the chat they'd like to donate. 1003 00:58:43.230 --> 00:58:44.690 Is there a way to donate? 1004 00:58:46.030 --> 00:58:47.230 Yeah. If you go to, 1005 00:58:48.030 --> 00:58:50.450 thank you for that. I mean, I I'm not soliciting, 1006 00:58:50.910 --> 00:58:53.654 but csmast.com. 1007 00:58:53.795 --> 00:58:55.954 Csmast.com. 1008 00:58:55.954 --> 00:59:00.775 It's a check. Website. And and, yeah. There it is. And, basically, 1009 00:59:01.634 --> 00:59:07.335 there's a it's kinda hard to get to, unfortunately, but if you get there, you can donate, and it does come 1010 00:59:07.960 --> 00:59:12.620 all to us. It doesn't go to, like, some central pot. You know? So, 1011 00:59:13.240 --> 00:59:18.680 anything helps, and and it's making making a huge difference. It's the only way. You know? 1012 00:59:18.680 --> 00:59:20.600 People helping people. That's what we're doing. 1013 00:59:20.600 --> 00:59:24.125 We're dedicating our whole life to this, so we're super excited. 1014 00:59:24.905 --> 00:59:35.485 Before you get started, I do wanna let you know that I have put a coupon code that we have for Gemelli Labs for the IBS Smart Test for anyone who's interested as well as for Trio Smart Test. 1015 00:59:35.690 --> 00:59:40.670 And then I also have a coupon there for you for the Elemental Diet at $50 off. That is, 1016 00:59:41.050 --> 00:59:45.550 a limited time. But I'm popping that into the chat. Also, there are, 1017 00:59:46.090 --> 00:59:47.390 doctor Allison Seabecker's 1018 00:59:48.025 --> 00:59:53.885 full script dispensary with over fifteen, twenty thousand professional grade products, including some extended NAC. 1019 00:59:53.945 --> 00:59:57.065 If you wanted to check that out and try it, that's also gonna be in the chat. Okay. 1020 00:59:57.065 --> 00:59:58.605 Doctor Seabecker, take it away. 1021 01:00:00.980 --> 01:00:01.859 Okay. So, 1022 01:00:02.420 --> 01:00:05.000 I had seen that you did a study 1023 01:00:05.380 --> 01:00:08.200 where you were looking at the levels of hydrogen sulfide, 1024 01:00:09.140 --> 01:00:11.319 and and what correlated best with symptoms. 1025 01:00:11.940 --> 01:00:13.079 And you were finding 1026 01:00:13.380 --> 01:00:14.440 1.5 1027 01:00:14.645 --> 01:00:20.025 parts per million. And so I was wondering, are you now changing your positive level 1028 01:00:20.405 --> 01:00:23.224 to 1.5 of where you'll start treating people? 1029 01:00:24.165 --> 01:00:24.665 So 1030 01:00:25.685 --> 01:00:26.185 it's 1031 01:00:26.565 --> 01:00:30.500 it's just like this question of sensitivity and specificity. 1032 01:00:30.640 --> 01:00:36.340 I'm kind of jumping the gun, but it it everything is on a continuum. And so it makes 1033 01:00:37.120 --> 01:00:39.380 the discussion about sensitivity and specificity 1034 01:00:39.680 --> 01:00:41.380 challenging when it comes to the microbiome. 1035 01:00:42.000 --> 01:00:42.500 But 1036 01:00:42.984 --> 01:00:46.685 we need hydrogen sulfide. The human body makes hydrogen sulfide, 1037 01:00:47.145 --> 01:00:50.685 and there's a system called redox where it controls the, 1038 01:00:51.305 --> 01:00:53.964 reductive and oxidative stresses in your cells. 1039 01:00:54.265 --> 01:00:58.525 And those systems wanna keep a balance. Like, everything in your body has to be in a in a balance. 1040 01:00:58.730 --> 01:01:01.549 And hydrogen sulfide produced by your cells 1041 01:01:02.170 --> 01:01:05.869 in your own redox system and to a little bit of an extent, 1042 01:01:06.250 --> 01:01:11.230 the microbes of the gut giving you a little hydrogen sulfide to give you that boost is a good thing. 1043 01:01:11.595 --> 01:01:14.255 So we see actually, and I don't show this, 1044 01:01:14.555 --> 01:01:16.895 but at less than 1.5, 1045 01:01:17.275 --> 01:01:22.335 the bugs are producing hydrogen sulfide. They're at low levels, and it's helping your cells. 1046 01:01:22.715 --> 01:01:26.510 You are actually benefiting from the hydrogen sulfide. So we don't wanna wipe these guys out. 1047 01:01:26.510 --> 01:01:28.210 We just wanna reduce them. K? 1048 01:01:29.230 --> 01:01:31.630 But as it goes above 1.5, 1049 01:01:31.630 --> 01:01:34.130 we start to see the deleterious 1050 01:01:34.670 --> 01:01:35.170 signal. 1051 01:01:35.869 --> 01:01:38.835 But when we get over two, that's when we see the symptoms. 1052 01:01:39.155 --> 01:01:44.214 We see the changes in the cells between one point five and two point zero. 1053 01:01:44.355 --> 01:01:49.494 But when we're over two point zero, at least in the in the study that we did with the 6,000 patients, 1054 01:01:49.795 --> 01:01:52.935 that's when we start to see the symptom repercussions. 1055 01:01:53.155 --> 01:01:56.650 Because maybe your your cells are not happy, but they're compensating. 1056 01:01:57.829 --> 01:01:58.329 So 1057 01:01:58.630 --> 01:01:59.210 I think 1058 01:01:59.670 --> 01:02:06.890 two point zero is what I use in clinic now until I have data that more strongly says 1.5 is better. 1059 01:02:07.645 --> 01:02:10.865 Oh, that's very helpful. Thank you. Yeah. You know, on that, 1060 01:02:11.325 --> 01:02:12.145 same vein, 1061 01:02:12.845 --> 01:02:16.705 talking about how the sulfide producers are beneficial at some point, 1062 01:02:17.245 --> 01:02:20.145 what about the methanogens? You had done also a study, 1063 01:02:20.445 --> 01:02:24.760 you know, checking out how many methanogens there are in the small intestine, finding 1064 01:02:25.060 --> 01:02:28.200 a lot of different types and different amounts. Is it normal, 1065 01:02:29.060 --> 01:02:31.240 for everybody to have methanogens 1066 01:02:31.619 --> 01:02:32.760 in the small intestine? 1067 01:02:34.260 --> 01:02:37.940 Yeah. So it's the same question as as sort of like C. Diff. C. 1068 01:02:37.940 --> 01:02:42.075 Diff is present in so so many people, just in a tiny amount. Is that okay? 1069 01:02:42.315 --> 01:02:44.495 I think it is, and, you know, people are healthy. 1070 01:02:45.115 --> 01:02:45.935 But methanogens 1071 01:02:46.235 --> 01:02:48.175 are more important because methanogens 1072 01:02:48.635 --> 01:02:49.135 do 1073 01:02:49.595 --> 01:02:51.275 control the microbial population. 1074 01:02:51.275 --> 01:02:54.415 Let me give you an example that we don't talk about in this talk at all. 1075 01:02:54.930 --> 01:02:58.310 Patients with Crohn's and ulcerative colitis don't have much methanogens. 1076 01:02:59.010 --> 01:03:03.190 And methanogens slow your gut down, and they have some anti inflammatory 1077 01:03:03.569 --> 01:03:04.069 properties. 1078 01:03:05.890 --> 01:03:10.825 So when I see a Crohn's patient in remission and they have methanogens, I don't get rid of the methanogens. 1079 01:03:11.365 --> 01:03:14.505 Even if they're constipated, I don't try to get them down 1080 01:03:14.805 --> 01:03:18.105 because I worry that the I think the methanogens are protective. 1081 01:03:18.405 --> 01:03:25.090 If it's of course, if they're too high, they get constipated, maybe you can zhuzh them or or scooch them down a little bit to relieve the constipation. 1082 01:03:25.310 --> 01:03:26.530 But methanogens 1083 01:03:26.830 --> 01:03:27.730 are important. 1084 01:03:28.590 --> 01:03:33.250 And it's like your mom said, too much of a good thing is not a good thing. So too much methanogens, 1085 01:03:33.550 --> 01:03:34.050 bad. 1086 01:03:34.430 --> 01:03:35.490 Too little methanogens, 1087 01:03:36.190 --> 01:03:36.690 bad. 1088 01:03:37.950 --> 01:03:40.055 And just the right sweet spot, 1089 01:03:40.595 --> 01:03:41.974 is is what you want. 1090 01:03:42.355 --> 01:03:45.315 What is that sweet spot? We need time to figure that out. 1091 01:03:45.315 --> 01:03:49.815 What exact what is the exact perfect amount of methanogens to keep you in balance? 1092 01:03:49.954 --> 01:03:52.295 And methanogens are what we call conveners. 1093 01:03:53.049 --> 01:03:58.190 So we see this when every time we see methanogens, we see higher microbial diversity. 1094 01:03:58.410 --> 01:04:00.029 For those of you who know about microbiome, 1095 01:04:00.490 --> 01:04:01.230 more diversity, 1096 01:04:01.769 --> 01:04:02.269 healthier. 1097 01:04:03.130 --> 01:04:05.789 I don't buy that whole story because methanogens, 1098 01:04:06.365 --> 01:04:09.744 when they're too high, you got tons of diversity, but you're constipated like crazy. 1099 01:04:10.605 --> 01:04:11.825 So that's not necessarily 1100 01:04:12.365 --> 01:04:13.265 feeling good. 1101 01:04:13.724 --> 01:04:14.224 But, 1102 01:04:15.964 --> 01:04:18.385 we've shown that Prevotella is a convener. 1103 01:04:18.650 --> 01:04:25.930 We've shown that methanogens are conveners because they they allow more bugs, more diversity, but isn't always a good thing. 1104 01:04:25.930 --> 01:04:27.230 That's what I'm trying to say. 1105 01:04:28.650 --> 01:04:29.150 Mhmm. 1106 01:04:30.010 --> 01:04:33.230 Okay. So you had done all these amazing studies recently 1107 01:04:33.770 --> 01:04:34.510 on CDTV 1108 01:04:35.105 --> 01:04:35.924 B and Vinculin. 1109 01:04:36.865 --> 01:04:41.984 And I was listening to a presentation you gave just recently where you talked about something so fascinating. 1110 01:04:41.984 --> 01:04:46.005 I was wondering if you could explain it here. You were talking about finding, 1111 01:04:47.380 --> 01:04:48.680 E coli having 1112 01:04:49.060 --> 01:04:50.280 CDT B toxin 1113 01:04:50.820 --> 01:04:51.480 in it. 1114 01:04:52.099 --> 01:04:53.960 And that that might be fueling, 1115 01:04:54.420 --> 01:04:55.480 the immune system's 1116 01:04:55.940 --> 01:04:57.000 continued reaction 1117 01:04:57.300 --> 01:04:58.520 to increase the antibodies 1118 01:04:58.820 --> 01:05:02.200 for CDT B and that may be keeping some people sick. 1119 01:05:02.580 --> 01:05:08.335 That's just amazing. Can you explain how the E. Coli bacteria contains the CD2B toxin? 1120 01:05:09.675 --> 01:05:10.395 Yeah. So, 1121 01:05:11.035 --> 01:05:15.195 so the analysis we did was not specifically looking for E. Coli. 1122 01:05:15.195 --> 01:05:22.309 We had already kinda lysed the cells, but we were looking for the presence of the talks and or the gene that produces the toxin, I should say. 1123 01:05:22.770 --> 01:05:29.109 And and we find it in people and we find it in some patients with a high CDT antibody. 1124 01:05:29.890 --> 01:05:32.869 So then could it be that you had the food poisoning, 1125 01:05:33.805 --> 01:05:43.265 you know, ten years ago, and everybody has some E coli in the gut, but the E coli that produced the CDTV that was the food poisoning has now colonized you? 1126 01:05:43.485 --> 01:05:46.625 Sort of like typhoid Mary. I don't know if you know typhoid Mary, but 1127 01:05:47.085 --> 01:05:47.665 she got 1128 01:05:48.090 --> 01:05:54.030 typhoid, and then she carried the salmonella typhi and then spread it to this person, this person, this person, and carried it forever. 1129 01:05:54.090 --> 01:05:57.630 And they couldn't ever get rid of it from her, and so she was basically a spreader. 1130 01:05:57.850 --> 01:06:00.750 And so we know some people in the population are spreaders. 1131 01:06:00.810 --> 01:06:03.635 They, once they're infected, they have a little bit of colonization. 1132 01:06:04.175 --> 01:06:08.515 And we saw that. And and so I don't know if that's perpetuating 1133 01:06:08.815 --> 01:06:10.355 IBS. I would imagine, yes. 1134 01:06:11.055 --> 01:06:19.369 But it opens up a little bit of a Pandora's box that some people are spreaders or chronic colonizers after the initial infection. 1135 01:06:20.869 --> 01:06:25.270 It's very interesting. You are you gonna be looking more into that? I would imagine. Oh, for sure. 1136 01:06:25.270 --> 01:06:27.930 Yes. It's a it's a very intriguing thing, but, 1137 01:06:29.270 --> 01:06:31.609 gonna be complicated research, but we'll we'll continue. 1138 01:06:32.214 --> 01:06:36.295 Yeah. Okay. Now, also, thank you so much for the update on CSO six. 1139 01:06:36.295 --> 01:06:40.474 I was I was waiting with beta breath to hear right we're at with that. So that was 1140 01:06:41.175 --> 01:06:46.474 really amazing. This this fabulous new, you know, molecule drug for methane. 1141 01:06:47.020 --> 01:06:47.760 I was 1142 01:06:48.140 --> 01:06:53.760 wondering, is is that a type of a statin, you know, similar to the treatments you had studied previously? 1143 01:06:54.460 --> 01:06:54.960 It's 1144 01:06:56.140 --> 01:06:56.640 we've 1145 01:06:56.940 --> 01:06:57.440 rejigged, 1146 01:06:59.365 --> 01:07:03.205 it it may have derived from a statin idea. The statin was 1147 01:07:03.605 --> 01:07:06.185 Sorry. Oh, the statin was the initial idea, 1148 01:07:06.485 --> 01:07:11.305 and we derived that the statin attacks this enzyme and derived a molecule 1149 01:07:11.925 --> 01:07:13.945 that is very different than statin, 1150 01:07:14.380 --> 01:07:16.000 So very uniquely different. 1151 01:07:17.020 --> 01:07:20.400 And next year, you'll be in trials, you think. That's just amazing. 1152 01:07:21.260 --> 01:07:23.660 Fingers crossed. Yeah. Fingers crossed. Fingers crossed. Yeah. 1153 01:07:23.660 --> 01:07:26.160 The sooner we can all get ahold of that, the better. 1154 01:07:26.845 --> 01:07:30.605 Yeah. Going as fast as I can, everybody always says, you said next year. You said next year. 1155 01:07:30.605 --> 01:07:32.685 You said next year, and then it next year comes in. 1156 01:07:32.685 --> 01:07:35.585 We're still dragging because some some bureaucratic, 1157 01:07:36.605 --> 01:07:41.369 you know, delay. So We know it's never on your end. You guys are just zooming. Well, no. 1158 01:07:41.369 --> 01:07:44.569 Sometimes it is our end, so I'm not gonna be totally innocent. 1159 01:07:44.569 --> 01:07:46.650 It's just it's just, you know, resources. Right? 1160 01:07:46.650 --> 01:07:51.049 You know, the more resources have you, faster you go. If you run out of resources, you slow down. 1161 01:07:51.049 --> 01:07:52.270 That's how it works, unfortunately. 1162 01:07:54.165 --> 01:07:54.745 AKA donate. 1163 01:07:55.285 --> 01:07:58.165 No. No. No. I get it. I'm not soliciting this time. I'm saying that. 1164 01:07:58.165 --> 01:08:00.885 I I appreciate your endorsement. But Yeah. Okay. 1165 01:08:00.885 --> 01:08:04.585 Now onto the others, treatments that you mentioned, the rifaximin 1166 01:08:05.045 --> 01:08:06.505 and the neomycin combination, 1167 01:08:07.200 --> 01:08:12.260 you've been mentioning how effective it is for hydrogen sulfide that you see that go down. 1168 01:08:12.400 --> 01:08:14.660 But have you seen it help hydrogen 1169 01:08:14.960 --> 01:08:15.940 or methane? 1170 01:08:18.319 --> 01:08:21.200 You're talking about rifaximin and bismuth? Oh. What are you talking about? No. 1171 01:08:21.520 --> 01:08:25.715 NAC, the combination. Oh, NAC. Okay. I thought you said, neomycin. 1172 01:08:26.175 --> 01:08:26.675 So, 1173 01:08:27.215 --> 01:08:28.115 so Rifaximin 1174 01:08:28.815 --> 01:08:29.315 and 1175 01:08:30.495 --> 01:08:35.395 I'm I'm I'm not sure I can give you the answer even though we have some partial answer. 1176 01:08:35.535 --> 01:08:36.755 I have seen patients 1177 01:08:37.340 --> 01:08:39.599 where they have methane, where we give rifaximin 1178 01:08:39.899 --> 01:08:40.719 with NAC, 1179 01:08:42.139 --> 01:08:43.760 and the methane goes down. 1180 01:08:44.380 --> 01:08:50.800 But it's not enough patience for me to conclusively say that this is going to be systematically beneficial. 1181 01:08:51.340 --> 01:08:51.500 So, 1182 01:08:53.085 --> 01:08:59.745 fortunately, in our trial, in our trial with diarrhea, occasionally, we get a patient with a little bit of methane in there, 1183 01:09:00.445 --> 01:09:06.145 and we hope to get a little bit of a signal on that and then decide whether we wanna do a trial for 1184 01:09:06.720 --> 01:09:09.140 for, methane and constipation at some point. 1185 01:09:09.920 --> 01:09:11.540 And and what about hydrogen? 1186 01:09:12.880 --> 01:09:18.660 Oh, hydrogen with NAC? Yeah. Oh, yeah. It comes down. So hydrogen and hydrogen sulfide for sure. 1187 01:09:18.814 --> 01:09:23.054 We Yeah. For sure those come down. It's just a matter of, looking at methane. 1188 01:09:23.054 --> 01:09:26.514 Could methane also be benefited? We don't know. Okay. 1189 01:09:27.135 --> 01:09:27.635 Thanks. 1190 01:09:28.094 --> 01:09:28.755 And then, 1191 01:09:29.295 --> 01:09:32.835 elemental diet. There, you know, you had a new study on, the ambiota, 1192 01:09:33.770 --> 01:09:37.550 elemental diet. It was really interesting. It was on IBS patients, 1193 01:09:37.930 --> 01:09:40.910 without a SIBO test, just looking at IBS only. 1194 01:09:41.050 --> 01:09:46.330 So we don't know whether these people would have SIBO or not and finding it extremely helpful. 1195 01:09:46.729 --> 01:09:50.404 All IBS subtypes were helped. Constipation, diarrhea mixed. 1196 01:09:51.824 --> 01:09:53.444 Bloating, distension, pain. 1197 01:09:53.505 --> 01:09:59.445 But the thing that was so fascinating to me is that the symptoms were still improving two weeks after finishing 1198 01:09:59.985 --> 01:10:04.324 two weeks of the elemental diet. And I just wanted to know if you wanted to comment on it. 1199 01:10:07.110 --> 01:10:08.330 So even with Rifaximin, 1200 01:10:09.590 --> 01:10:10.650 I tell patients, 1201 01:10:11.830 --> 01:10:15.450 don't tell me about your symptoms until you're two weeks done 1202 01:10:15.989 --> 01:10:16.489 because 1203 01:10:16.790 --> 01:10:17.930 there is a restoration 1204 01:10:18.310 --> 01:10:18.810 period 1205 01:10:19.165 --> 01:10:19.985 where the microbiome 1206 01:10:20.364 --> 01:10:21.425 starts to reconstitute. 1207 01:10:22.125 --> 01:10:23.824 And we've seen this in reimagine. 1208 01:10:23.965 --> 01:10:27.344 It's a little tricky in reimagine, but we see patients who've taken rifaximin 1209 01:10:27.885 --> 01:10:32.225 and then happened to get their reimagined stoscope and reimagine, like, 1210 01:10:32.710 --> 01:10:33.690 a month later, 1211 01:10:34.630 --> 01:10:37.130 we see the microbiomes come back to normal. 1212 01:10:37.670 --> 01:10:41.610 And and so by getting rid of the bullies, the E. Coli and klebsiella, 1213 01:10:42.070 --> 01:10:47.610 the normal 1,000 come back in a beautiful profile like the garden's blooming again. So, 1214 01:10:48.215 --> 01:10:50.635 I think the same thing is happening with m biota. 1215 01:10:51.335 --> 01:10:52.395 You get the repopulation 1216 01:10:53.014 --> 01:10:55.835 after the m biota sort of shock to the system. 1217 01:10:57.094 --> 01:11:00.454 I'm so glad you mentioned that because I saw one of the questions we had, 1218 01:11:01.639 --> 01:11:06.860 was was a perpetual question so many people have is, do we need to rebuild the microbiome 1219 01:11:07.639 --> 01:11:09.659 after taking antibiotics for SIBO? 1220 01:11:10.760 --> 01:11:12.619 And it sounds like maybe not. 1221 01:11:13.715 --> 01:11:14.215 Well, 1222 01:11:14.595 --> 01:11:18.775 I turned that question on the person who asked said, tell me how you do that. 1223 01:11:20.275 --> 01:11:22.115 Do you know the 1,000 1224 01:11:22.115 --> 01:11:25.175 bacteria that make that microbiome back to normal? 1225 01:11:25.740 --> 01:11:27.980 So what would you propose we give? 1226 01:11:27.980 --> 01:11:32.160 And and I'm not being rude or it's just that we talk about probiotics 1227 01:11:32.540 --> 01:11:35.120 and and those or even combinations of probiotics, 1228 01:11:35.500 --> 01:11:36.240 but lactobacillus 1229 01:11:36.780 --> 01:11:39.665 is not a major thing in the small bowel. Bifidobacteria 1230 01:11:40.764 --> 01:11:42.385 and Bacteroides organisms 1231 01:11:42.844 --> 01:11:43.344 are 1232 01:11:43.965 --> 01:11:48.625 a no no for the small bowel. Lactobacillus is a disruptor of the small bowel microbiome. 1233 01:11:49.085 --> 01:11:49.585 So, 1234 01:11:51.550 --> 01:11:52.170 you know, 1235 01:11:52.870 --> 01:11:56.570 gut restoration takes a lot of effort. It's not just probiotics. 1236 01:11:56.630 --> 01:11:58.250 There's a lot of things you need to consider. 1237 01:11:58.710 --> 01:11:59.350 But what I 1238 01:12:00.310 --> 01:12:03.690 I don't know if this question is gonna come up, but I'm gonna throw it out there. 1239 01:12:03.975 --> 01:12:12.074 Fibro maxing and all these weird things you're seeing on not weird, but things you're seeing on Instagram or proposed by certain people, 1240 01:12:12.695 --> 01:12:17.675 that's not going to restore your microbiome. That's gonna bring your overgrowth back in overgrowth. 1241 01:12:17.735 --> 01:12:20.610 You wanna do that as a healthy person? Be my 1242 01:12:20.910 --> 01:12:21.890 guest. You wanna, 1243 01:12:22.350 --> 01:12:26.989 you know, fiber max somebody with IBS and SIBO who just finished $750 1244 01:12:26.989 --> 01:12:28.130 ambiota diet? 1245 01:12:28.670 --> 01:12:33.390 Go for it. You're gonna have a very unhappy patient a month from now, telling you it didn't work. 1246 01:12:33.390 --> 01:12:36.735 It's all back. I gotta do it again and pay another $750. 1247 01:12:37.434 --> 01:12:39.855 I I don't yeah. Fibro maxing. 1248 01:12:40.074 --> 01:12:44.974 I'm not I'm not excited about fibro maxing for my IBS or SIBO patients. So, 1249 01:12:45.675 --> 01:12:51.180 you you don't know how to make the garden grow? Your mom does. She says eat a balanced diet, 1250 01:12:51.740 --> 01:12:52.660 and and, 1251 01:12:53.100 --> 01:12:56.000 don't don't over you don't max anything. 1252 01:12:56.700 --> 01:12:58.720 Too much of a good thing is a bad thing. 1253 01:13:00.540 --> 01:13:03.525 Okay. Now you covered testing really well. 1254 01:13:04.565 --> 01:13:09.225 But there was something I was wondering that a lot of people ask us. What is the best way 1255 01:13:09.605 --> 01:13:11.784 to test small intestine transit? 1256 01:13:12.645 --> 01:13:14.185 Is there a good way to do that? 1257 01:13:14.804 --> 01:13:15.304 So, 1258 01:13:18.750 --> 01:13:19.809 yes and no. 1259 01:13:20.909 --> 01:13:22.210 It's it's complicated 1260 01:13:22.590 --> 01:13:23.090 because 1261 01:13:23.949 --> 01:13:25.809 what do you want to know? 1262 01:13:26.190 --> 01:13:28.690 Do you want to know if you have cleaning waves? 1263 01:13:29.150 --> 01:13:30.210 Then take a capsule. 1264 01:13:30.635 --> 01:13:33.755 The capsule studies, even the wireless capsule and, 1265 01:13:34.395 --> 01:13:36.255 wireless capsule of the smart pill. 1266 01:13:37.195 --> 01:13:42.570 I argued with the inventor of it for a long time. I said it's not measuring transit. 1267 01:13:42.969 --> 01:13:56.055 It's measuring the time to the first migrating motor complex because anything over 3 mm in diameter will exit the stomach at the time of the migrating motor complex because anything bigger than that can't get out on its own. 1268 01:13:56.375 --> 01:14:00.795 And so it needs the migrating motor complex. And yes, that is an indirect measure 1269 01:14:01.335 --> 01:14:02.075 of transit. 1270 01:14:02.215 --> 01:14:08.235 But when you have a migrating motor complex everything's going to the colon in fifteen minutes if you ride the wave totally. 1271 01:14:08.775 --> 01:14:09.835 That's not transit. 1272 01:14:11.000 --> 01:14:15.400 Or do you measure transit with a meal? Well, meal is much slower. You gotta take the time. 1273 01:14:15.400 --> 01:14:17.560 You gotta absorb it. You gotta move it back and forth. 1274 01:14:17.560 --> 01:14:21.820 You gotta it depends on the composition of the meal. How long does it take to get so 1275 01:14:22.200 --> 01:14:23.660 transit of the stomach 1276 01:14:24.265 --> 01:14:27.485 is easier to measure than transit of the intestine. 1277 01:14:27.625 --> 01:14:32.585 Because if you catch the migrating motor complex, it's gonna end up in the colon in fifteen minutes. 1278 01:14:32.585 --> 01:14:37.545 That's not your transit. That's a beautiful migrating motor complex. That's not rapid transit. 1279 01:14:37.545 --> 01:14:42.080 That's a beautiful migrating motor complex. Please give me more of those for my IBS patients. 1280 01:14:42.540 --> 01:14:43.040 So, 1281 01:14:43.660 --> 01:14:47.280 but that might be called rapid transit. So what I'm, 1282 01:14:47.900 --> 01:14:50.719 I'm just telling you as a motility physiologist, 1283 01:14:51.340 --> 01:14:52.719 a cautionary tale 1284 01:14:53.260 --> 01:14:53.760 of 1285 01:14:54.695 --> 01:14:58.775 testing and understanding what you're getting from the test. I don't mind the test. 1286 01:14:58.775 --> 01:15:02.635 I love the tests. But you better know what you're doing and you better know what it means. 1287 01:15:02.935 --> 01:15:05.915 And that to me is more important than the actual test. 1288 01:15:07.659 --> 01:15:09.420 Okay. Now some questions about, 1289 01:15:09.900 --> 01:15:15.519 food poisoning in IBS smart test that we get all the time from people that are they're always wondering. 1290 01:15:16.380 --> 01:15:17.679 Is the test valid 1291 01:15:18.059 --> 01:15:22.480 for food poisoning that happened a long time ago, twenty, forty years ago? 1292 01:15:24.225 --> 01:15:24.725 So 1293 01:15:25.265 --> 01:15:26.245 in my practice, 1294 01:15:26.864 --> 01:15:32.485 our team, all of us, we do the test. If they come in with diarrhea or mixed IBS, we do the test. 1295 01:15:32.784 --> 01:15:40.640 Doesn't matter if you have a history of food poisoning, you don't remember, could have been twenty years ago, don't don't remember because there are people who Vinculin just stays up forever, 1296 01:15:41.420 --> 01:15:45.360 and never can go down. That's why we need a drug. If time repaired this, 1297 01:15:45.900 --> 01:15:50.000 we wouldn't need to develop any drug for it. Just give them time. 1298 01:15:50.860 --> 01:15:51.360 But, 1299 01:15:51.980 --> 01:15:54.855 yes. Doesn't matter. Could be ten, twenty years ago. 1300 01:15:54.915 --> 01:16:02.375 So one of the challenges though with food poisoning is that I'll so the patient comes into my office says, I've had IBS for five years. 1301 01:16:02.515 --> 01:16:04.215 I said, have you ever had food poisoning? 1302 01:16:04.995 --> 01:16:09.540 And they say, yes. A year ago. And I said, well, that doesn't fit. Right? 1303 01:16:09.540 --> 01:16:13.480 It you had IBS for five years. Now you had food poisoning a year ago. 1304 01:16:14.739 --> 01:16:18.840 This food poisoning didn't cause it, but maybe the other one did that you don't remember. 1305 01:16:19.219 --> 01:16:19.719 So 1306 01:16:20.554 --> 01:16:26.094 rather than trying to get people to remember something from ten years ago, just measure and then you'll know. 1307 01:16:27.594 --> 01:16:33.054 Yeah. That's such good advice. You know, I I also heard you say, recently that higher antibodies 1308 01:16:34.000 --> 01:16:36.020 predicts poor response to treatment, 1309 01:16:37.119 --> 01:16:39.840 which is it's very helpful to know that, right? 1310 01:16:39.840 --> 01:16:44.900 I mean, by running this test and then you can get a sense of how challenging the treatment will be. 1311 01:16:45.119 --> 01:16:50.915 When when you see that, is there anything in particular you do when you you expect a more challenging course of treatment? 1312 01:16:52.014 --> 01:16:54.915 So and I'm not trying to advocate for this, but 1313 01:16:55.375 --> 01:16:58.275 but, our whole team sees this all the time. And, 1314 01:16:59.135 --> 01:17:02.034 we just were discussing this this week in our clinic. 1315 01:17:02.400 --> 01:17:10.080 And all of us in the vinculin antibodies over three, almost every single one of those patients, they go on rifaximin, it works. 1316 01:17:10.080 --> 01:17:13.140 They stop it, it comes back literally within a week. 1317 01:17:13.360 --> 01:17:20.855 And so we keep those patients on chronic rifaximin. So three a day and then one a day as a chaser. 1318 01:17:21.155 --> 01:17:26.375 And as long as we do that, most of those patients, if they respond to rifaximin, they will stay better, 1319 01:17:27.635 --> 01:17:29.015 until we get a better cure. 1320 01:17:29.075 --> 01:17:34.710 So but I try not to do that because, obviously, it's very expensive, and it's a little off label. 1321 01:17:35.490 --> 01:17:35.990 But, 1322 01:17:36.370 --> 01:17:37.910 you know, these patients are miserable. 1323 01:17:38.370 --> 01:17:46.115 When you say doing it three times a day and then one day chaser, do you mean three times a day for the two weeks and then a once a day as a chaser? 1324 01:17:47.455 --> 01:17:53.215 Once a day indefinitely as a chaser. After. Yes. Three times a day for yeah. Yeah. Okay. Cool. 1325 01:17:53.215 --> 01:17:54.495 Thank you. $5.55 1326 01:17:54.495 --> 01:17:56.515 50 milligrams once a day ongoing. 1327 01:17:57.210 --> 01:18:02.510 Yeah. You can even do half of a five fifty if you get away with it. So try to Great. 1328 01:18:03.290 --> 01:18:06.030 Okay. And then this one comes up all the time. 1329 01:18:06.410 --> 01:18:10.010 If you get food poisoning, people of course, they're educated now about this. 1330 01:18:10.010 --> 01:18:12.695 They wanna do something to prevent getting SIBO. 1331 01:18:13.315 --> 01:18:14.695 Will taking antibiotics 1332 01:18:15.474 --> 01:18:16.614 for the food poisoning 1333 01:18:17.715 --> 01:18:19.255 prevent somebody getting SIBO? 1334 01:18:19.635 --> 01:18:20.135 Yeah. 1335 01:18:23.235 --> 01:18:25.735 We did a study like this in rats. 1336 01:18:26.440 --> 01:18:27.579 It prevents it. 1337 01:18:28.920 --> 01:18:31.420 But there is no such human trial 1338 01:18:32.199 --> 01:18:34.539 to give me proof that that would work, 1339 01:18:34.920 --> 01:18:36.940 except for the 100 gastroenterologists 1340 01:18:37.480 --> 01:18:38.920 at Cedars Sinai Medical Center. 1341 01:18:38.920 --> 01:18:43.725 When they travel outside The US, they all take Rifaximin preventatively because they know what I know. 1342 01:18:44.665 --> 01:18:51.165 So if they go to Southeast Asia or south of the border, they they tend to take Rifaximin with each meal to prevent IBS. 1343 01:18:52.585 --> 01:18:53.085 But 1344 01:18:54.020 --> 01:18:55.719 there's not a formal trial 1345 01:18:56.100 --> 01:18:58.600 that says that once you've got that food poisoning, 1346 01:18:59.380 --> 01:19:03.960 you can prevent IBS. But what we do know is that the more 1347 01:19:04.340 --> 01:19:07.480 the longer the food poisoning event is. 1348 01:19:08.074 --> 01:19:09.295 So let's say you got 1349 01:19:09.835 --> 01:19:10.495 E coli 1350 01:19:11.034 --> 01:19:12.895 and you're sick for a week. 1351 01:19:13.514 --> 01:19:16.415 You're more likely to get IBS than if you're sick for a day 1352 01:19:17.835 --> 01:19:19.614 from the E coli if you did nothing. 1353 01:19:20.090 --> 01:19:25.310 So we do know that Rifaximin, if you take it in that moment that you get that first diarrhea, 1354 01:19:25.690 --> 01:19:28.590 it shortens it down to twenty four hour illness. 1355 01:19:29.210 --> 01:19:31.390 And that's that's the actual 1356 01:19:32.090 --> 01:19:34.750 or first indication for Rifaximin was traveler's diarrhea. 1357 01:19:35.055 --> 01:19:38.915 So if you took Rifaximin with that traveler's diarrhea in that moment 1358 01:19:39.775 --> 01:19:41.555 and you shortened it to one day, 1359 01:19:42.574 --> 01:19:46.915 the extrapolation is that you should be able to reduce the chance of developing IBS. 1360 01:19:47.880 --> 01:19:51.739 Is that the best antibiotic to use if somebody gets food poisoning, is rifaximin? 1361 01:19:52.280 --> 01:19:52.780 No. 1362 01:19:53.159 --> 01:19:56.300 Rifaximin is the best one for E. Coli, which is mostly 1363 01:19:56.760 --> 01:20:00.060 South Of The US, Mexico, South America, Central America. 1364 01:20:00.655 --> 01:20:03.795 If you go to Southeast Asia, it's usually campylobacter. 1365 01:20:04.175 --> 01:20:04.915 And campylobacter 1366 01:20:05.455 --> 01:20:10.035 gets inside the cells of the gut lining, and rifaximin can't penetrate. 1367 01:20:10.175 --> 01:20:12.835 So then you have to do Cipro or azithromycin 1368 01:20:13.295 --> 01:20:17.159 or one of the absorbable antibiotics to cut it off, to cut it 1369 01:20:17.539 --> 01:20:17.940 short. 1370 01:20:17.940 --> 01:20:24.119 So, yeah, Rifaximin would not work almost ever in the Southeast Asian kind of food poisonings. 1371 01:20:24.820 --> 01:20:29.960 And just to clarify, when you say absorbable, that's because Rifaximin does not absorb into the blood. 1372 01:20:30.065 --> 01:20:33.425 So we're trying to Doesn't absorb. Doesn't get through the mucus. Doesn't get into the cells. 1373 01:20:33.425 --> 01:20:33.925 Correct. 1374 01:20:34.864 --> 01:20:36.725 Is there anything else that could prevent, 1375 01:20:37.344 --> 01:20:39.045 food poisoning turning into SIBO? 1376 01:20:40.145 --> 01:20:45.605 I mean, your your some of the old data says Pepto Bismol can prevent food poisoning if you take that while you travel. 1377 01:20:46.280 --> 01:20:48.540 So that's that's something that's been done. 1378 01:20:49.720 --> 01:20:50.220 But 1379 01:20:50.600 --> 01:20:54.300 that's pretty much it. And good hygiene when you travel. 1380 01:20:54.680 --> 01:20:58.700 Don't don't eat, drink the water, you know, the usual stuff. 1381 01:20:58.955 --> 01:21:00.975 Keep your mouth shut in the shower, people. 1382 01:21:01.915 --> 01:21:02.735 It's true. 1383 01:21:03.115 --> 01:21:06.155 It's true. Yes. Shower water. You can't believe it. 1384 01:21:06.155 --> 01:21:08.335 You don't even think about it when you're taking a shower. 1385 01:21:08.795 --> 01:21:10.655 And you're supposed to be getting clean. Right? 1386 01:21:11.630 --> 01:21:15.550 Yeah. Now you've said that vinculin doesn't come down over time. 1387 01:21:15.550 --> 01:21:17.329 Obviously, we've you discussed that. 1388 01:21:17.949 --> 01:21:19.809 What about CDT B antibody? 1389 01:21:22.030 --> 01:21:25.969 CDT B goes down over time more reliably than vinculin. 1390 01:21:26.835 --> 01:21:30.215 So think of CDTV as the antibody to the toxin 1391 01:21:30.915 --> 01:21:33.475 or like a COVID antibody. You got the COVID vaccine. 1392 01:21:33.475 --> 01:21:36.455 You get the antibodies to COVID produced from the vaccine. 1393 01:21:36.995 --> 01:21:42.295 And that's why you need a booster because over time, they go down, down, down, down, down, and you're susceptible again. 1394 01:21:43.130 --> 01:21:46.829 Same thing with CDTV. If you don't get food poisoning again, they will gradually diminish. 1395 01:21:47.530 --> 01:21:53.150 But if you develop the vinculin antibodies, you have vinculin in your body, so they tend to persist. 1396 01:21:53.610 --> 01:21:57.150 So we do see that in our clinic that that tends to happen. 1397 01:21:58.145 --> 01:22:00.965 And here's another question I get. If you have CDTV 1398 01:22:01.265 --> 01:22:02.885 positive but not Vinculin, 1399 01:22:03.505 --> 01:22:04.885 do you have autoimmunity? 1400 01:22:07.105 --> 01:22:08.725 It's a very good question, 1401 01:22:09.585 --> 01:22:12.565 probably to a degree that cannot so 1402 01:22:13.250 --> 01:22:16.210 like, everything else, everything's on a spectrum. Right? 1403 01:22:16.690 --> 01:22:17.190 So 1404 01:22:18.290 --> 01:22:21.429 the cutoff for vinculin is 1.6, 1405 01:22:21.810 --> 01:22:23.489 but can 1.5 1406 01:22:23.489 --> 01:22:26.710 be enough to be a little autoimmune for that patient? 1407 01:22:27.735 --> 01:22:32.875 Or you're measuring the CDTB. The CDTB is 1.7. The vinculin is 1.3, 1408 01:22:33.175 --> 01:22:36.235 but maybe the vinculin was a little bit higher at one point. 1409 01:22:37.015 --> 01:22:38.315 How much anti vinculin 1410 01:22:38.695 --> 01:22:39.435 is enough 1411 01:22:40.010 --> 01:22:42.590 to make you autoimmune versus me? 1412 01:22:43.450 --> 01:22:43.950 And 1413 01:22:44.330 --> 01:22:48.170 and those are subtle details that are very difficult to sort out. 1414 01:22:48.570 --> 01:22:49.070 But 1415 01:22:51.050 --> 01:22:56.255 I I don't have a good answer to that, but I would imagine there's a there's always a degree of autoimmunity 1416 01:22:56.715 --> 01:22:58.095 present even with CDTV, 1417 01:22:59.355 --> 01:23:01.855 because it those antibodies do cross react. 1418 01:23:02.475 --> 01:23:02.975 Mhmm. 1419 01:23:03.435 --> 01:23:07.295 Yeah. Okay. Last question. Thanks, Siobhan, because I know Siobhan has questions. 1420 01:23:11.239 --> 01:23:14.220 Okay. So we saw last year, we had a couple of papers 1421 01:23:14.760 --> 01:23:20.220 saying that, and I saw some questions about this in the chat, that GLP ones do increase the risk of getting SIBO. 1422 01:23:20.840 --> 01:23:22.940 And we also know that they can cause, 1423 01:23:23.485 --> 01:23:23.985 gastrointestinal 1424 01:23:24.285 --> 01:23:27.425 symptoms in and of themselves, whether they're causing SIBO or not. 1425 01:23:27.645 --> 01:23:29.985 How currently, how are you treating, 1426 01:23:31.005 --> 01:23:33.885 symptoms that come from GLP ones? Do you have any good, 1427 01:23:34.285 --> 01:23:35.425 symptomatic advice? 1428 01:23:35.990 --> 01:23:39.690 Well, I think I think what you have to do is before you start a GLP one, 1429 01:23:40.390 --> 01:23:42.890 and we see a lot of our patients are on GLP ones. 1430 01:23:43.270 --> 01:23:47.925 And you have to say, look. This is what you're going to get from your GLP one. 1431 01:23:48.324 --> 01:23:52.405 Flat out, this is what it is supposed to do. It is supposed to make you constipated. 1432 01:23:52.405 --> 01:23:55.864 It is supposed to slow you down. It is supposed to give you a degree of nausea. 1433 01:23:56.724 --> 01:23:57.224 So 1434 01:23:57.764 --> 01:24:01.640 you understand before you start this drug, that's how it's supposed to work. 1435 01:24:02.500 --> 01:24:04.199 And so we don't try 1436 01:24:04.820 --> 01:24:10.120 to treat the symptoms of GLP one because if we treat the symptoms, we counteract the drug. 1437 01:24:10.180 --> 01:24:11.560 So if I give a prokinetic 1438 01:24:12.045 --> 01:24:17.585 to make the stomach move better in a GLP one patient where you want the stomach not to move better, I'm just counteracting. 1439 01:24:18.605 --> 01:24:25.585 If you make the colon move faster because they're constipated from the GLP one, I'm counteracting the effect of the GLP one, which is also not good. 1440 01:24:25.804 --> 01:24:26.304 So 1441 01:24:26.790 --> 01:24:32.170 patients sort of have to accept that this is what it is. This is how it's supposed to feel. 1442 01:24:32.469 --> 01:24:34.170 It's not always pleasant, 1443 01:24:34.710 --> 01:24:38.809 but it's to the effect of getting weight loss. Right? So 1444 01:24:39.270 --> 01:24:39.770 yeah. 1445 01:24:40.695 --> 01:24:46.475 Thank you. Thank you so much. Siobhan, over to you. Okay. I have about 200 questions. 1446 01:24:46.935 --> 01:24:50.935 One of the most common so we aren't gonna get to everybody's, but, of course, we'll do our best. 1447 01:24:50.935 --> 01:24:52.635 We have twenty four minutes. 1448 01:24:54.135 --> 01:24:55.675 Doctor Pimentel, COVID 1449 01:24:56.590 --> 01:24:59.010 related to SIBO. A lot of people have experienced 1450 01:24:59.390 --> 01:25:00.130 a COVID 1451 01:25:01.230 --> 01:25:03.250 infection, and then they got SIBO. 1452 01:25:04.350 --> 01:25:04.850 Yeah. 1453 01:25:06.670 --> 01:25:07.170 It's 1454 01:25:08.030 --> 01:25:16.245 so interesting to me because there have been a couple of studies of good colleague of mine did a couple of studies in Mexico that showed that there was an association. 1455 01:25:18.705 --> 01:25:23.685 But my practice is, I don't know, seventy percent IBS, SIBO, etcetera, etcetera. 1456 01:25:24.619 --> 01:25:26.960 I can't describe on one hand 1457 01:25:27.980 --> 01:25:32.699 that number of patients that had worsening because of COVID. And they've all got COVID. 1458 01:25:32.699 --> 01:25:35.840 They all got COVID. They all got the vaccine. They didn't get worse. 1459 01:25:35.980 --> 01:25:38.415 So I'm having a hard time with it. 1460 01:25:39.215 --> 01:25:40.195 You know, fortunately, 1461 01:25:40.575 --> 01:25:47.155 our COVID situation has gotten so much better, and we don't really have to think too much about it anymore as as we used to. 1462 01:25:47.375 --> 01:25:51.555 But I I was never convinced that it made it worse. Okay. 1463 01:25:51.900 --> 01:25:55.120 There are a lot of people in the q and a that are saying 1464 01:25:55.900 --> 01:25:56.540 I got, 1465 01:25:57.100 --> 01:25:58.400 diagnosed with IMO. 1466 01:25:59.100 --> 01:26:03.040 I have diarrhea. I got diagnosed with hydrogen. I have constipation. 1467 01:26:03.675 --> 01:26:07.594 I don't feel I don't I don't feel like the rest of the crowd. Is am I okay? 1468 01:26:07.594 --> 01:26:10.895 Like, they feel different. Well So could you address that, please? 1469 01:26:11.915 --> 01:26:12.415 So 1470 01:26:12.795 --> 01:26:14.175 I wanna be clear. So, 1471 01:26:14.795 --> 01:26:18.014 in the 6,000 breath test study, there are people, 1472 01:26:19.050 --> 01:26:19.550 albeit 1473 01:26:20.010 --> 01:26:22.190 uncommon, who have methane, who have diarrhea. 1474 01:26:22.410 --> 01:26:31.070 But if they if you don't check for hydrogen sulfide, if you didn't do a hydrogen sulfide check, that I would do that because that will definitely override 1475 01:26:32.005 --> 01:26:34.345 the methane, and you will be diarrhea. 1476 01:26:34.725 --> 01:26:36.425 So that is the first step. 1477 01:26:36.805 --> 01:26:39.945 The second question is I've got hydrogen, and I'm constipated. 1478 01:26:40.885 --> 01:26:44.905 So in my clinic, hydrogen is not associated 1479 01:26:45.205 --> 01:26:46.025 with constipation. 1480 01:26:46.969 --> 01:26:49.870 But when it is elevated and a person is constipated, 1481 01:26:50.330 --> 01:26:52.429 I work that person up because 1482 01:26:52.969 --> 01:26:53.210 the 1483 01:26:54.090 --> 01:26:59.210 their hydrogen overgrowth is caused by something slowing the gut down. What's going on? 1484 01:26:59.210 --> 01:27:00.030 Are they hypothyroid? 1485 01:27:00.885 --> 01:27:06.105 Do they have a tumor in the colon that's blocking and causing constipation that nobody scoped them yet? 1486 01:27:06.885 --> 01:27:10.585 I need to find out what the heck is going on. You'll treat the hydrogen. 1487 01:27:10.644 --> 01:27:15.945 The bloating will be better, but they're still constipated, and it's the constipation that's causing the overgrowth. 1488 01:27:16.370 --> 01:27:20.790 So that's a very specific situation that I work those patients up. 1489 01:27:21.570 --> 01:27:26.550 How often do you see ovarian cancer being either misdiagnosed or right alongside SIBO? 1490 01:27:28.785 --> 01:27:32.965 I see it enough that it makes me very scared, but I don't see it often. 1491 01:27:33.425 --> 01:27:34.305 I've I've 1492 01:27:34.705 --> 01:27:36.485 what I've had more often 1493 01:27:37.025 --> 01:27:37.925 is endometriosis, 1494 01:27:38.865 --> 01:27:39.365 adhesions, 1495 01:27:40.305 --> 01:27:42.645 and and the occasional pancreas cancer. 1496 01:27:43.230 --> 01:27:44.050 Because pancreatic 1497 01:27:44.670 --> 01:27:45.170 insufficiency 1498 01:27:46.030 --> 01:27:50.930 of the real type, not the one that's, you know, everybody's going off on these days. 1499 01:27:51.150 --> 01:27:56.990 But literally, people with cysts in their pancreas and they don't produce enough, and then they get cancer of the pancreas. 1500 01:27:56.990 --> 01:27:58.530 That's associated with SIBO. 1501 01:27:58.935 --> 01:28:00.155 But don't be fooled. 1502 01:28:01.094 --> 01:28:02.554 You know, you gotta 1503 01:28:02.935 --> 01:28:04.474 make sure if they're losing weight, 1504 01:28:05.094 --> 01:28:08.474 study them. Look. Try and figure out what's going on. Okay. 1505 01:28:08.935 --> 01:28:14.310 What's your approach for treating someone who has IMO and ISO? So methane and hydrogen sulfide. 1506 01:28:14.310 --> 01:28:15.370 Do you see that a lot? 1507 01:28:16.150 --> 01:28:19.449 I see it often enough. I've had maybe 10 cases, 1508 01:28:20.550 --> 01:28:24.330 of of the last four years. And Okay. I give them rifaximin 1509 01:28:25.030 --> 01:28:25.770 with neomycin 1510 01:28:26.795 --> 01:28:31.835 with bismuth. I give all three. And what's the dosage of the Pepto Bismol? Just a swig? 1511 01:28:31.835 --> 01:28:33.215 So it's a it's a capful, 1512 01:28:33.835 --> 01:28:39.215 and the cap has a line on it. And that's a roughly 500 mg of Pepto Bismol 1513 01:28:39.755 --> 01:28:40.815 Okay. Or bismuth. 1514 01:28:41.370 --> 01:28:44.670 Okay. And you give it three times a day just with the Rifaximin 1515 01:28:45.370 --> 01:28:48.670 together. Oh, little yeah. Right there. Okay. Yeah. 1516 01:28:49.610 --> 01:28:50.110 Okay. 1517 01:28:51.690 --> 01:28:52.909 Any thoughts on 1518 01:28:54.585 --> 01:28:56.125 workaround for getting rifaximin 1519 01:28:56.505 --> 01:28:59.165 in a less expensive fashion, like the Salix 1520 01:28:59.465 --> 01:29:04.585 customer not cost patient support. They have, like, a program. You can go to the Salix site. 1521 01:29:04.585 --> 01:29:05.645 Any other suggestions? 1522 01:29:06.700 --> 01:29:08.880 Yeah. I mean, there are international pharmacies. 1523 01:29:09.340 --> 01:29:14.000 I'm not advocating to do that, but there are some people who like doing that, that 1524 01:29:14.700 --> 01:29:17.420 some of that pipelines have been shut down recently. 1525 01:29:17.420 --> 01:29:20.800 But more recently, we're there is some success in getting it internationally. 1526 01:29:22.735 --> 01:29:23.795 If you're traveling, 1527 01:29:24.815 --> 01:29:25.715 get it there. 1528 01:29:26.335 --> 01:29:29.555 Somebody just said Tony Vaughn said they got it from a Canadian pharmacy. 1529 01:29:30.095 --> 01:29:30.595 So, 1530 01:29:32.175 --> 01:29:35.550 so there are ways. And then, you know, Rifaximin 1531 01:29:36.090 --> 01:29:38.590 could become generic sometime in the next two years. 1532 01:29:38.970 --> 01:29:39.470 So, 1533 01:29:40.970 --> 01:29:42.590 Right right when you cure it. 1534 01:29:43.770 --> 01:29:48.185 See, I'm like That's a hot tip. Is that in the pipeline? Really? What's that? 1535 01:29:48.324 --> 01:29:52.244 That that's that's incredible. Is that really in the pipeline? Or Well, it could. 1536 01:29:52.485 --> 01:29:58.324 You know, there the fights for preventing that from happening are I think the last court battle said, nope. 1537 01:29:58.324 --> 01:29:59.704 2028, 1538 01:30:00.670 --> 01:30:05.170 I think, was what I heard from some of the pop read in some of the public documents that are available. 1539 01:30:05.470 --> 01:30:08.050 Okay. Can people get emo or methane 1540 01:30:09.070 --> 01:30:10.130 from food poisoning? 1541 01:30:12.285 --> 01:30:12.785 So 1542 01:30:13.645 --> 01:30:16.545 I see it occasionally, but it's not as common. 1543 01:30:16.925 --> 01:30:20.365 Okay. But it is It's not as common. It is valid. It does happen. It does happen. It's not as common. 1544 01:30:20.365 --> 01:30:22.465 Okay. So I don't, just to be clear, 1545 01:30:23.005 --> 01:30:27.025 the point is not to waste money. The point is to spend less money. 1546 01:30:27.420 --> 01:30:30.300 Here's how you spend less money. You do a breath test. You do it, 1547 01:30:30.860 --> 01:30:35.040 blood test. You don't need to do always a celiac test. You don't need to always do a colonoscopy. 1548 01:30:35.260 --> 01:30:38.080 You don't need to always do a barium study or a CT scan. 1549 01:30:38.140 --> 01:30:42.080 If these markers are positive, you're saving money. If you respond to rifaximin 1550 01:30:43.475 --> 01:30:44.855 and you're good for months, 1551 01:30:45.315 --> 01:30:51.015 you don't have Crohn's. You don't have celiac. You don't none of those diseases respond like that. 1552 01:30:51.315 --> 01:30:51.815 So 1553 01:30:52.275 --> 01:30:53.095 by treating 1554 01:30:53.475 --> 01:30:56.215 what you find on the breath test, you save a ton of money. 1555 01:30:57.079 --> 01:31:00.880 But I don't do the IBS Mark in the constipated methane patients. 1556 01:31:00.880 --> 01:31:03.579 It's a waste of money because it's not as often positive. 1557 01:31:04.119 --> 01:31:04.619 So, 1558 01:31:05.000 --> 01:31:06.219 yeah, don't waste money. 1559 01:31:06.760 --> 01:31:10.059 Okay. I'm Mark is saying, and I was gonna ask 1560 01:31:10.360 --> 01:31:11.179 about this, 1561 01:31:12.335 --> 01:31:13.875 that the Mark Cuban 1562 01:31:14.255 --> 01:31:15.795 cost plus pharmacy 1563 01:31:16.655 --> 01:31:17.155 has 1564 01:31:17.775 --> 01:31:18.275 Rifaximin. 1565 01:31:19.135 --> 01:31:21.635 So check it out. The way I found it was, like, 1566 01:31:22.094 --> 01:31:25.580 pharmacy with the guy from Shark Tank because because I couldn't remember his name. 1567 01:31:25.580 --> 01:31:26.880 I wanna call him Mark Rubin, 1568 01:31:27.260 --> 01:31:32.540 but I think that's, like, a American Idol guy. So check it out. There you go. Yeah. Alright. 1569 01:31:32.540 --> 01:31:35.040 Thanks for that. Thank you for that. Okay. 1570 01:31:36.220 --> 01:31:40.335 It's true. Mark Cuban Pharmacy is cheaper for a lot of specialized drugs. 1571 01:31:40.715 --> 01:31:41.215 Great. 1572 01:31:42.554 --> 01:31:46.574 So let's get a a final call here on the hearing issue with neomycin. 1573 01:31:47.514 --> 01:31:48.014 So 1574 01:31:48.954 --> 01:31:53.295 yes, no, maybe. If you have already hearing issues, do you stay away from it? 1575 01:31:53.900 --> 01:31:54.300 Yeah. 1576 01:31:54.300 --> 01:31:59.840 If if you're, like, an 80 year old and you have hearing issues and you have kidney problems, I probably wouldn't use neomycin. 1577 01:32:01.020 --> 01:32:01.520 But 1578 01:32:01.980 --> 01:32:04.300 I have never seen a hear oh, sorry. 1579 01:32:04.300 --> 01:32:09.200 I have one patient who described a hearing issue in that study with neomycin 1580 01:32:09.685 --> 01:32:11.385 because we had to do a hearing test 1581 01:32:12.005 --> 01:32:13.625 before they started the trial, 1582 01:32:14.565 --> 01:32:17.545 and then they took the knee they took the neomycin. 1583 01:32:17.605 --> 01:32:21.205 And the first patient in the trial said, I'm having hearing problems. We stopped the drug. 1584 01:32:21.205 --> 01:32:25.225 We re we it turns out they had a cold. We retested them, 1585 01:32:25.690 --> 01:32:26.190 and 1586 01:32:27.290 --> 01:32:31.370 then the the hearing was actually better. I'm not saying it makes it better. 1587 01:32:31.370 --> 01:32:35.450 I'm saying it was actually better, but it but the point is the that didn't happen. 1588 01:32:35.450 --> 01:32:39.390 I have not seen hearing loss. I see some comments of some people on online 1589 01:32:39.955 --> 01:32:42.855 that they had some kind of hearing changes with neomycin. 1590 01:32:43.475 --> 01:32:43.975 So 1591 01:32:44.435 --> 01:32:45.735 just to be clear, gentamicin 1592 01:32:46.115 --> 01:32:46.855 is an, 1593 01:32:47.475 --> 01:32:52.135 IV antibiotic. This is how we found out that mycins or these aminoglycosides 1594 01:32:52.755 --> 01:32:56.820 cause hearing loss. You have to give it for three months for let's say endocarditis, 1595 01:32:57.200 --> 01:33:01.700 three months IV, IV, IV, IV. And as it builds up in your bloodstream, you can have ototoxicity 1596 01:33:02.080 --> 01:33:03.060 or ear toxicity. 1597 01:33:03.680 --> 01:33:04.180 Neomycin 1598 01:33:04.800 --> 01:33:06.260 can cause ear toxicity. 1599 01:33:07.075 --> 01:33:09.255 In studies that we're looking at encephalopathy 1600 01:33:09.955 --> 01:33:12.455 from liver disease where you're taking neomycin 1601 01:33:12.835 --> 01:33:19.415 every day for a year, it also causes ear toxicity, but it takes a lot longer and a lot more dosing. 1602 01:33:19.989 --> 01:33:24.710 Can if you have to give it three or four times a year, is that a problem? Might be. Might be. 1603 01:33:24.710 --> 01:33:28.949 I'm not saying it wasn't. I haven't seen it. That's what I'm saying. Yep. 1604 01:33:28.949 --> 01:33:34.215 And doctor Pimentel is no one's doctor here unless you are seeing him at Cedars Sinai. 1605 01:33:34.215 --> 01:33:36.635 So this is not medical advice for you 1606 01:33:37.094 --> 01:33:40.635 personally, which I know you all know, but I'm just gonna restate it because 1607 01:33:41.175 --> 01:33:44.875 I've seen weird things. Okay. What about stool testing and microbiome 1608 01:33:45.415 --> 01:33:48.940 testing that people can order themselves out in the world? 1609 01:33:49.400 --> 01:33:52.940 And if they do find e coli or other identified, 1610 01:33:54.440 --> 01:33:59.820 organisms in the stool, is that a reflection of what might be going on in the small bowel? 1611 01:34:00.855 --> 01:34:05.115 So there are shadows of what goes on in the small bowel a little bit in the colon. 1612 01:34:05.655 --> 01:34:06.155 But 1613 01:34:07.015 --> 01:34:07.915 has anybody 1614 01:34:08.295 --> 01:34:08.795 validated 1615 01:34:09.175 --> 01:34:10.455 that this level of E. 1616 01:34:10.455 --> 01:34:16.869 Coli in the stool correlates with this much in the small bowel, correlates with this much in the breath, correlates with this 1617 01:34:17.170 --> 01:34:17.750 much symptoms? 1618 01:34:18.530 --> 01:34:22.150 No. Nothing done. Okay. So so it's 1619 01:34:22.690 --> 01:34:29.590 and there are studies that show if you take your stool and you send it to four different companies, you get four different results. 1620 01:34:30.290 --> 01:34:37.415 And that's not okay. And and then there are companies that say, oh, we do shotgun sequencing now. 1621 01:34:37.715 --> 01:34:38.615 Well, there's 1622 01:34:39.955 --> 01:34:40.855 shotgun sequencing, 1623 01:34:41.395 --> 01:34:44.935 then there's shotgun sequencing, and shotgun sequencing, and shotgun sequencing. 1624 01:34:45.075 --> 01:34:48.510 Let me what what do I mean by that? There is shallow shotgun, 1625 01:34:49.130 --> 01:34:50.110 medium shotgun, 1626 01:34:50.489 --> 01:34:55.050 and deep shotgun. Deep shotgun is probably a thousand dollars a person. 1627 01:34:55.050 --> 01:34:59.070 That's what we do in the lab back here. Deep shotgun. We don't do shallow shotgun. 1628 01:34:59.770 --> 01:35:00.270 So 1629 01:35:01.755 --> 01:35:07.835 if you're paying $50 for shotgun sequencing of the stool, you're getting as good you're getting the you're getting the penny shotgun. 1630 01:35:07.835 --> 01:35:13.035 You're not getting the you know? So are they doing the deep? Are they doing the shallow? 1631 01:35:13.035 --> 01:35:15.850 Are they doing the moderate? You get what you pay for. 1632 01:35:15.990 --> 01:35:19.770 If they do the deep, are you getting too much information? Does it even correlate with symptoms? 1633 01:35:20.310 --> 01:35:22.890 Yeah. That these are the questions that keep rising. 1634 01:35:23.590 --> 01:35:29.370 Okay. What about Pepcid for years? Does that contribute to SIBO or any of the PPIs out there? 1635 01:35:30.175 --> 01:35:33.795 We've done multiple PPI studies. They don't 1636 01:35:35.375 --> 01:35:36.195 the the microbiome 1637 01:35:36.495 --> 01:35:38.835 of a person on a PPI for years 1638 01:35:39.455 --> 01:35:41.235 is different, slightly, 1639 01:35:41.855 --> 01:35:42.355 less 1640 01:35:43.090 --> 01:35:47.430 clostridia, which may be why they get C. Diff because it opens up a niche for C. Diff, 1641 01:35:48.210 --> 01:35:51.590 and a couple of other organisms that change, but not SIBO. 1642 01:35:52.050 --> 01:35:52.550 You 1643 01:35:53.010 --> 01:36:00.835 know, that that that actually brings up another question that's related that we get all the time that you just did a study on, which is can antibiotics 1644 01:36:01.535 --> 01:36:05.555 lead to SIBO? And we certainly have a lot of patients who feel that they have. 1645 01:36:06.255 --> 01:36:08.275 Yep. And we studied that and reimagined. 1646 01:36:08.735 --> 01:36:09.555 Doesn't happen. 1647 01:36:10.040 --> 01:36:12.760 It doesn't. See, we don't see SIBO from antibiotics. 1648 01:36:12.760 --> 01:36:15.180 We looked at people who are on on antibiotics recently. 1649 01:36:15.640 --> 01:36:16.440 No SIBO. 1650 01:36:16.920 --> 01:36:17.420 Now 1651 01:36:18.120 --> 01:36:21.000 do you have to study thousands of people to find one person? 1652 01:36:21.000 --> 01:36:24.460 Could there be a person out there that got SIBO from antibiotics? Maybe. 1653 01:36:24.575 --> 01:36:26.915 I'm not denying that it's impossible. 1654 01:36:27.615 --> 01:36:29.455 I'm saying it's not common, 1655 01:36:29.935 --> 01:36:30.675 not common. 1656 01:36:32.015 --> 01:36:35.695 Okay. But I saw somebody said they hate Cipro. I hate Cipro too. 1657 01:36:35.695 --> 01:36:37.730 So whoever said that, I agree with you. 1658 01:36:37.790 --> 01:36:41.810 Cipro can cause tendon problems, so I don't use Cipro often, Amy. 1659 01:36:42.430 --> 01:36:45.970 I'm getting a lot of people saying, yes. Cipro evil. So 1660 01:36:46.830 --> 01:36:51.550 that was the evil. I mean, yes. It's not not in favor these days. Let's put it that way. 1661 01:36:51.550 --> 01:36:52.545 We'll put it that way. 1662 01:36:54.705 --> 01:36:56.965 I I've got a lot of people saying, 1663 01:36:58.225 --> 01:36:59.765 okay. They have 1664 01:37:00.225 --> 01:37:00.725 methanogen 1665 01:37:01.185 --> 01:37:01.685 overgrowth. 1666 01:37:02.304 --> 01:37:06.165 Can they take the IBS smart test and have that be helpful for them? 1667 01:37:06.620 --> 01:37:09.840 Because they're I think in the beginning, it was just like Yeah. Hydrogen. 1668 01:37:10.620 --> 01:37:13.520 Did we already could you just repeat it? Because they're still coming in. Sorry. 1669 01:37:13.900 --> 01:37:15.180 Yeah. So look. 1670 01:37:15.180 --> 01:37:20.800 If you if you think food poisoning started your illness and you have constipation and you have methane, I check those patients. 1671 01:37:21.260 --> 01:37:21.760 But 1672 01:37:22.095 --> 01:37:22.895 generally speaking 1673 01:37:23.695 --> 01:37:28.275 so about sixty, fifty six percent is the exact number of people with DIBS 1674 01:37:28.815 --> 01:37:29.555 test positive. 1675 01:37:30.335 --> 01:37:30.835 About 1676 01:37:31.455 --> 01:37:43.690 forty five percent if they're, mixed, about twenty five percent if they're constipated methane, and about ten percent or less if they're normal people who might test positive for one or either antibody. 1677 01:37:45.510 --> 01:37:51.449 So my so, yes, it's a little bit higher than normal, but is it worth the squeeze for the money? 1678 01:37:51.665 --> 01:37:56.165 I would say for the constipators, for me, it's generally not unless they have that history. 1679 01:37:56.225 --> 01:38:01.445 So and sounds like somebody does have that history. And so in in that case 1680 01:38:02.225 --> 01:38:02.965 k. Robert. 1681 01:38:03.920 --> 01:38:05.300 Paying attention to the vinculin 1682 01:38:05.840 --> 01:38:08.420 antibody and using prokinetics to counteract 1683 01:38:08.720 --> 01:38:12.800 the effects of the vinculin is important in my practice. That's how I do. Yeah. 1684 01:38:12.800 --> 01:38:17.540 And I can I can just add that I I've tested many patients because they have that exact history, 1685 01:38:18.135 --> 01:38:21.594 or because it's very mysterious and we've we've searched 1686 01:38:21.974 --> 01:38:24.135 really well to find an underlying cause? 1687 01:38:24.135 --> 01:38:29.195 And I've had many patients with constipation come positive on on the, IBS smart test. 1688 01:38:30.860 --> 01:38:36.800 Do you feel that the oral microbiome may be impacting SIBO or SIBO impacting the oral microbiome? 1689 01:38:40.139 --> 01:38:45.840 Probably the oral microbiome affecting SIBO more than the other way around because things don't tend to go backwards. 1690 01:38:46.715 --> 01:38:53.034 But there there is an effect. We do see some of the organisms here as well down there. But, 1691 01:38:54.155 --> 01:38:58.815 they haven't done enough work on it. So I can't I can't give you really good answers on that. 1692 01:38:59.355 --> 01:38:59.855 Okay. 1693 01:39:01.250 --> 01:39:05.670 Let's see. Okay. This is the other thing that's like a combination of several peoples. 1694 01:39:05.890 --> 01:39:09.270 I've tried everything or I've even tried the suggested, 1695 01:39:09.570 --> 01:39:10.710 like, you know, treatment, 1696 01:39:12.450 --> 01:39:13.750 and it didn't work. 1697 01:39:14.145 --> 01:39:17.105 Could you talk about doing the multiple rounds of treatment? 1698 01:39:17.105 --> 01:39:19.844 Because this is another blind spot that people have 1699 01:39:20.145 --> 01:39:28.645 about, like because that is a little bit abnormal compared to how we have taken treatments in the past of, like, you know, take this for ten days, the UTI goes away, all good, that kind of thing. 1700 01:39:30.300 --> 01:39:30.800 So, 1701 01:39:31.340 --> 01:39:32.300 there are patients. 1702 01:39:32.300 --> 01:39:36.460 I think this is what you're getting to where I give them rifaximin, then they get 20% better. 1703 01:39:36.460 --> 01:39:39.020 Then I give it again, and they're now at 60% better. 1704 01:39:39.020 --> 01:39:43.985 Then I give it again, and they're now at ninety percent better because they had to take multiple treatments. 1705 01:39:44.525 --> 01:39:49.245 It's not typical. It's not common, but we do have people like that. Okay. 1706 01:39:49.245 --> 01:39:52.205 Very expensive because you have to do it three times to get it to somewhere. 1707 01:39:52.205 --> 01:39:54.765 But then is it gonna relapse or they have Vinculin antibodies? 1708 01:39:54.765 --> 01:40:02.000 Are you gonna go through all of this and then the Vinculin antise are super positive and you gotta go back on this treatment again sometime in the near future? 1709 01:40:02.000 --> 01:40:06.340 So those are the things that bother me. But when when a person doesn't respond 1710 01:40:06.720 --> 01:40:07.220 classically, 1711 01:40:08.400 --> 01:40:16.925 that also bothers me, and I start to do further work up to make sure I know why the SIBO is there, whether it's the antibodies to vinculin or some other 1712 01:40:17.784 --> 01:40:22.505 event in the bowel. You know? Okay. Yes. I'm absolutely answering your questions. 1713 01:40:22.505 --> 01:40:23.804 I put all mine aside, 1714 01:40:24.184 --> 01:40:24.684 because 1715 01:40:24.990 --> 01:40:27.150 I have now 213 1716 01:40:27.150 --> 01:40:27.650 questions. 1717 01:40:29.150 --> 01:40:29.650 Okay. 1718 01:40:30.030 --> 01:40:34.610 Extended release NAC, could we try that with Rifaximin until the study is completed? 1719 01:40:36.190 --> 01:40:36.690 So 1720 01:40:38.125 --> 01:40:42.224 you can try NAC. It's over the counter for some in some instances and 1721 01:40:42.525 --> 01:40:44.465 see if it helps. I I 1722 01:40:44.844 --> 01:40:50.304 personally don't do that, honestly. Yeah. Even though they know what I'm doing, I generally 1723 01:40:50.605 --> 01:40:52.224 haven't I haven't used NAC 1724 01:40:53.430 --> 01:40:59.770 in six months even though I know what NAC can do because I haven't found that it's been as effective that way. 1725 01:40:59.830 --> 01:41:01.770 Let me explain. So NAC 1726 01:41:02.070 --> 01:41:04.010 gets consumed by mucus. 1727 01:41:04.310 --> 01:41:09.705 So it's not like a drug where it's there and it does its thing and then moves on to the next section and does its thing. 1728 01:41:09.705 --> 01:41:12.285 NAC gets consumed by new mucus. 1729 01:41:12.665 --> 01:41:18.205 And so when it's consumed, it's gone. And the stomach contains literally a cup full of mucus. 1730 01:41:18.580 --> 01:41:22.980 And so you take the neck, it's consumed, and then it never gets to the small bowel. 1731 01:41:22.980 --> 01:41:26.739 So I'm not saying it won't work. I'm just saying, yeah, try it. 1732 01:41:26.739 --> 01:41:29.719 And there's some people who are compounding it into 1733 01:41:30.420 --> 01:41:33.560 enteric coated form and trying to take it that way. 1734 01:41:34.435 --> 01:41:39.415 If you wanna try those kinds of things, go for it, but it's it's getting creative, and 1735 01:41:39.875 --> 01:41:43.554 I don't know if it'll work. Outside of the box. Yeah. Outside the box. Yeah. 1736 01:41:43.554 --> 01:41:48.375 We we there is sustained release NAC, and I think that's what most people are trying at this point. 1737 01:41:48.800 --> 01:41:55.920 And that is available for your experimentation on Fullscript and doctor Seabecker's professional dispensary there, and I just put that link in there. 1738 01:41:55.920 --> 01:41:58.580 You're getting 15% off. So Rachel, 1739 01:41:59.040 --> 01:42:02.260 has a summary question. So is IMO autoimmune? 1740 01:42:04.815 --> 01:42:06.275 I would say generally no. 1741 01:42:06.894 --> 01:42:10.675 Mostly not. We don't know why IMO occurs. We generally don't. 1742 01:42:11.054 --> 01:42:12.114 Interesting. Okay. 1743 01:42:12.655 --> 01:42:15.074 Are do how can someone come to Cedar 1744 01:42:15.614 --> 01:42:19.170 to Cedars to get an appointment in the motility clinic? 1745 01:42:20.750 --> 01:42:22.690 We are overwhelmed over here. 1746 01:42:22.989 --> 01:42:29.085 Everybody wants to come see us now because, you know, generally speaking, not a lot of people understand this as well as we do. 1747 01:42:29.645 --> 01:42:34.864 There is a way. You you just gotta go to the seniors website and and go to our GI motility 1748 01:42:35.165 --> 01:42:40.864 program, and you can call the office and see if you can get an appointment with one of our six lovely physicians. 1749 01:42:42.110 --> 01:42:52.050 Now we have had people go to that, and some of them have said some of the people have said that not everyone does your protocol, which, of course, we were horrified about. 1750 01:42:53.869 --> 01:42:58.405 Well, you know, everybody Do you want their names? I'll tell you later. No. Yeah. Oh, maybe. 1751 01:42:59.905 --> 01:43:05.285 So everybody has a style on or a variation on the theme based on their experience. 1752 01:43:06.145 --> 01:43:15.650 So there's hard and fast rules, and then there's, like, we've been discussing here, there's sort of, you know, rough spots where we don't have information or we're not quite sure, like the neck. 1753 01:43:15.650 --> 01:43:20.389 Could a long acting neck get into the small bowel and be effective? Could be. Yes. 1754 01:43:20.769 --> 01:43:21.269 So, 1755 01:43:22.530 --> 01:43:23.025 but 1756 01:43:23.344 --> 01:43:26.804 we need double blind studies, and that's basically how I how I operate. 1757 01:43:27.025 --> 01:43:30.385 So, yeah, I mean, there could be variations of the theme. Okay. 1758 01:43:30.385 --> 01:43:35.284 What do you think about b p one BPC one fifty seven and this new emergence of peptides 1759 01:43:35.640 --> 01:43:36.540 for gut health? 1760 01:43:38.680 --> 01:43:40.140 I mean, I don't use peptides. 1761 01:43:41.000 --> 01:43:42.060 I I have 1762 01:43:43.640 --> 01:43:49.800 there's a lot of pluses and minuses on the on social media and among experts on peptides. 1763 01:43:49.800 --> 01:43:52.465 I know a lot of the experts are very negative on peptides. 1764 01:43:53.885 --> 01:43:58.225 What I say about peptides is your gut is so fantastic 1765 01:43:58.765 --> 01:44:00.065 at digesting proteins 1766 01:44:00.845 --> 01:44:05.425 that those peptides are cut into pieces before they might take action mostly. 1767 01:44:07.600 --> 01:44:11.860 So could they have an effect? Possibly. I'd like to see studies. That's all I'm saying. 1768 01:44:12.880 --> 01:44:13.940 I never say 1769 01:44:14.240 --> 01:44:16.260 I never say no to anything. 1770 01:44:16.640 --> 01:44:17.620 I say maybe, 1771 01:44:18.560 --> 01:44:21.300 and I'd love to see some studies. Yeah. Okay. 1772 01:44:21.895 --> 01:44:23.835 That sounds more than reasonable. 1773 01:44:24.695 --> 01:44:30.075 My SIBO cause nutritional deficiencies. How do you manage SIBO induced nutritional deficiencies? 1774 01:44:31.575 --> 01:44:35.435 Yeah. So SIBO, if it's an extreme form, it can cause b twelve deficiencies, 1775 01:44:36.140 --> 01:44:41.360 can cause even iron deficiencies in some patients. And so those deficiencies need to be corrected. 1776 01:44:41.580 --> 01:44:44.080 If you can correct the SIBO, some of those get better. 1777 01:44:45.020 --> 01:44:48.880 Folate can be elevated actually in SIBO and can be a diagnostic for SIBO. 1778 01:44:50.035 --> 01:44:55.175 But be careful again because SIBO can occur in celiac, and celiac can cause nutritional deficiencies. 1779 01:44:55.235 --> 01:44:59.655 SIBO can be seen in some patients with Crohn's disease if they have strictures or adhesions. 1780 01:45:00.195 --> 01:45:02.835 And so you gotta be careful that you're not just 1781 01:45:03.530 --> 01:45:07.710 you're it's not just SIBO. It could be something else on top of it. You know? Okay. 1782 01:45:08.090 --> 01:45:08.910 And then, 1783 01:45:10.650 --> 01:45:11.150 okay. 1784 01:45:11.850 --> 01:45:13.790 Nope. We he he doesn't do remote. 1785 01:45:14.570 --> 01:45:15.950 Please repeat where to get Rifaximin. 1786 01:45:16.090 --> 01:45:20.065 Go ahead and watch the replay for that because we do talk about it, and some people are getting it compounded. 1787 01:45:20.605 --> 01:45:23.824 And Salix, s a l I x, is the manufacturer. 1788 01:45:25.885 --> 01:45:26.385 Okay. 1789 01:45:26.925 --> 01:45:29.985 Any suggestions on, like, how people could find a 1790 01:45:30.540 --> 01:45:31.040 gastroenterologist 1791 01:45:31.900 --> 01:45:36.960 that has is more aware of your research? Do you, like There you go. Any suggestions? 1792 01:45:37.580 --> 01:45:42.140 Yeah. We don't have, like, a website of Yeah. People who like me or I like them. 1793 01:45:42.140 --> 01:45:44.560 I think that's not that's not a good thing. Facebook. 1794 01:45:45.045 --> 01:45:48.565 Yeah. That's not I mean, not generally speaking, that's not even a good thing to say. 1795 01:45:49.045 --> 01:45:50.105 You know, it's just 1796 01:45:50.485 --> 01:45:54.745 who do actively do breath testing and have some kind of sophistication with treatment. 1797 01:45:55.205 --> 01:45:57.545 But they're out there. There are a lot of them out there. 1798 01:45:58.909 --> 01:45:59.310 Yes. 1799 01:45:59.310 --> 01:46:07.570 Our program is at the cutting edge, and so people really wanna come here because we are doing things in our clinic that nobody does because they don't know yet. 1800 01:46:07.790 --> 01:46:09.090 So sometimes that 1801 01:46:10.285 --> 01:46:12.605 overwhelms us because people wanna come here. 1802 01:46:13.245 --> 01:46:17.825 But there are doctors out there. Every state has doctors. 6,000 breath tests were done 1803 01:46:18.605 --> 01:46:21.105 in 50 states, so there are people who know. 1804 01:46:21.885 --> 01:46:25.745 Well, that's good to hear. Michelle Frank Michael Franklin. Sorry. I didn't call you Michelle. 1805 01:46:25.880 --> 01:46:29.400 Michael Franklin had a doctor who knew SIBO and tested him. 1806 01:46:29.400 --> 01:46:35.659 So so it's spreading, and people are getting awareness is going up, and we're doing these things to try 1807 01:46:36.040 --> 01:46:42.015 and get people up to speed. So Thank you. In UK, I saw UK. Colab does TrioSmart. 1808 01:46:42.955 --> 01:46:43.455 Colab, 1809 01:46:44.475 --> 01:46:45.855 How do you spell it? Colab 1810 01:46:46.235 --> 01:46:49.275 colab e colabeu.com, 1811 01:46:49.275 --> 01:46:51.475 colabeu.com. 1812 01:46:51.595 --> 01:46:56.660 Website for international testing. Yeah. So you can do it in UK now for the first time. 1813 01:46:56.660 --> 01:46:57.800 So that's pretty exciting. 1814 01:46:58.500 --> 01:47:02.900 That's also one way that we often recommend people is sort of back engineer it. 1815 01:47:02.900 --> 01:47:08.520 Call some of the labs and ask if they could give you names of doctors that order tests from them in your area. 1816 01:47:09.635 --> 01:47:10.135 Exactly. 1817 01:47:10.595 --> 01:47:13.815 Exactly. That is a great one. Okay. We have two minutes. 1818 01:47:13.955 --> 01:47:19.335 So what I would really appreciate is a lot of love into the chat for doctor Pimentel. 1819 01:47:20.035 --> 01:47:24.535 Thanking him. Thank you, sir, for your time, your energy, your effort. Send our love 1820 01:47:25.030 --> 01:47:30.890 to everyone back at the lab and your families because we know you're making sacrifices all over the place. 1821 01:47:31.270 --> 01:47:35.450 We wish that we could have gotten to more questions. We literally have hundreds, plural. 1822 01:47:35.910 --> 01:47:37.605 So I did put into the chat, 1823 01:47:38.165 --> 01:47:46.645 if you wanna continue with some questions where, like, doctor c Seabecker can help out, we have ways for getting some more questions answered. 1824 01:47:46.645 --> 01:47:51.605 And, it's called the two ways we can help, and you can find more about that at ciboinfo.com 1825 01:47:51.605 --> 01:47:53.370 and cibosos.com. 1826 01:47:54.730 --> 01:47:55.230 Donate. 1827 01:47:58.010 --> 01:48:00.750 Spread the word. Forward this to a friend. 1828 01:48:00.810 --> 01:48:05.370 Like, subscribe, and, you know, all that stuff at ciboinfo.com 1829 01:48:05.370 --> 01:48:10.485 or, the Cibo Info's, YouTube channel and Cibo SOS YouTube channel, please. 1830 01:48:10.785 --> 01:48:15.845 The recording will go out tonight. Thanks for the reminder, Carol. We that's our automatic protocol. 1831 01:48:15.905 --> 01:48:19.365 Our goal is to, like, have as many people see this as possible. 1832 01:48:19.825 --> 01:48:21.905 So please definitely do that. 1833 01:48:21.905 --> 01:48:28.079 Also, the Siobhan show health, wealth, Wisdom is launching January 20 January. No, Siobhan. 1834 01:48:28.619 --> 01:48:30.619 06/20/2026. 1835 01:48:30.619 --> 01:48:34.780 Yeah. I know. In three days, I've been working on this idea for over ten years. 1836 01:48:34.780 --> 01:48:37.635 So please also like, subscribe, and share that. 1837 01:48:37.875 --> 01:48:41.574 YouTube for Sha'Vonne Sarnoff official and, you know, Spotify and Apple. 1838 01:48:41.635 --> 01:48:46.054 And the first guest is doctor Allison Seabecker, and we will be putting this there, 1839 01:48:46.675 --> 01:48:47.175 this 1840 01:48:48.594 --> 01:48:50.375 this session there in the podcast, 1841 01:48:50.755 --> 01:48:52.140 and we're working on that. So 1842 01:48:52.620 --> 01:48:57.140 getting it out there. So much. Like, just your work is just soaring Magnificent. 1843 01:48:57.580 --> 01:48:58.080 Incredible. 1844 01:48:58.380 --> 01:49:04.060 Thank you for taking the time to come, and you're, you know, you're so busy, but you come to educate all of us. 1845 01:49:04.060 --> 01:49:05.805 Thank you so much. Yeah. No. 1846 01:49:05.805 --> 01:49:14.705 And I'm just watching all these questions come across, and I I can I see these patients in my clinic, and I there's so much help that we can be given, 1847 01:49:15.725 --> 01:49:17.565 once the doctors can get up to speed? 1848 01:49:17.565 --> 01:49:21.880 And I and I feel bad that these patients are struggling out there not finding the right practitioner. 1849 01:49:22.020 --> 01:49:23.400 I'm sorry for that, but 1850 01:49:23.780 --> 01:49:25.300 you can't divide us up. 1851 01:49:25.540 --> 01:49:30.120 We've we're we're only one body, so we're we're trying to disseminate this information. 1852 01:49:30.180 --> 01:49:33.000 We're doing our best. So Yeah. Alright, doctor Pimentel. 1853 01:49:33.605 --> 01:49:38.885 Make it across campus for that next session. Thank you so much, sir. Okay. Take care. Thank you. 1854 01:49:38.885 --> 01:49:40.344 Bye. Thank you. Bye bye. 1855 01:49:40.645 --> 01:49:44.885 Thank you all so much for coming. Be sure to check your emails from what we're up to. 1856 01:49:44.885 --> 01:49:48.560 We have a tough cases SIBO master class tomorrow, 1857 01:49:49.100 --> 01:49:50.300 as a matter of fact. 1858 01:49:50.300 --> 01:49:55.360 By the way, I I interviewed doctor Pimentel for that along with 11 other colleagues. 1859 01:49:55.580 --> 01:49:58.320 So incredible advice if you have a tough case. 1860 01:49:59.074 --> 01:50:04.375 I would love it, doctor Seabecker, if you could grab me that link, and I will pop it into the chat. 1861 01:50:04.594 --> 01:50:06.855 And because I just wanna do one other things. 1862 01:50:07.315 --> 01:50:13.020 Pelvic floor. So, yes, we didn't get to that today, and I'm sorry about that. But if you look, 1863 01:50:13.980 --> 01:50:16.960 at our YouTube channel, SIBO SOS and SIBOinfo, 1864 01:50:17.500 --> 01:50:21.200 there is some information about pelvic floor, like from doctor Rao, 1865 01:50:21.580 --> 01:50:23.920 r a o, that you can look up there, 1866 01:50:24.460 --> 01:50:26.240 talking about that. So, 1867 01:50:29.065 --> 01:50:32.364 he's doctor Pimentel is working, Christopher, on 1868 01:50:32.905 --> 01:50:35.804 the anti vinculin and the other antibody. 1869 01:50:37.625 --> 01:50:40.824 He just talked about that earlier in the presentation. They wanna get rid of it. 1870 01:50:40.824 --> 01:50:42.585 They're working that's what they're actively working on. 1871 01:50:42.585 --> 01:50:45.910 They're working on cures, and they are working, like, for, 1872 01:50:46.370 --> 01:50:52.630 you know, the more obvious symptoms stuff, but they're also in addition and combined with that, they are looking to address the, 1873 01:50:53.570 --> 01:50:57.910 antibodies. And he said he alluded to it within two years, but 1874 01:50:59.205 --> 01:51:03.284 that's actually the fastest I've ever heard him say it because we ask him all the time. Yeah. 1875 01:51:03.284 --> 01:51:04.905 And so that really was the fastest. 1876 01:51:06.085 --> 01:51:11.284 Well, I think I'll put the link for the, master class tomorrow, but it's some crazy long link. 1877 01:51:11.284 --> 01:51:14.460 Oh, is it? Okay. Yeah. I'll put it in there. But Okay. Yeah. Go ahead. 1878 01:51:14.860 --> 01:51:17.260 So I don't know why it converts like that. The 1879 01:51:17.980 --> 01:51:19.660 crazy. The but doable. 1880 01:51:19.660 --> 01:51:24.239 The master class that we're doing tomorrow is doctor Seabecker's tough cases master class. 1881 01:51:24.300 --> 01:51:26.080 And as she just said, she interviewed 1882 01:51:26.635 --> 01:51:28.815 the other SIBO specialist that she knows 1883 01:51:29.195 --> 01:51:33.775 that Including doctor Pimentel. And, of course, all my advice, all I ever see is tough cases. 1884 01:51:34.315 --> 01:51:38.655 And then it's followed by two hours of q and a, with doctor Seabecker. 1885 01:51:39.180 --> 01:51:41.340 So it's a watch party. We watch it together. 1886 01:51:41.340 --> 01:51:44.800 On the other hand, you could also just instantly watch it. It's on demand. 1887 01:51:44.860 --> 01:51:51.360 And then the two hours after that is live. So it starts at three eastern time and then at 4PM, 1888 01:51:53.135 --> 01:51:56.255 because I think it's an hour long. It's a two hour q and a with her. 1889 01:51:56.255 --> 01:52:00.345 If you are watching this and it is not June 1890 01:52:00.345 --> 01:52:01.395 2026, 1891 01:52:01.855 --> 01:52:07.700 then you can still get a hold of that because we do share an opportunity for you to get the recordings. 1892 01:52:07.920 --> 01:52:10.500 It's called part of the SIBO solution series. Okay. 1893 01:52:10.800 --> 01:52:16.515 That's it. We love you. One more thing. Uh-oh. Mentioned the call. We do I do a q and a every month. 1894 01:52:16.595 --> 01:52:19.235 So I'm happy to help answer your questions. 1895 01:52:19.235 --> 01:52:23.415 I know you have a lot of people had a lot of case questions that we couldn't get to today. 1896 01:52:23.555 --> 01:52:27.315 So I'd be happy to do that. Thank you. And this is a $33 1897 01:52:27.315 --> 01:52:31.415 a month membership, this the SIBO and IBS membership. 1898 01:52:32.100 --> 01:52:36.020 And you get access to our courses, the SIBO recovery roadmap course. 1899 01:52:36.020 --> 01:52:39.080 You get access to all kinds of q and a's that we've done in the past, 1900 01:52:39.780 --> 01:52:43.619 mold master class, all kinds of things, and a monthly q and a. 1901 01:52:43.619 --> 01:52:48.525 So I see someone ask me when the next q and a is. Let me look that up. Also, somebody asking about 1902 01:52:48.985 --> 01:52:51.705 that you you use Fullscript through another doctor. 1903 01:52:51.705 --> 01:52:56.685 You just need my link, which Siobhan has put in there. If you just hit my link, it goes into 1904 01:52:57.065 --> 01:52:57.565 mine. 1905 01:52:58.120 --> 01:53:02.219 So you can have you can use different doctors' links for full script. 1906 01:53:02.600 --> 01:53:06.700 Okay. And, also, if you do join the membership, it is 20% off full script, 1907 01:53:07.560 --> 01:53:10.815 while you're in the membership. And we have small group coaching. So check it all out. 1908 01:53:10.975 --> 01:53:15.855 What a treat July 16 is our next is my next q and a. Okay. Great. 1909 01:53:15.855 --> 01:53:18.435 We are you sure that's not when small group coaching starts? 1910 01:53:19.969 --> 01:53:23.349 I haven't asked for membership q and a. Okay. Alright. 1911 01:53:24.849 --> 01:53:26.949 I'm gonna stop the recording. Thanks, everybody. 1912 01:53:27.329 --> 01:53:29.829 Thanks, everyone. Thank you all so much.