Hello Friends,

In this episode of “At the Bench”, we have the privilege of interviewing one of our hosts, Dr. Misty Good. Dr. Good discusses her amazing career journey from learning to pipette water at the beginning of her neonatology fellowship to becoming a multiple R01-funded investigator. She shares how she is inspired every day to improve the care of preterm infants with necrotizing enterocolitis through her research and how she decided to pursue a career as a physician-scientist due to the desire to improve the lives of all babies. Dr. Good’s story serves as an inspiration to early career faculty and those navigating the challenging but incredibly rewarding career path of a neonatologist-scientist.

Enjoy!

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 Some Highlighted Papers:

Lanik WE, Luke CJ, Nolan LS, Gong Q, Frazer LC, Rimer JM, Gale SE, Luc R, Bidani SS, Sibbald CA, Lewis AN, Mihi B, Agrawal P, Goree M, Maestas MM, Hu E, Peters DG, Good M. Microfluidic device facilitates in vitro modeling of human neonatal necrotizing enterocolitis-on-a-chip. JCI Insight. 2023 Apr 24;8(8):e146496. PMID: 36881475. PMCID: PMC10243823. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10243823/ 

Good M, Sodhi CP, Egan CE, Afrazi A, Jia H, Yamaguchi Y, Lu P, Branca MF, Ma C, Prindle T Jr, Mielo S, Pompa A, Hodzic Z, Ozolek JA, Hackam DJ. Breast milk protects against the development of necrotizing enterocolitis through inhibition of Toll-like receptor 4 in the intestinal epithelium via activation of the epidermal growth factor receptor. Mucosal Immunol. 2015 Sep;8(5):1166-79. PMID: 25899687. PMCID: PMC4540669. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4540669/ 

Good M, Sodhi CP, Yamaguchi Y, Jia H, Lu P, Fulton WB, Martin LY, Prindle T, Nino DF, Zhou Q, Ma C, Ozolek JA, Buck RH, Goehring KC, Hackam DJ. The human milk oligosaccharide 2-fucosyllactose attenuates the severity of experimental necrotizing enterocolitis by enhancing mesenteric perfusion in the neonatal intestine. Br J Nutr. 2016 Oct;116(7):1175-1187. PMID: 27609061. PMCID: PMC5124125. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5124125/

Lanik WE, Xu L, Luke CJ, Hu EZ, Agrawal P, Liu VS, Kumar R, Bolock AM, Ma C, Good M. Breast Milk Enhances Growth of Enteroids: An Ex Vivo Model of Cell Proliferation.  J. Vis. Exp. 2018 Feb 15;(132). PMID: 29553558. PMCID: PMC5912412. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5912412/ 

Good M, Siggers RH, Sodhi CP, Afrazi A, Alkhudari F, Egan CE, Neal MD, Yazji I, Jia H, Lin J, Branca MF, Ma C, Prindle T, Grant Z, Shah S, Slagle D, Paredes J, Ozolek J, Gittes GK, Hackam DJ. Amniotic fluid inhibits Toll-like receptor 4 signaling in the fetal and neonatal intestinal epithelium. Proc Natl Acad Sci U S A. 2012 Jul 10;109(28):11330-5. PMID: 22733781. PMCID:PMC3396489. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3396489/ 

Good M, McElroy SJ, Berger JN, Wynn, JL. Name and Characteristics of National Institutes of Health R01-Funded Pediatric Physician-Scientists: Hope and Challenges for the Vanishing Pediatric Physician-Scientists. JAMA Pediatrics. 2018 Mar 1;172(3):297-299. PMID: 29340570. PMCID: PMC5885833. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5885833/ 

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Short Bio: Dr. Misty Good is a neonatologist-scientist and the Division Chief of Neonatology at the University of North Carolina at Chapel Hill. Dr. Good’s laboratory combines innovative, precision medicine bench-to-the-bedside approaches focused on necrotizing enterocolitis (NEC), a devastating intestinal disease that primarily affects premature infants. She is the founder and director of the NEC Biorepository, which is the largest biorepository of samples from preterm neonates in the United States and is a collaborative effort of 10 institutions across the country. Dr. Good’s long-term goal is to combine basic science and translational research to inform the development of clinical treatments to prevent and cure NEC altogether. In addition, Dr. Good is committed to fostering the development of the next generation of pediatric physician-scientists and leads national efforts to support and retain early-career scientists.

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The transcript of today's episode can be found below 👇

Welcome to At the Bench, the neonatal physician scientist podcast where we are incubating discoveries. I'm Dr. David McCully and I'm co-hosting this program with Dr. Betsy Crouch and Dr. Misty Good.

We're aiming to highlight outstanding people, their cutting edge research, the hottest techniques and career development, for NICU fellows and faculty, and anyone who wants to talk about how to take results from experiments and use them to improve babies' health. This is a new edition of the Incubator podcast now at the bench. We are all neonatologist scientists with different areas of scientific expertise. We are also passionate about inspiring and training the next generation of researchers with dual clinical and investigational skills.

Welcome back to At the Bench, the physician scientist podcast of the incubator. I'm David McCully and one of the co-hosts of this program.

And hi, I'm Betsy Crouch. I'm also a co-host of At the Bench. I'm a neonatologist at University of California, San Francisco. David, you want to introduce our guests for today? Yeah. So today we're going to continue with our introduction program where we're interviewing one of our own co-hosts. Today we're excited to be able to interview Dr. Misty Good. Misty, could you introduce yourself?

Sure. Hi everyone. I'm Misty Good. I'm the division chief of neonatology at the University of North Carolina at Chapel Hill, and I'm honored to be on the podcast today.

Well, we're thrilled to get to interview you. I have to say that I sort of knew who you were even before I got to talk with you as a friend and colleague from your clinical trial for NEC and doing some of your therapies that we're going to talk about today, and also your outstanding social media presence. So for all of these and your leadership qualities, we're excited to hear more about your journey and about what inspires you today. So we always like to start by talking about your career trajectory. And notably, you're now the division chief and principal investigator of a lab. But I do know that being a basic scientist wasn't always your career plan.

How did you get interested in science?

Well, I first joined a pediatric surgery lab as a second year neonatology fellow when I was at the University of Pittsburgh. And I had no background at all in science. And so, I spent the first two weeks when I joined the lab just pipetting water, actually, which was pretty ridiculous. Literally pipetting water. And I think because nobody in the lab trusted me to do anything else. And so I was literally pipetting water and they would weigh it and see if I was accurate or not. So it took me a while to get there.

Did you pass? I passed. Yeah, I passed. As I learned more techniques, I became really interested in basic science research and thought it was really exciting that we have the opportunity to develop and test new drugs, especially for diseases that are really hard to treat. And so when I was a third year fellow, and needed to start looking for a job, I was torn at the time. Do I continue with what I thought I was going to do, which was be a clinician educator and stay in academia, or did I want to pursue a physician scientist career? And obviously, I chose the physician scientist path.

Misty, you've been spending a lot of time investigating necrotizing enterocolitis, and I just wanted to know a little bit more about how you got interested in NEC and what sort of...

drove you down this path of research?

Sure. Thank you for that question. I first became interested in NEC when I was a pediatric resident. And we would be covering a handful of babies in the NICU. And then you would go home for the day and then come back the next day. And there would be a new baby in a previous patient that we were taking care of in that bed space. And so when I asked the nurse practitioners, what happened to the baby? Where did that baby go? They said, oh, that baby died overnight from NEC. I was completely devastated and shocked. Like, was it something we did? Was it something we didn't do? Was it something that was missed? How can we do better? And so I remember not knowing anything about the disease, but I knew that I was totally terrified of it and everyone in the NICU was also. And when I started thinking about it more and researching more of the literature of what we knew on NEC, it was so clear that there wasn't, there was so much we didn't know, and there was so much that we still needed to do. There were no preventative strategies, no treatments, real treatment strategies. And we just started our treatment and hoped for the best. And there were certainly no biomarkers for the disease.

It's interesting even in like the way that we talk about NEC totalis, right? Which is like the worst thing that you can say, in terms of the severity of this disease. But also, if you think about those words, I mean, it's so unspecific, right? It just means literally, there's just NEC everywhere and that's all we can say and there's nothing we can do. And that's the end point. So I don't know, I'm really grateful that you decided to try to create some clarity. Thank you. Yeah. It's the most just dreadful disease that we study.

When I became a Neonatology fellow, I really was like, we have to do something. You know, you have to pick a project, obviously, to study when you're a fellow. And so I knew that even if I could just, you know, for the next few years, just focus on this disease and try to learn a little bit more, I would feel better about it. But then as I was, you know, in the lab and learning more, I became really passionate about it, and we really need to do better for our babies and their families and for all the healthcare providers taking care of them, because everyone's devastated by this disease. And it impacts us every day. Like, babies on a NEC watch or, you know, a rule out. And it's just really frustrating.

Yeah, our last bad M&M was for a baby who died of NEC totalis. And we're still trying to figure out how we could have done better, but you know, there isn't a lot. Can I ask one question, which is, when you were just starting in the lab, how did you go from pipetting water to what was your first experiment? And how did that take you down this path that now you're a pioneer in this disease?

Yeah, I think in terms of first experiments, I did have to learn how to do intestinal epithelial cell culture. So you know, first, working with cell lines, I had to learn how to handle mice, and so that was one of the early things that I needed to learn. We had, as I mentioned, I joined this pediatric surgery lab, and so I had to learn our neonatal mouse model of necrotizing enterocolitis, and so that requires hand feeding by gavage neonatal mice, you know, special formula, and special microbiome, etc. It's a technically challenging procedure. And so, hand feeding the mice; those were probably some of the first early experiments.

Was there somebody in the lab who was helping you, who was like mentoring you and showing you what to do? Because it's never the principal investigator, usually, unless you're joined like a small lab.

No, I agree. We had this amazing lab family. There was just a team of PhDs and technicians that were teaching me at the bench literally every day, you know, how to do a Western blot, how to do quantitative PCR, how to do immunofluorescence of the intestines and look for different protein markers. And we had an animal manager that was in charge of the mice that taught us how to hand feed them. So how to draw blood, you know, do all those things that we do for the in vivo studies.

That's awesome, Misty. One of the things I wonder about, and I think it's common to a lot of the diseases that we study, is that there's a lot of different ways that babies will develop NEC. It's a really heterogeneous disease. And I just wonder, like, how do you begin to think about, you know, designing a project or even a simple experiment that takes into consideration, you know, how heterogeneous the process of NEC actually is?

The biggest thing when you're doing basic science research is you want to develop your model systems, right? And you want to know exactly what outcomes you're looking for in, you know, related to the human condition. So we obviously study the human condition and we get a large volume of patient samples from babies that have NEC compared to those babies that didn't develop NEC. And then we basically go back to, you know, from the bedside to the bench and incorporate that knowledge into our mouse models and our in vitro models. And so when it comes to our mouse model of NEC, over the years, it's actually evolved into knowing more about the microbiome, for example, and, you know, specifically taking the microbiome of a baby with NEC totalis and adding that to a special formula that we feed the mice. And then learning about innate immunity and how our babies are affected by a lack of innate immunity and how we can model that in the mouse by adding things to the formula like lipopolysaccharide or LPS, which is the ligand for Toll-like receptor 4, which is one of the innate immune receptors.  Because we know from studies from David Hackam's lab and others that this is a very important immune receptor in the disease. So taking what we know and then applying it to those models, I think is really important.

I just wonder with that experiment, I think that helps to think about the heterogeneity of NEC. Because it's so heterogeneous, it's unlikely that you'll find any single genetic variant that is associated with NEC, but you may find subgroups of patients with NEC that do have similar genetic variants, but that there's a single one is probably not too likely. I would imagine the same reason for germinal matrix hemorrhage, and it's definitely the same for CDH. But just thinking about that is like thinking about are there preventative things that you could do to identify patients who are at risk of developing NEC or who are in earlier phases of the disease? It seems like you've done a ton of work on this line of thinking. I don't know if you can you just summarize some of that or how should we think about it?

The million dollar or multi-million dollar question is really how can we prevent NEC or how can we also determine which babies are going to get NEC and then, you know, be able to either administer some type of preventative therapy or preventative nutritional therapeutic. That would be the ideal thing rather than thinking about how can we better treat the disease, which is also an area of active investigation. But, I will say when I first started in the lab, it had been known for decades that the only way that we could protect against NEC was to provide the infants with maternal breast milk, and there's a lot of great amazing components that are in mother's milk and my fellow project was actually looking at individual components of maternal milk and how they can protect the gut from intestinal inflammation even though there's like so many different things. But at the time, we focused specifically on a growth factor that was present in amniotic fluid, because we all know that fetuses don't get necrotizing enterocolitis. And so we were looking at commonalities between amniotic fluid and breast milk. And one of them is epidermal growth factor, or EGF. There was a lot of good data coming out that EGF protect against adult intestinal diseases and so we wanted to focus on that. That was one of my first projects when I was also trying to figure out how to get breast milk from mice, so we could use them in our experiments. So EGF is, I think, very intriguing.

Were there other components of breast milk that you think are also, I don't know, that you could highlight? Yeah, a couple of specific components that you think are most effective?

After EGF, I studied two fucosyllactose, that's a sugar, human milk oligosaccharide, that's present in breast milk. And there was some really great data coming out at the time looking at moms that are secretors of these human milk oligosaccharides or non-secretors. And depending on the composition of the breast milk, their infant will be more or less likely to get NEC. And so, you know, certainly that could be one of the risk factors. But we're not doing personalized nutrition at the bedside, and we're not doing a lot of that, at least in most NICUs. And so, you know, hopefully personalized nutrition is the wave of the future. But I'll say one exciting component that we have looked at, and basically after I had done, my first postdoc in the lab which was looking at mostly pathogenesis of NEC and breast milk components. I did a second postdoc with Dr. Jay Kolls, who is a Th17 expert and pediatric pulmonologist. And he studies interleukin 17 and IL-22. And he was looking at using IL-22 as an immunotherapeutic strategy for various diseases, not NEC, but respiratory diseases. And so, when I joined his lab, we wanted to look at using IL-22 as an immunotherapy for NEC. And so we've been doing that for the last, I would say, over five years now, and have done a lot of experiments looking at the prevention and treatment of NEC with IL-22 as an immunotherapy. And we have a patent now, which is really exciting, approved for the use of IL-22 to prevent and treat NEC and we're working with the FDA to get this approved for clinical trials in the NICU. So super exciting, more to come on that.

Can you tell us more about how it works?

Yeah, so I can. So we've looked at all different, I would say, preventative strategies and timing of administration, and it seems there's certainly an optimal time to administer the IL-22, and preventative would be would be the best thing. But in terms of when you're trying to design a clinical trial for these fragile neonates, you can't give everybody the drug. And so what we have looked at is if we can get the drug in within six hours into our neonatal mice, we can attenuate the intestinal inflammation, we can decrease the pro-inflammatory cytokines in the gut at the mRNA and protein level. There's all the cell death pathways are down-regulated, like apoptosis, ferroptosis, necroptosis, and really the IL-22 is acting on the epithelial cell and helping the epithelial cell turnover and regeneration, and it seems like it’s healing the gut that way. Now, too much of a good thing when you're thinking about immunotherapies is really important, and so we know that the lowest dose possible is going to be important for our babies so that we don't over-activate their already premature immune system. So we've done all kinds of toxicity studies as well to make sure that we're not giving too high of a dose. And we basically take those doses that we've tested and then we can extrapolate them to our babies.

I'm going to ask a very selfish question because as a vascular biologist, I've always been fascinated by the vascular component to NEC. So do you think are any of these components that you mentioned acting directly on the vasculature? Or you think they're all acting on the intestinal epithelium?

I will say when we were looking at the HMO studies that we were doing, we did look at the intestinal perfusion and we basically intracardiac injected some tomato lectin and then let it circulate around and then looked at the staining for that as a surrogate for intestinal perfusion after the animal was euthanized and found that in NEC, there was decreased intestinal perfusion, which we can see clinically in our babies and certainly see in our mouse model of NEC. But when we added the human milk oligosaccharide to their mouse formula, we saw that they had improved intestinal perfusion, suggesting that one of the ways in which the HMO is protecting from NEC is by at least enhancing the vasculature, but I'm not a vascular biologist.

I know, those are where my questions are going. Is it vascular proliferation? Is it the barrier function?

Yeah, we do know with interleukin-22, it can improve the barrier function. And so we have seen that in vivo, and we have another model called our NEC-on-a-Chip model that we are testing various drugs and looking at different tight junctions and cell death markers and other items.

Misty, I thought it was really cool how you mentioned that finding the balance, especially when thinking about immunomodulation is really important. I think a lot of people tend to think of things as kind of being a black or white or on or off switch, I think really helpful to think about how do you restore a healthy state by maintaining balance or something like that. I wonder if you could talk a little bit about that. And also just because we were talking about how NEC is heterogeneous and you're talking about doing this translational work, how you have been thinking about trying to identify the patients that are the ideal candidates for this type of intervention?

In neonatology, we see a lot of diseases that are heterogeneous and when you have a good idea, but then apply it to a really broad group of patients, you don't end up finding anything that seems to work. But there might be a subgroup of patients that can really benefit. One of the most frustrating parts of studying NEC is just the heterogeneity of the disease. And it's really the biggest challenge that we face as NEC investigators. And I would say one of the ways that we've been trying to address these challenges is by developing the NEC biorepository. So I started this in 2017, well, I actually started collecting samples when I was a fellow, long before that. But then moved it into a multi-center NEC biorepository in collaboration with the NEC Society because we were really trying to break down the barriers in the field and get a biomarker for the disease because, as you mentioned, we don't know which babies will go on to develop NEC. We know that the smallest and sickest are at the highest risk, but then those babies don't get NEC, and we have twins where one gets NEC, and one doesn't.

Or what about cardiac? That's the other thing I've been waiting to ask are you modeling the cardiac kids who get NEC at all?

We are not modeling cardiac NEC in the lab, no. We mostly model premature NEC in the lab. I will say that some personalized, now that we're a little off topic, but some personalized approaches that we're looking at using our NEC-on-a-Chip model, which I can talk more about. We obtain pieces of intestine for our biorepository and for our experiments. We obtain pieces of intestine that are resected for NEC or any indication. And so babies, whether they're preterm babies or babies that are term or late preterm or even with cardiac NEC, we obtain pieces of intestine and then utilize them in the lab. So we can isolate the stem cells out, we can isolate the epithelial cells, and the immune cells for various parts of the experiment, and we can grow up these little mini-guts in the lab called enteroids, and you can do experiments directly on the enteroids, or you can take those enteroids and then dissociate them a little bit and put them on a microfluidic chip that mimics the peristalsis of the intestine and the continuous flow. The chips get stretched in their module in the incubator. And so you can, after several days, you can see that there's an intact epithelium, you can see intestinal villi developing, which is really cool. Once you have all those tight junctions and the gut barrier in the chip has developed, you can then add on patient microbiome or, feed the chip various things, or test different therapies. So we have an R01 that is focused on specifically testing various therapies in the chip to see how we can make the gut stronger in the lab, but utilizing patient samples that have either already been affected by NAC or just our premature intestine that comes out for other reasons like volvulus or atresia, et cetera.

I love that, just hearing about how you're tackling these problems, which I think have prevented people from making progress in this for a long time.

Definitely trying. I think the biorepository is really one of the things that is helping the field break down some of these barriers because as we talked about a little bit, NEC is, even though we see it a lot at each center, it is very heterogeneous, and it's considered a rare disease. Even though we see it a lot, it is considered rare. There aren't that many patients at any one center that are getting NEC, and we need to be studying them all. The disease is so heterogeneous. Luckily we have 10 centers, and I found it easy to get this started to collaborate with my friends who also study NEC and inspire me to do better. We have developed this just amazing infrastructure across the nation to obtain samples and train coordinators and really collaborate, write grants, and really try to get at which babies are at the highest risk, and then how can we develop biomarkers.

It's awesome to hear how you personally are coming after NEC from multiple different angles to try to figure it out using a lot of different approaches. And also you have this national group of people who are similarly interested in trying to better understand the underlying mechanisms responsible for NEC but come up with novel ways of thinking about it. I think that's really inspiring to young physician scientists who are trying to develop a research interest of their own, so it's really great to hear how that has been working. Are there other challenges you've faced that you feel like are interesting to cover here that people would benefit from knowing more about? I think we all face a lot of challenges, and our work is challenging, but just curious to hear what you think.

I think in science there are so many different challenges that we have to encounter and overcome and it makes us really resilient. I would say this disease humbles us every day and keeps us going because we have to do better. And thinking about that and how devastated our team gets when we lose a baby that has NEC, we have to think about it in the lab and what happened. And like Betsy was saying earlier when, you know, they just had an M&M on a baby. We really have to look at every single case and can we do better? Is there anything we could have done differently? And always the answer is no, so we have to do better in the lab and we have to do better at figuring out what can we learn from our patient samples, for example. And so I would say hypothesis-driven science is what we were all trained to do. And with this disease, you kind of have to flip that all around and just say we have to get samples and take an unbiased approach to everything. And with as many next-gen sequencing techniques are out there now, and there's new techniques every day, applying those techniques to the samples that we have been so fortunate to obtain, I think is the way we're going to learn more about the disease. But I think the biggest challenge is, after you overcome getting the samples, it's really knowing what to do with them, and then how to judiciously make sure that we're getting the most information out of that precious patient specimen.

I think one of the things that we struggle with a little bit is that we're in a similar position where we really need to be doing a lot of hypothesis generating work, but we're expected to do hypothesis-driven work. And so just curious, how do you think about those two issues? Just thinking about writing a new grant that usually needs to be centered on a central

new ideas. How do you think about that?

I think when you're thinking about different grant mechanisms and what you're going to submit, certainly the NIH, we've been really fortunate to have NIH funding that has been focused on hypothesis-driven science, I would say, really mechanistic studies. I think there are other funding mechanisms that you can look at that may be hypothesis-generating. We've been really fortunate to collaborate with amazing, brilliant scientists across the country. And in collaboration with Scott Magness at UNC, Cami Martin at Cornell, Troy Markle at Indiana, and Amy Hair at Baylor and the NEC Society, we were so blessed to get this grant from the Chan Zuckerberg Initiative, a funding mechanism that was focused on single cell RNA sequencing and looking specifically at pediatric inflammatory diseases. And we were one of five groups out of, close to 300 in the world that were awarded this grant. That's one of those funding mechanisms that is just incredible, and they let you sequence a bunch of the samples. It's really going to be hypothesis generating for all of us that study NEC for the next, hopefully several decades, but hopefully, we can cure this disease before then.

I did want to offer that like as another kind of encouraging story that I do find that if you have a track record of productivity, as a neonatal physician scientist, and you're studying something that impacts babies, I found that if you can write a good grant and just show them that, yes, I can do science, I can do experiments, I can write papers, I can get them accepted, that there's a lot of urgency, and I think there's a lot of passion for our topic, right? Like what's better than preventing mortality to a baby, but also the morbidity that happens, right? If a baby has short gut, et cetera. In germinal matrix hemorrhage, if a baby has neurological deficits for life, I just find that once you get to a point as a physician scientist in neonatology that I found the funding not as difficult to acquire as I think other scientists because the topic is fairly novel and the patient could not be more compelling. So I did want to highlight that aspect of your journey, that once you get there, that the funding can be, I don’t know, sometimes things fall into place with neonatology.

It is true. I mean, who doesn't want to fund babies? Our lab motto is that we're saving the babies from NEC, and that's what we truly believe. And we've been really fortunate to have amazing funding sources over the years.

Your story is super compelling. I just wondered, thinking in the near future, what's inspiring you now?

Oh my gosh, so many things. The patients and families inspire us every day to do better.  And there's so many questions in this field that really need to be answered. And what gets me out of bed in the morning is the ability to do amazing basic science and translational work in our lab with a fantastic team that's really dedicated to improving outcomes for babies. And I get to collaborate with a bunch of amazing, smart, brilliant people across the country, which is always, always awesome. And then one of my other hats that I wear is I'm the co-program director of our UNC pediatric residency and fellowship physician scientist training program. And I love that I get to inspire and foster the next generation of pediatric physician scientists. And now we have this incredible podcast with the two of you to be able to also do that for our field. So it's really, really incredible. And I love to see it all playing out.

If you had to draw a picture, like you're saying, like a model, an illustration or a schematic, what are the key factors that drive NEC pathogenesis that you think about?

In terms of NEC pathogenesis, I would say the working hypothesis of what we think happens really comes from the microbiome data in humans and that 48 to 72 hours prior to a diagnosis of NEC, these babies will develop microbial dysbiosis in the intestine, which is a bloom, basically, of pathogenic bacteria. And we don't know if it's necessarily a cause or a consequence of the disease, because again, there are no good biomarkers. But what we think happens is that bacterial dysbiosis in the setting of a preterm intestine, for example, can lead to activation of Toll-like receptor 4, that innate immune receptor that we talked about previously. And what happens when that TLR4 gets activated is downstream, there's a pro-inflammatory response that in the context of a premature gut, is an exaggerated inflammatory response. And when that inflammation goes unchecked it can lead to all kinds of what we see at the bedside, like cytokine storm, and a baby seems like they're having sepsis and can develop septic shock type appearance. And at that time, the intestine is dying, and those epithelial cells are dying. And  whether they die fast or slow, or what is the mechanism that determines how quickly the disease progresses, we don't really fully understand it all. But in the context of leaky gut, when you have that bacterial bloom, those bacteria basically translocate across the gut barrier. And that aids in this big pro-inflammatory response that we see clinically.

Yeah, and the pneumatosis, literally, right?

And the pneumatosis, the only biomarker that we have eludes us all sometimes.

Yeah, that's true. Portal venous gas, right? The worst phone call you can get from the radiologist who looked at the film that you didn't catch. Doctor, there was some portal venous gas on this the next morning. Thank you for the help.

I have one one random question also. You moved. And I just wonder, with diseases where there's such a significant or central component of the immune system. It seems like when you relocate your mouse colony in particular that the microbiome is really different and I wondered if that was a problem for you or if you learned anything from that or was it an issue?

It was an issue actually when I moved from the University of Pittsburgh to Washington University in St. Louis and our mouse colony, like we moved the entire mouse colony and the microbiome of the animal facility was different. And even though, we moved the same mice, etcetera, the food is a little bit different that the parent mice eat, and that can affect the offspring as well and we did have to make some modifications to the model. We started NEC’ing them a little bit smaller and a little bit younger to make sure that their intestines were just a little bit less mature than previously.

And then we did play with the microbiome of the formula that we added to the feeding. So we played with the microbiome. We also started adding lipopolysaccharide because we really wanted to titrate the severity of the disease to what we see at the bedside. Especially when we were doing a lot of those studies for pre-IND with the FDA, we wanted to make sure that we had NEC-related mortality in our mouse model, and we could see severe intestinal inflammation and intestinal perforations, for example, that we see in humans. And how can we make the gut stronger? How can we protect against the intestinal inflammation that's seen? And really how can we prevent NEC-related mortality are the big questions that we were going after. So yes, after you move, it can affect several model systems, and it did affect ours, and we worked hard to overcome it and did.

It's cool how just like what seems like a challenge like that can often open doors for new ways of thinking about the central problem or the disease in general, so it's always interesting to learn more about that.

Absolutely, and as you know, we enroll different patients and get different samples. You then can bring them to the lab and see how they behave in your mouse model or your in vitro models as well. And we try to do that often.

This has been awesome, Misty. I think in the future, we would love to hear, and I mean, this is great. You covered a lot of your science and how you got to study NEC in such a detailed way. One of the other things I think we would really love to talk with you more about is your leadership roles, where you are now, and just in general but today we'll just mainly stay focused on the science. Betsy, I think you might have one last question to ask. Did you want to ask that?

Yeah, thanks again, Misty. I've learned so much about NEC and it's been an honor to get to ask you about the thing that you are staying up late nights and trying to solve for all of these small lives. We wanted to end on something fun, kind of on a lighter note. Could you tell us what's the best piece of advice that you've ever been given in your scientific career?

When I was first really trying to decide which career path to take, whether it was going to be a clinician educator or be a physician scientist, my division chief at the time, Dr. Gary Silverman, said to me, well, why just save one baby when you can save them all with your research? And I thought that was pretty profound and inspiring. And it was really like at that moment that I decided that I was going to dedicate my whole career to studying this disease until we can cure it completely. And we never have to see another baby with NEC again. So that's the best piece of advice I received. And it changed my whole career trajectory and really was inspiring for me.

Yeah, we're grateful to him for seeing your potential and your brilliance and making sure that you went into something that was going to help the most amount of babies. David, do you wanna wrap us up?  I don't have any further comments other than to walk out and think about the fact that Misty, I feel like you're about a decade ahead of me with NEC versus germinal matrix hemorrhage. I've been so stimulated by thinking about how I could adapt some of your ideas and models to studying a very different disease.

I would love that, happy to help in any way. I just want say thank you also Misty. That was really great. Thanks for taking the time with us. And thanks to our audience. So again, this is the At the Bench podcast. Please come back again next time where it will be interviewing me and I'll tell you a little bit about my work investigating congenital diaphragmatic hernia. Thanks so much for tuning in and hope to talk to you again soon.

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