The Modern Parasitology Lab

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. If you've enjoyed Lab Medicine Rounds podcast please subscribe and until our next rounds together we encourage you to continue to connect lab medicine and the clinical practice through insightful conversations, just like Dr. Pritt is showing us.