Ahmad Ameri

Clinical Oncologist

Imam Hossein Hospital

Mar 22, 2021

Ep. 295, COVID Miniseries: Ahmad Ameri - Clinical Oncologist, Imam Hossein Hospital
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Bret Kugelmass
So we are here today with Dr. Ahmad Ameri, who is a clinical oncologist at the Imam Hossein Hospital in Tehran, Iran. Thank you so much for joining us today.

Ahmad Ameri
Thank you. Thank you for inviting me for this interesting discussion about radiation.

Bret Kugelmass
We're here to hear about the amazing work that you're doing. And so I'd love if you could start off by giving us an introduction as to your background, and how you entered into this field of study.

Ahmad Ameri
I'm a radiation oncologist. Now I'm an associate professor in Shahid Beheshti University of Medical Sciences in Tehran and working in the clinical oncology ward of Imam Hossein hospital. I'm on faculty since 2003 and now I'm an associate professor. I also study medical education now, I'm about to finish it, and my major duty in the university is education for the residents of radiation oncology or clinical oncology. In Iran, radiation oncologists treat cancer with systemic treatment and also radiation. That's why we named its clinical oncologist and but we also treat the patients in private and governmental hospitals. My interest is head and neck cancer, treating head and neck cancer with chemotherapy, radiotherapy or immunotherapy nowadays, but we do also research. But most of research or clinical research for our patients.

Bret Kugelmass
Can you maybe tell us what motivated you to become a doctor? Was there in your childhood? Did you have a family of doctors? Did you have an interest in medicine? What was the original passion?

Ahmad Ameri
My father pressure. My father asked me to be a doctor. I was not interested to medicine. I just started mathematics in my branch in the school was mathematics. But my father forced me to be a doctor. And I participated in the medical conquer and accepted in the Urmia University of Medical Sciences. That was the real reason.

Bret Kugelmass
That's probably the same anywhere you go in the world.

Ahmad Ameri
Yes, but now I'm happy with this decision

Bret Kugelmass
Are you going to pressure your kids to become doctors as well?

Ahmad Ameri
My son is an intern and he will finish one years later. But he also decide by own not by my pressure.

Bret Kugelmass
Sure he did. And then was there something that drew you once you became a doctor, was there something that brought you to the field of oncology and treatment of cancer? Why that instead of a different fields like orthopedics?

Ahmad Ameri
Back into my background about mathematics. I tell that radiation oncology is a field full of physics and technology. But when I entered the residency, I saw that this is not the technique. It's completely clinical branch. And especially in Iran, because we are involved with the patients from the diagnosis until the death. That why this was a misconcept about the radiation oncology in Iran. But now I, I think it's motivated branch and is very high level of education and treatment, you are involved in the technology decision and everything that has in the medicine you can have together to help your patients in this good feeling.

Bret Kugelmass
Most people that are not in medicine probably don't know much about chemotherapy, about radiation, about cancer treatment at all. And how many, but radiation saves lives most people are probably scared of radiation. But how many lives have we saved with radiation?

Ahmad Ameri
Yes, you are right. Cancer had treatment, three main treatments. One is the surgery. One is the radiation. And one is the systemic treatment, including chemotherapy, hormone therapy, and nowadays immunotherapy. But based on the research and based on the international organization surgery can cure about 40% of cancer patients. Radiation also cured about 40% to 50% of patients and systemic therapy in cure about 10% to 15% of cancer patients. But most of patients need a combination of these treatments. Consider that cancer, some of cancer are local, just local growth, but some of cancer have a propensity to designate in the body. That's why we need systemic treatment. And we combine systemic treatment with local treatment to achieve more and more effective treatment for our patients. I think radiation, I think most of people know the cancer with the chemotherapy because of the side effects. All patients are worried about the side effects of treatment. And in cancer treatment side effects of chemotherapy is more than two others options, including surgery and radiotherapy. That's why when you speak about cancer, all patient bring in mind hair loss, vomiting, and something like this. Although the chemotherapy just cure 15% of patients. But chemotherapy, use drugs, drugs has a support as the pharmaceutical companies, they support the medicine they support the chemotherapy drugs and that's why all patients know cancer with chemotherapy. All his studies has been done with chemotherapy. Radiation and surgery has less support especially radiation because radiation is the second step in patient management, most people have the biopsy site or then refer for radiation or had surgery and then refer for radiotherapy. So, when you are designing a trial for the radiation maybe you cannot accrue enough patient for this study or know what there is more study in radiation has been started due to immunotherapy because it was defined that the radiation with unusual fractionation can increase the effect of immunotherapy. That's why we have more to study with radiation. That's because of support of pharmacological companies

Bret Kugelmass
And but why why is that? Why has nobody decided to look at studies just with radiation or start with radiation before you cut into someone or before you apply chemotherapy to isolate the effectiveness of the radiation?

Ahmad Ameri
Because the study need money. Somebody when should pay for the study. All the studies in their chemotherapy or immunotherapy in hormone therapy, were supported by the pharmaceutical company that they are rich companies. But for radiation, no, for radiation, there is no support. It's a business that they sell the machines and then support for maintenance. And they can give their benefits. That's why we cannot have the radiation only a study we have, but most of them are supported by the government or or international communities, not by the pharmaceutical companies or by the radiation producing companies.

Bret Kugelmass
Where did you first see the idea to use radiation to fight the cytokine storm? The inflammation due to COVID? Where did you first see this in the world or in publications? How did you know to start conducting studies along these lines?

Ahmad Ameri
I didn't see at first. Our hospital was the center for COVID patients. And all our wards was full of COVID patients, neurology ward, orthopedic, any wards was occupied by the huge number of patients with COVID-19. We was in the very shortage of the human resources and the medical equipments, including ventilators, monitors and something like this. I think how can we help them? We we have an insulated ward, clinical oncology ward is isolated from the other hospital that was there. So we was not involved in the COVID. But we saw every day that patient passed and passed away. No. That's what we think about the helping them I asked a pulmonologist what's the reason for dying the patient with COVID. And he told me it's just by the bleeding in the lungs. I thought about it because we use radiation to stop bleeding. When a tumor is bleeding, we use radiation with the high dose per fraction just one or two fractions will stop the bleeding.

Bret Kugelmass
Why is that? What is the mechanism by which radiation stops bleeding?

Ahmad Ameri
Radiation has different affected in my opinion, today radiation is a systemic therapy could be a systemic therapy right but it depends on the dose per fraction, part of body that irradiated, how much body irradiated. They all affect the effects of radiotherapy on the patient. When when you use the large fraction, prescribing large fraction of radiation, they usually make the vessels to be shrink to constrict them yes that to constrict them them and that's the reason for stopping bleeding. But when you use with a lower dose per fraction, usually the vessels will repair themselves. When you use a large fraction severe inflammation will occur within the vessels and they cause too we say coagulation stopping the clotting the blood within the vessels and that's why the bleeding will stop what when you use lower fraction, lower dose in each fraction. This this kind of reaction was not accurate.

Bret Kugelmass
So what is the what is the dose where this occurs in grays? How many grays might be applied to cause this coagulation effect?

Ahmad Ameri
Five, six gray per fraction.

Bret Kugelmass
And what's a fraction? What is a fraction?

Ahmad Ameri
In cancer treatment radiation will prescribe in different fractionation. Total, those will be divided in fractions and each fraction, maybe one fraction per day, maybe two fraction a day prescribe to the patient for cancer treatment that's why the 30 fraction of two gray means 60 gray during six weeks.

Bret Kugelmass
Wow, that's a lot.

Ahmad Ameri
Yes, that's that for the cancer, for example, lung cancer. But nowadays, all things are changing. Now cancer patients who have not metastases and cannot be cured by surgery or surgery is not possible radiation with a fractionation of 18 gray 12 gray 16 gray 18 gray in three or four fraction will cure the patient. Wow.

Bret Kugelmass
So even higher per fraction

Ahmad Ameri
Yes, higher. We name it sbrt Stereotactic Body Radiation Therapy or Fractionated SRS stereotactic radiosurgery

Bret Kugelmass
And this 18 gray fraction dose, what are the consequences of this? What are the negative side effects of going that high? I understand the patient is in bad shape and so it's a last resort. But why have we not gone this high previously? What are the possible negative outcomes of going that high per fraction?

Ahmad Ameri
Yeah. Radiation goal is to prescribe high dose to the target and spare other targets. It's now possible but in the past, it was not possible, to cure patient with such a fraction for such a high fraction per day. With the new technologies as the it's apparent in the name is through tactic. When when with this new technologies, we can confirm the doses just around the tumor and spare one millimeter, two millimeter away. All the tissues.

Bret Kugelmass
I see, it allows you to focus the dose into a smaller area.

Ahmad Ameri
Yes,

Bret Kugelmass
I see.

Ahmad Ameri
Smaller area and confirm it.

Bret Kugelmass
That means the volume as well. You're able to narrow it not just in terms of like a cross sectional area but you're able to find a circle within the body. The balloon within and be able to target that balloon.

Ahmad Ameri
Yes, yes, like this. That's why we can now we can prescribe radiation in this regard with when you can spare more tissue, more normal tissue, you can prescribe more doses to the tumor. But whenever you cannot do this, for example, when the tumor is near the organ at risk, critical organs such as vessels, such as the brain, such as the when you are near the optic nerve, for example, you cannot prescribe that large doses. You will have to bring down the doses. But more than the previous you can prescribe now.

Bret Kugelmass
And I'm sorry, I interrupted you before. You had met with a pulmonologist and they had said the problem with COVID is the bleeding. And so you thought well I know how to stop bleeding with radiation please continue.

Ahmad Ameri
Yes. I thought about it that if we prescribe the high doses for the place the lung had - and started to study, we saw that the radiation has different affected we saw that low dose radiation was used for pneumonia about one century ago with good results.

Bret Kugelmass
How did that? How did you find that piece of information

Ahmad Ameri
I saw in there, I saw in the publications, I search for it.

Bret Kugelmass
You were able to just do an internet search through publications, journals, and it just appeared.

Ahmad Ameri
Yes, yes, yes. We found in the journals in the publications that the radiation has a different effect with different doses when we searching for the topics, we also know more and more about the mechanism of the ARDS in the COVID-19. And we actually do during time interested to the low dose radiation, we saw previous studies. And a good review in 2013 about the radiation, low dose radiation effects. We saw that most people about 30,000 patients treated with low dose radiotherapy for artheritis in Germany, every year, about 30,000 patients are treated with radiation, not with corticosteroids, not with aspirin, and other things. And

Bret Kugelmass
What is the dose that is applied in the Arthritis case in Germany to 30,000 patients a year? What's the dose?

Ahmad Ameri
I think it's about three, two, one to three different doses, because there is no standard doses for this it's perscribed per patient. I think it's between one as I remember, I hope to be correct. As one to four gray one to four.

Bret Kugelmass
So within a similar range as to what we're talking about here for treating COVID as well.

Ahmad Ameri
Yeah, that's what I think when they when they were searching for the plan you know. And I hope to can help the patient because we saw a catastrophic event in our wards. And when we decide to prepare a proposal for approval to the review board, we reach to 70, 0.7 gray as an optimal dose at this.

Bret Kugelmass
Yeah, so less than one gray.

Ahmad Ameri
Yes less than one gray.

Bret Kugelmass
That's all your asking for asking for to the review. Less than one.

Ahmad Ameri
Less than one gray. We also found some studies that use whole body 0.1 gray. The whole body. Whole body. 0.1 gray for treating lymphoma, Hodgkin lymphoma. Okay, as a system, I told you before, radiation, could be a systemic treatment.

Bret Kugelmass
How does that work? I know, I have limited experience personally. But I've been to the dentist and you know, they have the device that goes focuses on your mouth. What does the whole body machine look like? How do you apply a systemic dose of radiation.

Ahmad Ameri
You know it needs some special machines. We usually treat patient on the bed, under the head of the machine. But when we decide to treat patient whole body, we have to use the patient in upright position away from the machine and the machine head turn about 90 degrees with more distance from the machine head that you can fit the whole body in the radiation fields.

Bret Kugelmass
So it's just like a flashlight. If I were to hold the flashlight up against a wall it would only occupy a few inches. But if I walk back across the room, the flashlight will shine over a larger area, even at a lower level of illumination as well. Do you have to perform mathematical calculations to determine the dose as a function of distance from?

Ahmad Ameri
Yeah, I'm not a physicist, but it's a complicated calculation. And our physicists have to design the machines and the calculation and the monitor unit that this the machine will release for this treatment. I have no experience with this. But I just imagine how can we treat patients whole body radiation, with whole body radiation? Yes, I thought the 0.1 gray has prescribe it to the Hodgkin Lymphoma before the local treatment on the tumors, it low doses, very low doses modulate the immune system of the body. And when we know about the mechanism of the COVID-19, cytokine storm, we decide to try 0.5 gray as a prescription to the lungs. We also know that the effect of radiation on immune modulation will disappear after 48 or 72 hours and we decide to add a additional dose after 72 hours if the clinicians if their patient's physician requests us.

Bret Kugelmass
If you see signs of the immune system still overacting after 72 hours, you want to modulate it a dose of a low dose radiation system systemically across the body.

Ahmad Ameri
Yes, yes.

Bret Kugelmass
And when did you first start this study? What month?

Ahmad Ameri
We starting searching for the proposal and preparing the proposal to approve in the ethics committee about March. But the first patient was entered to our study I think it's 20 of May. I think so.

Bret Kugelmass
And is it difficult to to acquire patients for this type of study.

Ahmad Ameri
It's very, very difficult, especially in the first five patients that we presented, it was very difficult, more of our patients have unwanted or unwarranted fear of the radiation, also, scientific community in our hospital also has this fear. They was not agree with us.

Bret Kugelmass
And I'm finding similar stories as what you're telling me across the world with other research scientists that are conducting similar studies. But my perspective is COVID when you are in a hospital is very serious. A lot of people die when they get brought to the hospital with COVID. And they should be very afraid of that. Not just of radiation. And also if 30,000 patients in Germany are getting even more radiation and it's just to treat artheritis. It seems to me that that would calm people down and help reduce fears. What happened in your experience?

Ahmad Ameri
At at first nobody accept our tests, nobody. I treated first three patients by myself. Yeah, as patients. There was yes, there was a fear of radiation for patients. And there was additional fear about their radiation oncology ward staff, that bringing patients with COVID-19 into the wards and treat them that's what the resist about the treatment. We accept about 40 patients to participate all in our trials. And just five accepted, just five patient acceptance. Yes, I also asked about five our staff to help us to treat these patients. But just one accepted.

Bret Kugelmass
Why why was the staff who is dedicated to medicine not interested?

Ahmad Ameri
Yes because in our wars due to sanction we have a shortage bout most of the equipment and the monitors and somehow drugs. That's why everybody thought that if if if I got COVID what's happened for me? I think so.

Bret Kugelmass
And what about if there's a shortage of equipment for radiation what about diagnostic equipment, is it possible to use diagnostic equipment to get up to a half a gray dose?

Ahmad Ameri
I have no experience with this machine. But now I know that it would be very difficult because for the radiation machines were radiation treatment machines. They're one gray is a low dose, just as a blinking. But for the imaging machines, it would be very high dose, and it needed pressure on the machines, machines that are needed for diagnosis,

Bret Kugelmass
I see, I see

Ahmad Ameri
Yes, I think is not possible, at least in our hospital is not possible.

Bret Kugelmass
So you were able to get five patients into your initial study. What was the results?

Ahmad Ameri
I think our study has some shortcomings, especially we started in the emergency situation, we could not give the best supportive care to our patients after radiation. That's what we discharge some patients that will be admitted. Who will be who would be who should be on the ventilator or under supervision. But the result was very amazing. Every patient after the first doses after radiation therapy, the day after the radiation, all patient I saw all patients after the radiation and all have different face. They were very relaxed. But but the complimentary treatments was not effective was not available. We need our beds for more complicated patients. But I think it was very effective after three patients. I told my wife, if I got COVID-19 pneumonia, my first choice would be radiotherapy.

Bret Kugelmass
Yeah. So you're saying you got the the worst of the patients, most dire of cases, no support to help you know, in any treatment, you need additional resources and support to help nurture a patient. And even given these horrible circumstances. You saw incredible results from the radiation in a short period of time too.

Ahmad Ameri
Yes, yes, we we achieved a clinical response of about 80% in the first five patients

Bret Kugelmass
80% effectiveness in the first five patients you ever tried the song and you hadn't even figured out the right tuning the right amount of dose the right time, the right post treatment and still 80% effectiveness.

Ahmad Ameri
Yes. We achieved a key person's response. But you know, response was defined in different way in different studies. But we saw the oxygen saturation increased, inflammatory markers decrease, you know, and for five for first five patients, we achieve about 80% response for the when when he added five more patients. We we achieved a response about the 66%. A bit lower

Bret Kugelmass
And what four accounts for that. I mean, I know it's low numbers

Ahmad Ameri
When when we start to accrue the patient to the trial we saw that trials of Emory in a print publication. They use yes, they use the 1.5 gray with dramatic with dramatic response. And that's why we we know we knew that the lower doses is better to control cytokine storm to modulate immune response- In print version, we decide to increase doses. We decided to create it four more patients four less patients with one gray with longer the study is very small. But show us that half gray may be better than one gray. Yes, the results show us this differences that we tell from the first lower doses is more effective for modulation of immune system.

Bret Kugelmass
I see. And so where did, where do your studies stand now? Where can you now that you've done 10 total patients? Are you trying to increase the patient count beyond 10?

Ahmad Ameri
Yes, we asked our ethical committee to let us to conduct this study with the more patients they accept, but their resources don't let us to go ahead. We had the two machine in our wards for radiation. They these machines work from the 7am until 9pm. And we have a lot of problem with the services, this machine should be service should be maintained. And there is a lot of shortage about the accessories of this system. That's why I have haven't give the agreement of our wards or chief. That's why we are trying to conduct a more and bigger study with different doses we are interested in define the better doses for these kinds of patients. But I don't know I can.

Bret Kugelmass
It's so but it seems to me that while it might seem in the short term, that this treatment would consume resources, in the long term on net across the whole country, it could save many resources, because think of all the people that would not have to occupy hospital beds would not have to take drugs would not have to take doctors time. If it was as quick as the blink of a button from one of the radiation machines.

Ahmad Ameri
Yes, it's my, I think also like you, but somebody else should be decided about it. Make them make them happy with our mind is very difficult. It's very difficult, because this kind of trial, this kind of study have not been occurred before. And other disciplines and other disciplines have the patience, and the treatment will be deliver in with other disciplines. You know, that's why we cannot bring them in the table for this kind of study. We asked also for the earlier patient, earlier stage of the disease or for patients who just are very, very in good condition. And they can go to the radiation ward by walk and received the radiation to decrease the hospital beds, occupations, yes, we also write a proposal for this kind of the treatment. But we are still on que to approve it.

Bret Kugelmass
And tell me though, what access to resources do you have not officially but unofficially, beyond your hospital? For instance are you part of a society with other radiation oncologists across Iran, where you can discuss learnings and call them up and say, here's what happened with my equipment, maybe in your hospital you should try your equipment. Does this type of collaboration occur?

Ahmad Ameri
All over we have, we have a shortage of the radiation machines due to sanction.

Bret Kugelmass
The whole country.

Ahmad Ameri
All over the country, not just in our hospitals, all over the country. I also work in the private section but all of them have the machine and need to save their machine to treat cancer patients. Treating COVID-19 with just one fraction, has no money, has no money for the private sections. I was the secretary of the Iranian Society of Clinical Oncology and I asked all the other governmental hospitals to participate in our study to be a multi-institutional study, by no one's except this, all had the same problem all prefer to treat patients with cancer instead of the COVID-19.

Bret Kugelmass
And, and I can understand, I can understand if there's a shortage of equipment how, how people can't see, you know, all of the angles and all of the the bigger picture and how they're just focused on their short term and more immediate concerns. Which brings me back to my previous question. If the goal is to apply a half a gray dose, can't we look at other types of equipment, and just run them for a longer period of time, like a diagnostic chest X ray, or, or even dental equipment and just leave it on for 15 minutes, perhaps instead of a blink of time to still apply that half gray dose, and perhaps let people even in the private sector, apply this therapy off protocol to start getting more results and save lives?

Ahmad Ameri
I think it's not possible. I think their effects of radiation depends on the doses also dose rates, you can prescribe half gray in one second. Also, you can prescribe half gray in half hours. They have different-

Bret Kugelmass
I see, no, I understand.

Ahmad Ameri
Yeah. It has different effects. You can prescribe radiation half gray to just one tooth and you can prescribe half gray to whole body. If you prescribe 8 gray to total body, 8 gray to total body, we have seen we would see the actual radiation syndrome. And patient usually die within 48 hours. Yeah, yeah. What if you if you prescribe 8 gray to just, well, limited area nothing happen. After 10 years, you can see just a scar of this treatment.

Bret Kugelmass
I see. So they'll be like a local burn almost because energy being imparted. But it doesn't do damage to the entire system. Yes, I see. What you're saying is there is there's an art, there's a science to the application of radiation. And there are different dials. And one dial is time. Another dial is area. And the product of these different dials creates a whole range of effects on the body. And so there are maybe 1000 actually different types of radiation treatment, even with radiation with the same radiation based on how much you apply, how long you apply, and over what area you apply.

Ahmad Ameri
Yeah, we usually use this. I talked before that when we are near the critical organs we adjust the doses per fraction, we can adjust the time between doses, one day, two days, three days between two prescription of doses that help us to save normal tissues. Radiation affect all cells in the body and also micro environment around the body. For example, vessels, proteins, cytokines, mRNA, DNA. All of these are affected by the radiation, and all are affected in different ways by different doses. We don't know about the effect of radiation, I think radiation is all treatment for all disease. All treatment for all disease, but we just know about the side effects. We know about the side effects of radiation more than remdesivir because it's old. We know everything about the side effects but about effects. It was suppressed after the antibiotics for inflammatory disease. You No, that's why we need more and more about radiation. I thought at first, the radiation now I think is as is systemic treatment. Now one of the more exciting treatment for cancer nowadays is immunotherapy. What is a treatment that modulate the interaction between tumor and the immune system. The interaction just this we use chemotherapy, chemotherapy is a cytotoxic and kill the cells. But even modulation immunotherapy just modulating interaction between cells and immunes, cancer cells and immune cells. And I think radiation could be replaced for this immunotherapy.

Bret Kugelmass
And it seems to me by many of the people that I've met, that it's oncologists who have the most experience with radiation. Are there other doctors around the world like immunologists, that are now also developing experience with radiation? Or is it still mostly a discipline of oncologists?

Ahmad Ameri
No most of is related to the oncologist. Oncologist, I told you that we have clinical oncologists that prescribe systemic treatment and radiation. And also we have medical oncologists that just prescribed drugs. And we have also radiation oncologists that just prescribed radiation, not systemic treatment.

Bret Kugelmass
It seems to me, though, that based on what we understand of radiation's effect on inflammation, which is an immunological response, both in the German case, in the old case of viral pneumonia, and many other cases where even in oncology post cancer treatments where it's used to tamper the immune response and tamper inflammation or your blood clotting sample, it seems that the applications of radiation are broader than just oncology and it should be partially a discipline of immunologists. It surprises me that you don't have immunological researchers around the world around the whole world that are desperate to try studies with radiation to see how it might impact their field and move their field forward.

Ahmad Ameri
Yes, yes, yes, you're right. Completely, immunologist likes radiation two days because radiation with with high dose refraction, as we explained before you for lung cancer can produce new antigens. Different way yes, they in the high dose per fraction, high dose fraction suppress the immune system and excuse me, excite the immune system and cause inflammation, but at the same time, it could make new antigens, cancer have some antigen that is a foreign antigen to the body. And immune system will suppress by the cancer cells. When you use high dose radiation, you make new you make new antigen and the cancer cells and the immune system will assimilate against this new antigen and attacked him. That's why today we use high dose radiation with immunotherapy.

Bret Kugelmass
So just to paraphrase, the cancer has a mechanism to combat the immune system normally, it's able to suppress the immune system it does, though. It has its own way of of hurting your body. Yes. And so we need to find a way sometimes to supercharge the body's natural protective forces in order to defeat back the cancers force, a war between you the cancer and your immune system and the radiation is a signal to the immune system to gear up and fight the cancer.

Ahmad Ameri
Yes, exactly, exactly. I told you, we can use low dose ruled by the radiation to modulate the immune system to be activated and use high dose local radiation to the tumor to make new antigen, most of them- for more immune system in this for the immune immune system will be overcome the cancer cells.

Bret Kugelmass
And so, as we wrap up here, maybe just kind of tell me about the future of what you think might happen in with COVID in your country with this treatment, do you think that some of the shortcomings of the equipment might be overcome? Or that there might be more international recognition? Or do we think this is the best we can do for this time period and it's just going to take a long time to bring this therapy into practice?

Ahmad Ameri
I think there is some barrier for this hypothesis, because the shortage of the equipment in our country is one, just one reason. There are another reasons we know radiation was suppressed due to the Rockefeller Foundation decision. They decide about the side effects of radiation. They bring the acceptable doses lower and lower, you know, but but the effect of radiation is more than corticosteroid, I think more than remdesivir more than every other drugs. You know, dexamethasone has been approved as treatment for these in their large trials, recovery trial. Yes. But when you see most of patients stay in hospital after 20 days. You know, but about radiation, no. Radiation has no support. Yeah, but this is the second part. And the third one. If the equipment if the equipment provided in our country or other parts of the war, the interdisciplinary connection is very difficult. We don't have such kind of the trials. I hope that if if we could conduct a more, more larger trials, randomized trials, maybe maybe we can go ahead for designing a special machine for this kind of treatments. That no, no complicated, like, accelerators that we use for the treatment of cancer, I told you, we need to confirm those as to the tumor. But for this kind of treatment, we can use a more simple machines, and we'll design for this purpose.

Bret Kugelmass
Yes. And I guess maybe one last thing. You're able to, a lot of people are very closed minded about the application of radiation, but you're very open minded to it. What separates you? How come you are able to try new things where some of your colleagues might be more conservative and stuck in the old ways?

Ahmad Ameri
I should ask from them. But, but I think I saw a lot of this. I have to do something. What I can do, I bought about six monitors, six full monitor for our hospital from my pocket. That was the first things I do. I did. You know, after that, I decided to do other things. And that's why my caught my work. That's what my work. I don't know why there are others people's think, how they think. Especially, we had pulmonologist, we have ICU care, and other specialties in our team. But they are not deciding the people who decide about the radiation treatment should be open minded. It needs more work involved. If we could have the results of large randomized trials. They help us to convince them that help us for trating patient with this kind of radiation.

Bret Kugelmass
Dr. Ameri, thank you so much for the work that you've done so far. Thank you for taking the time to explain it to me and my audience, and we wish you the best of luck in the future as well.

Ahmad Ameri
Thank you for inviting me for this interesting talk. Thank you. Thank you very much.

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