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This is Lab Medicine
Rounds, a curated podcast

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for physicians, laboratory
professionals and students.

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I'm your host, Justin Kreuter,
the Bow Tie, bandit of Blood

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a transfusion medicine
pathologist at Mayo Clinic.

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Today we're rounding with Dr.

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Bobby Pritt, professor and interim chair

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for the Department of Laboratory Medicine

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and Pathology at Mayo Clinic in Rochester

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Minnesota to discuss the
modern parasitology laboratory.

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Thanks for joining us today

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Dr. Pritt.

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Oh, it's my pleasure Dr.

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Kreuter. It's always fun to be here.

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So you are a frequent guest

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but let's kind of kind of
remind our listeners

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why did you decide to pursue parasitology?

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Well, it was definitely
an interest of mine.

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I always found parasites to be fascinating

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but there was also a little
bit of luck thrown in there

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because there happened
to be a position open to

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be the director

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of the parasitology lab when
I was doing my fellowship.

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And so I look back

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to what got me interested
in parasites to begin with,

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I would say it was my love

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for biology and particularly
zoology, the study of animals.

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It's just that instead of
lions, tigers, and bears

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these are little microscopic animals

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like little protozoa and
helmets and arthropods

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and they're very
fascinating little critters

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with their own complex life cycles

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and means of transmission.

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And so it was perfect for me.

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I like that trifecta

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Broke

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Down. So, you know, for many of us

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maybe students that are
going into the field

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or maybe for many of us
in practice, we probably

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haven't really been around
the field of parasitology.

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I know for me last time I
was really kind of up close

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and personal was during my residency.

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It was maybe more

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of a limited aspect of the
practice for where I was.

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I'm kind of curious, can
you kind of elaborate

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what does the modern day
parasitology lab look like?

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Well, you know, it probably
hasn't changed that much Dr.

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Kreuter, but it is changing.

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I will say right now though,
the modern parasitology

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laboratory still is
very microscopy driven.

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We spend a lot of time
looking at specimens

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like stool and blood under
the microscope looking

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for parasites and being
the bowtie bandit of blood,

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you certainly know some of
the parasites that could end

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up in blood like malaria and bia.

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But we also are doing more
and more molecular testing

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and then I'll just hint at
it now and explain later

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but we are starting to dip our toes

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into digitalization and
artificial intelligence.

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Oh, that's interesting.

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So how are those starting
the artificial intelligence?

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Because it sounds like
as you bring that up

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that that sounds like it's
almost like a blending

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of some of those conventional
techniques and maybe some

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of the molecular, at least
that's where my mind goes

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as you talk about artificial intelligence.

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Am I understanding that right?

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Well, you could use
artificial intelligence

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in so many different ways.

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So it could have been
molecular, but we're not

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really using it for molecular
testing at this point

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although that's a
possibility in the future.

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But instead we are digitalizing
our images, our we're

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digitalizing our slides to
create whole slide scanned images

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like we're doing in
other parts of pathology.

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And then we're having the
computer algorithms look

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at those images and pick
out the objects of interest

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which in this case happen
to be parasites instead

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of say tumor cells in
anatomic pathology.

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Wow, okay.

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So, I remember when I
was a resident in training

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I found the one malaria example

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on the slide in an on call situation.

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I remember the next day or on Monday

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the medical director kind of calling me

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over and saying like,
where did you find this?

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And for fortunately I was
able to locate it again

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but it sounds like

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so that's how we're able
to kind of increase some

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of that diagnostic a
accuracy or is it workflow?

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Yeah, with kind of the primary driver.

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It's really all of the above.

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So first of all

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when we think of parasitology
in the United States

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there are not that many parasites
compared to endemic areas.

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So a lot of the specimens we look

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at don't have parasites at
all good for the patient.

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But for our technologists who
have to sit there and sort

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through slide after slide,
it could be very tedious.

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It could be ergonomically
challenging, it could be quite

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quite frankly boring for them.

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And it's easy to lose
your train of thought

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and kind of zone out when you're looking

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at negative after negative
and you're trying to

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find that metaphorical
needle in the haystack.

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Again, having a computer
be able to really identify

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that quickly takes away the risk

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of subjectivity, human error, fatigue

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and decreases the risk
for ergonomic injuries.

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And is this something that is, you know

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easy to kind of train up into
using and and integrating?

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Or has this been an easy
lift to get people used

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to working in this way?

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Well, we're just starting,
but yes, it is essential to

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get your workforce to
embrace the technology.

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If your techs aren't on board

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you are not gonna have
successful implementation.

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So our technologists, our
lead technologists that have

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that specialized training have been

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on board right from the start.

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They evaluated the systems

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and decided they thought
it was a really cool thing

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and they also realized the potential

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for increasing accuracy, sensitivity

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the ability to detect parasites
that humans might miss.

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So it really was led by the laboratory

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and we plan on implementing,
implementing later this summer

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first with tricone stain stool specimens

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but we eventually wanna branch

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out into other exams including looking

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for that lone malaria plasmodium
ring in a blood slide.

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Excellent. So we've been kind of going

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down this pathway of talking about AI

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and how this is maybe changing
very early cutting edge

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in the process of changing
the parasitology lab.

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Can you elaborate a little bit

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about the molecular aspects of
how that might be integrated?

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I think we've, we've been used

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to seeing some of those kind of come

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into other areas of
infectious disease testing.

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Is this also kind of a

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a very newer aspect for parasitology?

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Yeah, you know it, I wouldn't say

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that it's all that new
in a sense when you think

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of molecular testing, like
molecular amplification methods

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P C R and other nucleic
acid amplification tests

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they've been around
now for several decades

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and they really did
revolutionize the detection

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of parasites in certain specimens.

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If you think of trichomonas vaginalis

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a sexually transmitted
protozoan parasite has a lot

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of potential risks for preterm pregnancy

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increased risk of
acquiring H I V infection.

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So important to detect and treat.

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We now know

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that the nucleic acid
amplification tests are superior

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to every other test we
have for detecting them.

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So that's been part of the mainstream now

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for several decades, at least
the past couple decades.

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Toxoplasma gondii, that's another
one where we've used PCR

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and there have been a number

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of tests targets that
are really well studied.

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And then probably most recently we've had

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the syndromic panels introduced mostly

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for diarrhea because we deal

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with a lot of stool in the
parasitology laboratory.

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And so someone that shows up
with diarrhea and the patient

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the physician thinks
it might be infectious

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can order a syndromic panel

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for diarrhea that will detect
multiple different types

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of organisms that cause
diarrhea, including parasites.

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In fact, you can get, you know, 20

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30 different organisms that you detect

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in a single specimen sometimes
in less than an hour.

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So that's really
revolutionized parasitology.

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There's other ways that
molecular diagnostics has helped

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but they aren't as well
embraced and widely available.

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For example, you can
look at gene mutations

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in plasmodium species
that cause malaria to see

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if they're gonna be
resistant to different drugs.

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But the only people that
are doing that are probably

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the scientists at the C D
C and some research labs.

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Oh, that's interesting.

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That kind of makes me think
about, and makes me curious

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how has this kind

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of impacted your training
for clinical fellows, right?

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If you know

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maybe some things might
be controversial right now

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but how do you prepare them
to kind of navigate the

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the this future ahead?

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Yeah, that's always been the challenge.

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Dr. Kreuter, I think being at
a place like Mayo Clinic too

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which tends to be at the cutting edge

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you still have to teach
them the so-called bread

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and butter organisms and
laboratory techniques.

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But at the same time, you
want them to have the exposure

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to the really cool cutting edge stuff.

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So it's a lot of, well here are the basics

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or here is an advanced
test, this is how we use it.

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But then also telling them
that if they're somewhere else

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that they may be using a different test

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or this might be a send out test

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if they happen to be in a smaller lab

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and the turnaround time
would be much different.

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So if we're at Mayo Clinic
and we have an advanced test

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we can perform it in a few hours

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that's really great for patient care.

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Whereas that same test that's a send out

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for a small community
care hospital might take

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two days turnaround time.

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So maybe that wouldn't
be your first line test.

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Hmm. It kind of makes me also think some

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of this integration and it, and I mean

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you said that with kind of this idea

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of a syndromic panel
that could be ordered right

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as we have kind of more
specialized testing

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and also our conventional testing on hand

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and in what context is one
versus the other better.

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Have you heard any kind

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of feedback from ordering
providers about, you know

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is the ability to have
kind of syndromic panel

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and then you know, the
laboratory can chase it?

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Has that kind of been a, you
know, positively received

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are there any challenges that come

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up with that kind of style of ordering?

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There are, and so it's always important

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and I'm sure you do this
in your practice too

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to work with our ordering
providers right off the bat

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and tell them when we have a new test

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so we can then develop
ordering algorithms together.

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And we did that for the
syndromic panel for diarrhea.

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We did studies to show
that for the patient

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in which testing is
appropriate, it's actually

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more cost effective to
order a single test rather

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than a whole panel of tests

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some of which can take several days.

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And you get your result very quickly.

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Part of it is just recognizing
that not all patients

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with a certain syndrome need to be tested.

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If you have diarrhea

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most people will get
better in a couple days.

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It's usually due to a virus
and it's self-limited.

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So you actually have to wait

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until about seven days before
you'd consider testing.

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Or if you have a patient who's very sick

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or at risk for being very sick.

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So I've always been a firm believer

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in working with my colleagues
and trying to figure

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out when we have a fancy new test

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how that test should be used

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and if we should even use it at all.

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Sometimes I go to my colleagues

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and I'll just say, we have this test

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would you be interested
in me bringing it in?

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Is there even any clinical utility?

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Wow. You know, I think
there's a lot of these themes

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on change management
that are kind of, I think

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percolating through a
lot of this conversation.

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And I, I hope that, you know

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listeners are really kind of picking

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up on these insights that Dr.

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Pritt sharing with us.

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You made mention to kind
of where things are going

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and a couple of, you know, I'm curious

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if you could elaborate and share
what are couple of the kind

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of hot topics in the field
for parasitology in in 2023?

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Yeah, definitely.

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So first of all

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the hot topics are the things
we've talked about already.

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Digital parasitology is gonna
be huge as it's going to be

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with any field that uses
microscopy based diagnostics.

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So we're gonna be seeing
more and more of that.

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Hopefully we'll start seeing
some F D A approved platforms

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in the next five years or so.

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Right now it's all lab developed tests

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and there's only a couple
companies, a few companies

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but we'll see that expand for sure.

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And we're gonna see more
molecular diagnostics

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and more panels.

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There's actually a new panel

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that syndromic panel
that was just released

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that detects all of
these different pathogens

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that can cause really terrible diseases

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like Ebola and Marburg
and Plasmodium Falciparum

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the deadliest cause of malaria is
also on that panel.

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So we're gonna see more

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of these panels that have
parasites on them, but I'll

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I'll mention a couple
other things that are maybe

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a little bit more just not so much fun.

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And that's our workforce shortage.

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I think every lab

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across the country is facing
this clinical laboratories.

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And so I think that leads

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to the fact that we have to
embrace these new technologies.

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We have to embrace
automation, digitalization

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artificial intelligence, high

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through molecular platforms.

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And yes, there's gonna
be change management

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and we have to do it in the right way

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and we have to have our whole lab on board

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but honestly we're gonna need to do it

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because of the workforce shortages.

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There's also a, a lack
of skilled readers to

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be able to identify
parasites using a microscope.

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And as we lose our more
experienced readers

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and we can't train the
new ones fast enough

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we need methods that are more objective

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that don't rely on a, you know,
six month training program

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before they're able to
be competent to read.

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So some of this is gonna be driven

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by the changes in the in the field.

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Others are though just
really positive changes

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that I'm just really excited to see

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because it's gonna be
better for patient care.

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That's phenomenal.

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Thank you so much for rounding with us

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Dr. Pritt.

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My pleasure.

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So thank you for joining us

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and if you're interested
in learning more, Dr.

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Pritt is gonna be doing a
parasitology workshop in August.

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So check the show notes for
the direct link to register.

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And to all of our listeners,
thank you for joining us today.

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We invite you to share your thoughts

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00:14:48,460 --> 00:14:49,920
and suggestions via email.

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00:14:49,920 --> 00:14:51,860
Please direct any suggestions

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00:14:51,860 --> 00:14:55,980
to M MCL education@mayo.edu
in reference this podcast.

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00:14:55,980 --> 00:14:57,900
If you've enjoyed Lab
Medicine Rounds podcast

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00:14:57,900 --> 00:15:00,780
please subscribe and until
our next rounds together

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00:15:00,780 --> 00:15:04,020
we encourage you to continue
to connect lab medicine

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and the clinical practice

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through insightful
conversations, just like Dr.

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Pritt is showing us.