MedicalExpo e-Magazine - #23 – Greetings From the LabMedicalExpo e-Magazine

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Greetings From the Lab




For this new edition of MedicalExpo e-magazine, we are opening the doors of the laboratory. You’ll find out how the rapid diagnostic tests can be amazing tools to diagnose diseases like HIV, malaria and even Zika. You’ll also discover an impressive, fully automated microbiology lab in action, as well as the immense proliferation of microscopy techniques that continues to reveal new wonders.

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We’ll see probably a wave of new rapid tests in the next three to five years
Kids in Uganda (Courtesy of VisMedia)

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Rapid diagnostic tests are high quality, low-cost and easy-to-perform tests for use in resource-poor settings. Mainly used for HIV or malaria, they are frequently in the news with the development of rapid tests for Zika virus. We talked with Bill Rodriguez, chief medical officer at FIND, a non-profit organization that...


Hot Topics
Although automated lab procedures would help improve the speed as well as the quality of such tasks, they are still somewhat of a novelty in medical microbiology
NHS Tayside in Dundee, Scotland (Courtesy of NHS Tayside)

When it comes to lab automation, microbiology used to lag behind other laboratory disciplines – at least up to now. U.S. medical company Becton Dickinson has developed the fully automated sample processing system BD Kiestra TLA. This new technology, which is currently being tested at the Heidelberg University Hospital, is highly promising, particularly when dealing with the global challenge posed by microorganisms with multiple drug resistance.

 

If done manually, growing and identifying infecting agents in artificial culture media, such as agar plates, is a tedious job: From preparing the specimen, to streaking it across the culture medium with a wire loop, to providing it with the correct atmospheric conditions in an incubator, to labeling the plates and checking on them following a certain schedule, the necessary working steps can not only be time-consuming, but also prone to error. Although automated lab procedures would help improve the speed as well as the quality of such tasks, they are still somewhat of a novelty in medical microbiology.

“In contrast to for example clinical chemistry or hematology, where patient specimens have been processed in fully automated ways for several years, medical microbiology is one of the last areas of in vitro diagnostics, where manual procedures are still the rule—to a large part using the same techniques that were already established by Robert Koch,” a celebrated German physician and pioneering microbiologist, Dr. Detlef Storm, marketing manager for central Europe at BD Diagnostics Heidelberg, Germany, told us.

sans-titre-3

Lab automation (Courtesy of BD and Messe München)

To him, the main reason for this situation is that the methods of medical microbiology are relatively hard to standardize. After all, the microbial world is both tiny and vast.

BD Acquired Kiestra for a Total Lab Automation

While at least semi-automated systems have been available for almost 10 years, fully automated microbiology lab systems are still taking baby steps. Along with companies like bioMérieux and Copan, Becton Dickinson was one of the first companies to work on a fully automated solution. To that end, four years ago BD acquired Netherlands-based company Kiestra—a pioneer in automated microbial water analytics that developed a semi-automated medical microbiology lab.

The result of this cooperation is the new BD Kiestra Total Lab Automation (TLA), which fully automatizes and digitalizes all major working steps necessary to generate a microbiological test result from a patient specimen.

Here’s how it works:

 

When a barcoded test tube is inserted in BD Kiestra TLA, the system automatically recognizes the type of material, retrieves and labels the appropriate culture plates from integrated petri dish storage containers, opens the test tube to pick up an aliquot with a pipet, and is able to inoculate up to five plates at the same time, using a patented streaking technology.

“Properly streaking the specimen across the plate is critical to separating the different microbial colonies from one another. Therefore we developed the magnetic rolling bead technology: A small metallic blob rolls over the culture medium and can generate streak lengths of up to four meters,” said Storm about this feature, which has been shown to produce up to three to five times more single colonies compared with manual methods.

The BD Kiestra TLA fully automatizesall major working steps (Courtesy of BD)

The BD Kiestra TLA fully automatizes all major working steps (Courtesy of BD)

The system then automatically transports the inoculated plates to the appropriate incubators, where each plate can be photographed up to every two hours. The lab technicians can then digitally review the plates on high-resolution monitors.

In April 2016, a BD Kiestra TLA was officially inaugurated at the microbiological laboratory of the Heidelberg University Hospital, led by Professor Dr. Klaus Heeg.

“We had two main reasons for implementing the system in our laboratory: The strong increase of test volumes as a quantitative aspect, and the fact that automated plate inoculation provides a significantly higher test resolution for microbic samples than manual methods as a qualitative aspect,” explained Dr. Stefan Zimmermann, Head of Division Bacteriology in Heeg’s laboratory. Zimmermann estimates that the test volumes at the laboratory have doubled in the last seven to eight years, mostly due to a surge in screenings for microorganisms with multiple drug resistances (MDR).

“Currently we receive about 700 samples every day from the different clinics. About 300 of those are nasal or rectal swabs for MDR screenings. These screenings have already been validated for routine testing on our BD Kiestra TLA along with all urine samples, which add up to approximately 100 samples per day,” said Zimmermann. Within the few months since the opening of BD Kiestra TLA, the lab was already able to reduce the time for most MRSA (Methicillin-resistant Staphylococcus aureus) screening results from about two days to 25 hours, thanks to the system’s ability to accurately manage inoculation times for every single culture plate.

Crossover Trial

According to Zimmermann another advantage of using the fully automated system is that lab technicians and physicians now have more time for clinically relevant tasks, such as interpreting findings or counseling clinicians about antimicrobial treatment. To better understand the effects of using BD Kiestra TLA on clinical outcomes, the lab will start conducting a crossover trial with two intensive care units, starting this fall.

The lab is also looking into training BD Kiestra TLA to become more intelligent.

“We hope that using a fully automated system will lead to quantifiable benefits for our patients, and eventually possibly even bigger scale effects such as reducing the incidence of antimicrobial resistance,” Zimmermann, who expects first preliminary results of the study in mid-2017, told us.

Together with Becton Dickinson, the lab is also looking into training BD Kiestra TLA to become more intelligent. In a first step, the system is supposed to learn to automatically identify Methicillin-resistant Staphylococcus aureus (MRSA) bacteria by recognizing the unique red hue they generate on chromogenic culture plates.


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  • Retort 1850 (Painting of William Jensen - Oesper Collections, University of Cincinnati)

    Behold the humble test tube. If you think it’s the symbol of chemistry, you’d be wrong, argues William Jensen, a chemistry historian and professor emeritus at the University of Cincinnati Department of Chemistry.

     

    “At best, it’s a co-symbol,” said Jensen, who has combed paintings and old chemistry texts in search of data to date the test tube and other apparatus used in chemistry labs.

    If you think the test tube dates back to alchemy, wrong again, said Jensen, who has been able to trace the test tube back only to the first decade of the 19th centuryActually, you’d probably be thinking of spherical vessels with a long downward-pointing neck known as the retort, glass or copper vessels used in distillation. (The idiom “snappish retort” may refer to the vessel.)

    Liquids are placed in the retort to be heated. The neck acts as a condenser, allowing the vapors to condense, flow along the neck and be collected underneath, according to Wikipedia. In the case of alchemy, you would actually be thinking instead of a retort. No self-respecting alchemist would’ve been without one.

    Jensen said, “Virtually every modern-day artistic depiction of an alchemist will feature a retort as the centerpiece of the alchemist’s laboratory,” he said. “Perhaps no single piece of laboratory apparatus is more intimately associated in popular culture with the practice of chemistry than is the retort.”

    A Snappy Retort

    1494

    1494 (Painting of chemist William Jensen – Oesper Collections, University of Cincinnati)

    A retort is depicted on the Boy Scouts of America’s chemistry merit badge, said Jensen. Likewise, the insignia for the Chemical Corps of the United States Army incorporates retorts.

    Retorts first appeared in the literature dealing with distillation sometime in the 14th or 15th century, he said in an article entitled “A Snappy Retort” in Notes from the Oesper Collections (Museum Notes, January/February 2013, 1-6).

    Common laboratory apparatus, including flasks (think Walter White, the high school chemistry teacher turned meth kingpin), beaker (think the Muppets) and retorts (think Merlin) before the 19th century was flawed. 

    Jensen said that’s because it did not have a high melting point; was not resistant to being destroyed by water, alkalis and acids; was not colorless and transparent; and was not resistant to thermal and mechanical stress.

    Jensen has traced the creation of the test tube to the beginning of the 19th century. He said test tubes were used to heat chemicals, which, based on the colors that were seen, allowed chemists to identify chemicals.

    Here Comes the Pyrex

    Throughout the century, innovations in glassmaking, such as making it thin with tough glass, made the modern test tube possible.

    Test tube rack from 1880s (Courtesy of Oesper Collections, University of Cincinnati)

    In 1915, Corning Glass introduced Pyrex, which was superior in withstanding mechanical shock, Jensen wrote in his Ask the Historian column entitled “The Origin of Pyrex” (J. Chem. Educ., 2006, 83, 692-693). Pyrex first was used in cookware, but soon was applied to lab glassware. Test tubes are hanging in there. Retorts have been in decline for more than a century.

    “Ironically, despite its continued use as a symbol for the practice of chemistry, the retort had already begun to disappear from day-to-day laboratory practice by the early decades of the 20th century…”, he said.

     


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    The SOMATOM Force (Courtesy of Siemens Healthineers)

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    At the Congress for the European Society of Cardiology (ESC) from August 27-31 in Rome, Siemens Healthineers presented what it calls its new “workflow approach” for complex, minimally invasive procedures. The goal is to help cardiologists optimize medical imaging at every stage of cardiology treatment, from diagnosis to follow-up care.

     

    Imagine a patient with a heart valve problem—not an emergency situation, but a complex, ongoing case, with the quality of the patient’s life going down significantly. First of all, an exact patient assessment is crucial to decide for the optimal treatment. Based on this information, an interdisciplinary heart team decides whether surgical or minimally invasive intervention is the most appropriate treatment approach.

    In those cases, a minimally invasive procedure is the best choice to treat structural heart diseases. With minimally invasive procedures, open thorax surgery is not needed. The patient would probably avoid general anesthesia which translates into shortened recovery time and therefore less time to be spent at the hospital.

    The ACUSON SC2000 (Courtesy of Siemens Healthineers)

    The ACUSON SC2000 (Courtesy of Siemens Healthineers)

    “Minimally invasive procedures are an alternative for some patients, but the physicians face also some challenges,” explained Doris Pommi, head of marketing in cardiology at Siemens Healthineers, during a phone interview with MedicalExpo e-mag. “Physicians treat the patient by inserting a catheter via a femoral or apical access for heart valve treatment. Therefore, the physicians don’t see the [heart] valve physically, like in an open surgery, so the need of excellent image quality, information about anatomy and physiology, and guidance during the procedure is crucial,” she added.

    Devices become smaller and the material they’re made of could be difficult to visualize.  For an optimal outcome, it is necessary to assess the correct placement, deployment and function of the device. That’s where Siemens Healthineers comes into the game. The German company offers to “provide the imaging modalities and tools to support the assessment of the patient before the procedure”, to “guide the exact placement during the procedure” and finally to provide imaging and tools to support after the procedure if everything is working well.

    Therapy: Checking the Placement of the Implant Immediately

    These are two examples for the diagnosis and assessment step:

    The ACUSOM SC2000 Prime combines two technologies: the ultrasound system that can produce 3-D transesophageal echocardiography full-volume color Doppler images of the heart and blood flow, and the integrated eSie Valves analysis software that supports precise measurements of the individual heart valves in just seconds.

    Dual-source CT scanners from Siemens Healthineers make it possible to perform CT imaging with low doses of radiation. The high rotational speed of the SOMATOM Force and the resulting temporal resolution, make it unnecessary for patients to hold their breath during the scan or to take medications to regulate their heartbeat, explained Siemens Healthineers in a press release.

    ct-scanner_somatom-force-01175614-10

    The SOMATOM Force (Courtesy of Siemens Healthineers)

    Finally, the real-time 3-D ultrasound imaging provided by the ACUSON SC2000 Prime comes into play with minimally invasive mitral valve therapy, since its full-volume color Doppler function enables the assessment of the implant immediately, while the patient is still on the operating table. The heart team sees immediately, if the treatment was successful.

    The whole clinical pathway needs “very good teamwork,” said Pommi.


    CONTRIBUTORS



    Daniel Allen

    Daniel Allen is a writer and a photographer. His work has been featured in numerous publications, including CNN, BBC, The Sunday Times, The Guardian, National Geographic Traveller, Discovery Channel.


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    Celia Sampol

    Celia Sampol has been a journalist for 15 years. She worked in Brussels and Washington for national medias (Agence France Presse, Liberation). She’s now the editor-in-chief of MedicalExpo e-magazine.


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    Howard Wolinsky

    Howard Wolinsky is a Chicago-based freelance journalist specializing in health-care topics.


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    Laura Newman

    Laura Newman is a New York-based medical writer who writes frequently about medical technological advances and health policy.


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    Christina Kuhrcke

    Christina Kuhrcke is a Berlin-based freelance journalist, doctor and digital storyteller.


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