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
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