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Blood, Sweat and Smears - A Machaon Diagnostics Podcast
5 Questions with Dr. Anthony Sabulski
00:16:57
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- [00:06]
Dr. Brad Lewis
Hello and welcome to Blood, Sweat and Smears, your Macheon Diagnostics podcast with tag team hosts, including Our medical director, Dr. Brad Lewis, senior director Bjorn Stromses.
- [00:17]
Bjorn Stromses
That's me.
- [00:18]
Dr. Brad Lewis
And other guest hosts. We hope you find these podcasts interesting and informative. Thank you for listening. And away we go.
- [00:28]
Bjorn Stromses
Hi, my name is bjorn in for Dr. Lewis for our series 5 questions posing 5 questions to physicians in and around the disease areas we work in. On today's podcast, we'll make definite and contractually binding plans for a future tattoo, and we'll address some big questions. So buckle up. My guest today is Dr. Tony Cybulski, assistant Professor of pediatrics and a member of the division of Bone Marrow Transplantation and Immune Deficiency at Cincinnati Children's. Thanks for joining us today, Dr. Cybulsky.
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Dr. Tony Cybulski
Thank you. I'm excited. I really appreciate you guys asking me to do this.
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Bjorn Stromses
Absolutely. All right, so our first question for you is. It's a softball, or in your case, maybe a slow pitch baseball. What is the absolute best thing about what you do?
- [01:18]
Dr. Tony Cybulski
Yeah, so, I mean, this is an incredible field. I think the way I would answer this is from my specific role and perspective in the field. So I am what a lot of people would say as a physician scientist. So, you know, I do 80%, roughly of my time doing research, and then I do about 20% clinical. I don't primarily take care of patients like in clinic, but I, you know, round on the attending service and the inpatient service. So the unique thing about that is a lot of these patients don't know me. When I show up at Saturday morning, you know, I'm the new guy. I have this badge that says I'm credentialed to be there, but they might not be familiar with me. I'm not the guy who's been in clinic with them, you know, for weeks and weeks and weeks coming up to their transplant. So the. There's a burden on me. I see. Or a role for me to establish their trust as a stranger. And, you know, over the course of a couple days, it's really my goal to bond with them and break through to them so that they can trust me if they're one of the kids who has something serious happen while they're admitted. And what I really like about this is I think it speaks to how important human interaction is in this field. We all get caught up in all these crazy, crazy details of immunology and this gene and that gene and this disease and what this does. But at the core of it, in this field that's so important. And like when I think about the most memorable, important moments when I've been on service and taking care of patients, it's really about things like that. So a couple months ago actually there was a patient, a non English speaking family who was extremely sick, was in the ICU and things weren't looking very optimistic for them. And after I got done speaking to the mom with the interpreter, she asked me to stay and spoke a little bit of English and she said, Dr. Cybulsky, I just want to say thank you for being here. Thank you for everything you're doing. Whenever you're here, it feels like I still can have hope. And that's nothing to do with my intelligence or what I know about transplant. I think that's everything to do with the relationships that you build. So for me that's, I think, one of the coolest things that you can do and have the opportunity to do. I'm going to follow that with a less heavy and a little more cool component of this is, you know, when you are a physician scientist, you have that ability. Everybody talks about the bench to bedside kind of thing. So when I was a fellow, I was on service with Sonata Jodell, who's the queen of TMA and bone marrow transplant. And we had a patient, it was the second one in a few weeks, who had had a graft rejection. And we're sitting there after rounds just having a cup of coffee and it's like one of those moments you read about with some of these discoveries, right? You're just sitting there talking casually like, this is terrible. There's got to be something we could do for these patients. And we just came up with a couple biomarkers that we would do a little pilot study for to see if, you know, maybe these things can help us predict these graph rejections earlier and let us actually do something about it. And you know, fast forward to about a year ago, we got a clinical trial funded for one of the pathways that one of these biomarkers is a part of. So not only did we find some biomarkers having a cup of coffee, but you know, one of them happened to have a targeted inhibitor and now we have it in a clinical trial and that's 100% how that happened. So like thinking about the ability of you see something happening that rubs you the wrong way and you feel like you could do something about it and being able to do that, I think that's just, it's awesome. It's why I think a lot of us get into this field.
- [05:16]
Bjorn Stromses
Fantastic. Second question. I know Cincinnati Children's runs CL9. As do we. When we first brought it up, I naively thought it would be mostly used in the diagnosis of hlh. And it seems while it is used that way, it is just as useful around transplant. How do you use CXC aligned for those patients?
- [05:35]
Dr. Tony Cybulski
Yeah, we really use it a ton and the indications or situations where we're using it are absolutely growing. So that same story I just told one of those markers was CXCL9. So that's how we got into using interferon inhibitors for graft rejection. So for us, CXCL9 has found its way into. For patients who have multiple risk factors for graft rejection, we are testing 6cl9s at multiple time points throughout the transplant to use that as a marker. We also in TMA, as part of my work with Dr. Jodell, we have an active R01 right now that's looking at the role of interferon in tma. Because what we found is there is a lot of interferon activation in tma. Complement, of course, gets all the glory. But we think that maybe in some of these patients interferon pathway activation may be what's driving some continued complement activation. And so there may be a role for interferon directed therapies there. We also have been looking at MBK virus. When you're a trainee or a med student and you see these people, these attendings that have that one molecule that they're obsessed with and you're like, how in God's name did you ever end up with this one specific thing? Well, this is how, because you start connecting the dots and you see the overlap across different diseases. And the other thing that's not necessarily transplant related, where I at least use 6cl9, a lot is in the consult setting. So at least at our institution, the BMT immune deficiency group gets involved with a lot of just really sick patients who. It's kind of like they've gone through everybody. Nobody can figure it out. Let's see if BMT can come up with some ideas. And in those situations, I'm looking for, of course, is there a disease I can identify? But then I'm also looking, is there something, is there some target that I can maybe find that's activated that maybe will help this kid get out of this situation that people really just don't understand why they're there? So there's a couple different markers I use, 6L9 being one of them, where I'm really just looking for some kind of silver bullet that I could use for these kids to just get them out of what they're in.
- [07:50]
Bjorn Stromses
Yeah, absolutely. In pediatric bmt, the stakes are pretty big. To what extent do you try to ensure that the patient understands what is going on? And are there times when maybe that isn't appropriate?
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Dr. Tony Cybulski
Yeah, I think it's really unique and delicate. In pediatric bmt, we really have two different patients. We have the actual patient and then we have the family. Whether it's mom and dad, one or the other, or grandparent. Your approach to both of them has to be different. Most of your interaction, your discussions is going to be with the, the parent or the family, but you're having, of course, some conversations with the child. So I think for both of them, one of the things that I really like to stress to people and think about is a lot of times people will assume that somebody's just not getting it because they're not talking about the severe things. So in a kid who's really sick, if the parent's not always talking about that, they know that they're likely going to die or they know that the odds of them surviving are very low. I think it triggers people to think, well, they're not understanding it. But I really try to emphasize not underestimating how smart our patients are and how smart the families are. Just because they don't want to talk about it most of the time means they just don't want to talk about it, you know, and I think recognizing that, you don't have to come in there and say those things every day. And that's where I think the balance is. You want to be transparent with both your families and the patients about what's going on and how you feel about what's going on. But I think the best thing we could do is, is not underestimate, you know, what their understanding is and, you know, when it comes to the patient specifically, of course, there's a huge spectrum of ages. You know, the 13 year old or the 15 year old is going to be a lot different than four or five year old. And for me, I really like to rely on our palliative team to work with me in those situations. We have a fantastic palliative care team who sees every single one of our patients at Cincinnati Children's. So they're experts in kind of analyzing where the patient is with understanding things, what they think is appropriate for them to discuss, what they think they would like to discuss with you. And so I rely on them for that because that's their expertise. And then, you know, they help guide me and have a sit down and we'll talk about these things.
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Bjorn Stromses
So, on a more hopeful note, when you look at the emergence of gene therapy and expand that view out into the future, what disease or diseases are you most hopeful will be effectively cured in the next decade?
- [10:35]
Dr. Tony Cybulski
Yeah, the gene therapy is just so cool. You know, we're all nerds at heart, so I think gene therapy is just a really neat thing. And then it's exciting to see how much it's becoming part of our practice. I think when you look at specific diseases, one way to look at it is what kind of diseases have the most impact globally and would benefit the most from cure. So something like sickle cell disease. It's so exciting to see the gene therapy advancing there. And I think the minute we can get it to where it's something we can do in the low resource setting, which is, of course, where all of the predominant amount of sickle cell disease is, I mean, that would be just absolutely amazing. The other way I think, to look at it is just kind of challenging diseases or just really devastating diseases. So for us in bmt, one of the first ones that comes to mind is Fanconi anemia. Because in a lot of things in bmt, we do the bmt. If you survive the BMT and you don't have terrible side effects, you're good. That's it. We did it. But the thing with Fanconi that is so devastating is that prolongs their life, but they still will die earlier of something else, whether it's a solid tumor or liver disease. So for me, the idea of we did the bmt, it worked, but you're still not out of the woods. I think that's such a challenging thing. And the last one I'll mention, just from a perspective of just an absolutely devastating disease is epidermolysis bullosa at Cincinnati Children's. We have a clinic for that here. I've taken care of some of those patients as a resident and a couple patients during fellowship who developed malignancies from it. But when you think of just an absolutely terrible disease for the child living with it every single minute of their life, dealing with that, that's one that I think if gene therapy could be successful there, which I know there are some studies, I mean, that would. That is just an awful disease.
- [12:44]
Bjorn Stromses
So our fifth question here is, you know, the complement cascade and the coagulation cascade are super fun and everyone understands them. Of course, if you were to have One factor tattooed on you. Which might it be?
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Dr. Tony Cybulski
I absolutely love this question. I think we need to put this into the faculty interview process for anybody coming to hemonc. But so I think the kind of gimme answer is Mac, it's got a cool name. It's a very important thing. It's the terminal component. You could do smack smack if you want. But as I think about this more, and again, we're all nerds and I'm going complement system, coagulation system is good, but I think you got to go complement system. You could look at some of the regulatory factors and think about it as, you know, you're regulating things. Or C1Q is an initiator. Are you an initiator person? But what I'm going to land on, and I never would have guessed this is C3 Convertase. Because when you look at the cascade, you have your three different pathways and everything feeds into C3 Convertase. So I kind of view it as like a general or a leader. Right? You're getting the inputs and then you're making the decision whether you're about to go activate the calvary. So I'm going C3 Convertase.
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Bjorn Stromses
All right. We look forward to seeing where you get that placed.
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Dr. Tony Cybulski
It's a big. It's a bigger word than some of the other ones.
- [14:23]
Bjorn Stromses
All right, well, if you've been counting along, that is five questions. And that brings us to our bonus question, which is what is something? And it can be anything that you'd recommend.
- [14:33]
Dr. Tony Cybulski
So in the last couple months, I got a record player and it has totally changed my evenings, and I just absolutely love it. And the thing I think you don't realize, like, as someone who's never had a record player growing up or anything, there is just something so awesome and relaxing about sitting there next to the spinner, the turntable. And you have to listen to every song. And so all this stuff that, like, on your playlist, you skip through, you got to listen to it. And it turns out, yep, can't skip ahead. It turns out, like there's a lot of good songs in there that you just. They don't connect to you when you're in a different setting. And the other thing I really have enjoyed about it, in addition to drinking some bourbon while I'm doing it, is it makes you listen to different music than you do normally. Right? So I like Zach Bryan, I like Noah Khan, Lumineers. So I got all them. But then makes you think about Credence or the Beastie Boys or like Miles Davis. Like I don't listen to them going to work, but when I come home and I'm sitting there relaxing. I have been so obsessed with this thing and thankfully my wife is too or else it would be a short lived obsession. So that's my recommendation.
- [15:58]
Bjorn Stromses
Fantastic. That's a good one. That was wonderful. Thank you for spending the time with us today. Yeah, really enjoyed the conversation.
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Dr. Tony Cybulski
Yeah, thank you again. Appreciate it.
- [16:09]
Dr. Brad Lewis
That's it for us here at Blood, Sweat and Smears, a podcast produced by Matrion Diagnostics. You're a reference lab and CRO specializing in thrombosis, hemostasis and rare disease. Thank you for listening. And if you have a question or comment or there's a topic you'd like Dr. Lewis to speak to, please send us an email to blood sweatandsmearsatriondiagnostics.com that's M A C H A O-N diagnostics.com you can follow Macheon at Twitter at matriondx. Be sure to subscribe to stay in the know. Share this podcast with clinicians you think might appreciate it and we hope you'll join us next time here at Blood, Sweat and Smears.