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A Mayo Clinic podcast for laboratory professionals, physicians, and students, hosted by Justin Kreuter, M.D., assistant professor of laboratory medicine and pathology at Mayo Clinic, featuring educational topics and insightful takeaways to apply in your practice.
This is Lab Medicine
Rounds, a curated podcast
for physicians, laboratory
professionals and students.
I'm your host, Justin Kreuter,
the Bow Tie, bandit of Blood
a transfusion medicine
pathologist at Mayo Clinic.
Today we're rounding with Dr.
Bobby Pritt, professor and interim chair
for the Department of Laboratory Medicine
and Pathology at Mayo Clinic in Rochester
Minnesota to discuss the
modern parasitology laboratory.
Thanks for joining us today
Dr. Pritt.
Oh, it's my pleasure Dr.
Kreuter. It's always fun to be here.
So you are a frequent guest
but let's kind of kind of
remind our listeners
why did you decide to pursue parasitology?
Well, it was definitely
an interest of mine.
I always found parasites to be fascinating
but there was also a little
bit of luck thrown in there
because there happened
to be a position open to
be the director
of the parasitology lab when
I was doing my fellowship.
And so I look back
to what got me interested
in parasites to begin with,
I would say it was my love
for biology and particularly
zoology, the study of animals.
It's just that instead of
lions, tigers, and bears
these are little microscopic animals
like little protozoa and
helmets and arthropods
and they're very
fascinating little critters
with their own complex life cycles
and means of transmission.
And so it was perfect for me.
I like that trifecta
Broke
Down. So, you know, for many of us
maybe students that are
going into the field
or maybe for many of us
in practice, we probably
haven't really been around
the field of parasitology.
I know for me last time I
was really kind of up close
and personal was during my residency.
It was maybe more
of a limited aspect of the
practice for where I was.
I'm kind of curious, can
you kind of elaborate
what does the modern day
parasitology lab look like?
Well, you know, it probably
hasn't changed that much Dr.
Kreuter, but it is changing.
I will say right now though,
the modern parasitology
laboratory still is
very microscopy driven.
We spend a lot of time
looking at specimens
like stool and blood under
the microscope looking
for parasites and being
the bowtie bandit of blood,
you certainly know some of
the parasites that could end
up in blood like malaria and bia.
But we also are doing more
and more molecular testing
and then I'll just hint at
it now and explain later
but we are starting to dip our toes
into digitalization and
artificial intelligence.
Oh, that's interesting.
So how are those starting
the artificial intelligence?
Because it sounds like
as you bring that up
that that sounds like it's
almost like a blending
of some of those conventional
techniques and maybe some
of the molecular, at least
that's where my mind goes
as you talk about artificial intelligence.
Am I understanding that right?
Well, you could use
artificial intelligence
in so many different ways.
So it could have been
molecular, but we're not
really using it for molecular
testing at this point
although that's a
possibility in the future.
But instead we are digitalizing
our images, our we're
digitalizing our slides to
create whole slide scanned images
like we're doing in
other parts of pathology.
And then we're having the
computer algorithms look
at those images and pick
out the objects of interest
which in this case happen
to be parasites instead
of say tumor cells in
anatomic pathology.
Wow, okay.
So, I remember when I
was a resident in training
I found the one malaria example
on the slide in an on call situation.
I remember the next day or on Monday
the medical director kind of calling me
over and saying like,
where did you find this?
And for fortunately I was
able to locate it again
but it sounds like
so that's how we're able
to kind of increase some
of that diagnostic a
accuracy or is it workflow?
Yeah, with kind of the primary driver.
It's really all of the above.
So first of all
when we think of parasitology
in the United States
there are not that many parasites
compared to endemic areas.
So a lot of the specimens we look
at don't have parasites at
all good for the patient.
But for our technologists who
have to sit there and sort
through slide after slide,
it could be very tedious.
It could be ergonomically
challenging, it could be quite
quite frankly boring for them.
And it's easy to lose
your train of thought
and kind of zone out when you're looking
at negative after negative
and you're trying to
find that metaphorical
needle in the haystack.
Again, having a computer
be able to really identify
that quickly takes away the risk
of subjectivity, human error, fatigue
and decreases the risk
for ergonomic injuries.
And is this something that is, you know
easy to kind of train up into
using and and integrating?
Or has this been an easy
lift to get people used
to working in this way?
Well, we're just starting,
but yes, it is essential to
get your workforce to
embrace the technology.
If your techs aren't on board
you are not gonna have
successful implementation.
So our technologists, our
lead technologists that have
that specialized training have been
on board right from the start.
They evaluated the systems
and decided they thought
it was a really cool thing
and they also realized the potential
for increasing accuracy, sensitivity
the ability to detect parasites
that humans might miss.
So it really was led by the laboratory
and we plan on implementing,
implementing later this summer
first with tricone stain stool specimens
but we eventually wanna branch
out into other exams including looking
for that lone malaria plasmodium
ring in a blood slide.
Excellent. So we've been kind of going
down this pathway of talking about AI
and how this is maybe changing
very early cutting edge
in the process of changing
the parasitology lab.
Can you elaborate a little bit
about the molecular aspects of
how that might be integrated?
I think we've, we've been used
to seeing some of those kind of come
into other areas of
infectious disease testing.
Is this also kind of a
a very newer aspect for parasitology?
Yeah, you know it, I wouldn't say
that it's all that new
in a sense when you think
of molecular testing, like
molecular amplification methods
P C R and other nucleic
acid amplification tests
they've been around
now for several decades
and they really did
revolutionize the detection
of parasites in certain specimens.
If you think of trichomonas vaginalis
a sexually transmitted
protozoan parasite has a lot
of potential risks for preterm pregnancy
increased risk of
acquiring H I V infection.
So important to detect and treat.
We now know
that the nucleic acid
amplification tests are superior
to every other test we
have for detecting them.
So that's been part of the mainstream now
for several decades, at least
the past couple decades.
Toxoplasma gondii, that's another
one where we've used PCR
and there have been a number
of tests targets that
are really well studied.
And then probably most recently we've had
the syndromic panels introduced mostly
for diarrhea because we deal
with a lot of stool in the
parasitology laboratory.
And so someone that shows up
with diarrhea and the patient
the physician thinks
it might be infectious
can order a syndromic panel
for diarrhea that will detect
multiple different types
of organisms that cause
diarrhea, including parasites.
In fact, you can get, you know, 20
30 different organisms that you detect
in a single specimen sometimes
in less than an hour.
So that's really
revolutionized parasitology.
There's other ways that
molecular diagnostics has helped
but they aren't as well
embraced and widely available.
For example, you can
look at gene mutations
in plasmodium species
that cause malaria to see
if they're gonna be
resistant to different drugs.
But the only people that
are doing that are probably
the scientists at the C D
C and some research labs.
Oh, that's interesting.
That kind of makes me think
about, and makes me curious
how has this kind
of impacted your training
for clinical fellows, right?
If you know
maybe some things might
be controversial right now
but how do you prepare them
to kind of navigate the
the this future ahead?
Yeah, that's always been the challenge.
Dr. Kreuter, I think being at
a place like Mayo Clinic too
which tends to be at the cutting edge
you still have to teach
them the so-called bread
and butter organisms and
laboratory techniques.
But at the same time, you
want them to have the exposure
to the really cool cutting edge stuff.
So it's a lot of, well here are the basics
or here is an advanced
test, this is how we use it.
But then also telling them
that if they're somewhere else
that they may be using a different test
or this might be a send out test
if they happen to be in a smaller lab
and the turnaround time
would be much different.
So if we're at Mayo Clinic
and we have an advanced test
we can perform it in a few hours
that's really great for patient care.
Whereas that same test that's a send out
for a small community
care hospital might take
two days turnaround time.
So maybe that wouldn't
be your first line test.
Hmm. It kind of makes me also think some
of this integration and it, and I mean
you said that with kind of this idea
of a syndromic panel
that could be ordered right
as we have kind of more
specialized testing
and also our conventional testing on hand
and in what context is one
versus the other better.
Have you heard any kind
of feedback from ordering
providers about, you know
is the ability to have
kind of syndromic panel
and then you know, the
laboratory can chase it?
Has that kind of been a, you
know, positively received
are there any challenges that come
up with that kind of style of ordering?
There are, and so it's always important
and I'm sure you do this
in your practice too
to work with our ordering
providers right off the bat
and tell them when we have a new test
so we can then develop
ordering algorithms together.
And we did that for the
syndromic panel for diarrhea.
We did studies to show
that for the patient
in which testing is
appropriate, it's actually
more cost effective to
order a single test rather
than a whole panel of tests
some of which can take several days.
And you get your result very quickly.
Part of it is just recognizing
that not all patients
with a certain syndrome need to be tested.
If you have diarrhea
most people will get
better in a couple days.
It's usually due to a virus
and it's self-limited.
So you actually have to wait
until about seven days before
you'd consider testing.
Or if you have a patient who's very sick
or at risk for being very sick.
So I've always been a firm believer
in working with my colleagues
and trying to figure
out when we have a fancy new test
how that test should be used
and if we should even use it at all.
Sometimes I go to my colleagues
and I'll just say, we have this test
would you be interested
in me bringing it in?
Is there even any clinical utility?
Wow. You know, I think
there's a lot of these themes
on change management
that are kind of, I think
percolating through a
lot of this conversation.
And I, I hope that, you know
listeners are really kind of picking
up on these insights that Dr.
Pritt sharing with us.
You made mention to kind
of where things are going
and a couple of, you know, I'm curious
if you could elaborate and share
what are couple of the kind
of hot topics in the field
for parasitology in in 2023?
Yeah, definitely.
So first of all
the hot topics are the things
we've talked about already.
Digital parasitology is gonna
be huge as it's going to be
with any field that uses
microscopy based diagnostics.
So we're gonna be seeing
more and more of that.
Hopefully we'll start seeing
some F D A approved platforms
in the next five years or so.
Right now it's all lab developed tests
and there's only a couple
companies, a few companies
but we'll see that expand for sure.
And we're gonna see more
molecular diagnostics
and more panels.
There's actually a new panel
that syndromic panel
that was just released
that detects all of
these different pathogens
that can cause really terrible diseases
like Ebola and Marburg
and Plasmodium Falciparum
the deadliest cause of malaria is
also on that panel.
So we're gonna see more
of these panels that have
parasites on them, but I'll
I'll mention a couple
other things that are maybe
a little bit more just not so much fun.
And that's our workforce shortage.
I think every lab
across the country is facing
this clinical laboratories.
And so I think that leads
to the fact that we have to
embrace these new technologies.
We have to embrace
automation, digitalization
artificial intelligence, high
through molecular platforms.
And yes, there's gonna
be change management
and we have to do it in the right way
and we have to have our whole lab on board
but honestly we're gonna need to do it
because of the workforce shortages.
There's also a, a lack
of skilled readers to
be able to identify
parasites using a microscope.
And as we lose our more
experienced readers
and we can't train the
new ones fast enough
we need methods that are more objective
that don't rely on a, you know,
six month training program
before they're able to
be competent to read.
So some of this is gonna be driven
by the changes in the in the field.
Others are though just
really positive changes
that I'm just really excited to see
because it's gonna be
better for patient care.
That's phenomenal.
Thank you so much for rounding with us
Dr. Pritt.
My pleasure.
So thank you for joining us
and if you're interested
in learning more, Dr.
Pritt is gonna be doing a
parasitology workshop in August.
So check the show notes for
the direct link to register.
And to all of our listeners,
thank you for joining us today.
We invite you to share your thoughts
and suggestions via email.
Please direct any suggestions
to M MCL education@mayo.edu
in reference this podcast.
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we encourage you to continue
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conversations, just like Dr.
Pritt is showing us.