Clinical laboratories in patient care

Dr Satish Amarnath

The advances in the field of microelectronics, information technology and robotics along with the advances in laboratory medicine have transformed patient care delivery in the last decade. The strides taken by the biomedical scientists have largely contributed to the identification and diagnosis of new diseases and also discovered new facets of old diseases which will change the way we will deliver medical care in the next decade. We would examine a few areas in laboratory medicine and see how the changes have allowed the laboratory to deliver the laboratory testing to the form it exists today and will emerge tomorrow.

Clinical Biochemistry

The strides taken in chemical pathology have changed laboratory medicine. Miniaturisation has evolved testing strategies which uses less of the patients sample and microcuvettes have replaced test tubes. This on one hand, has reduced the amount of patient’s sample used, but has evolved in the way we can now detect molecules of interest which has significant implications for therapy. The detection of inborn errors of metabolism from a blood sample by HPLC (High Performance Liquid Chromatography) and use of mass spectra for the detection of lead and other heavy metal contamination and thereby disease is a striking example.

Today molecules like C peptide, Thyroid receptor binding globulin and Islet cell antibodies are striking examples where these detections have made laboratory not only participate in diagnosis, but also in the follow up of diseases like lead poisoning, thyrotoxicosis and diabetes.

Clinical Pathology and Haematology

This realm of laboratory medicine has seen the introduction of cell counters, making simple blood counts reliable and reproduceable. In addition, techniques like flow cytometry has revolutionised haematology; it is now possible to use this technique to immunophenotye (subtype) haematological malignancies. This testing of blood cancers makes diagnosis on a more firmer footing, but also again partners the laboratory in moving forward to join hands with the clinician in monitoring and treating cancers. In addition to cancer infections, malaria has seen methods emerge in microscopy, where it is now possible not only to see the deadly parasite by microscopy, but also follow up resistance on treatment and look for signatures which were not even perceived a few years back because of emergence of simpler technologies like immunochromatography and gene mapping.

Clinical Histopathology

This branch of anatomical (morphology) based diagnosis was the last bastion to fall to the strides in technology. Today processing of tissue for diagnosis is automated, faster and hands off. In fact, the staining automation has produced results that are comparable between laboratories. The detection of tumour markers has made the diagnosis of disease like lymphnode cancers on a more firmer footing and has also given pointers like how the therapy of cancer can behave like in the case of breast cancers.

Clinical Microbiology

Technology has transformed the practice of microbiology the most. The microbiologist has today introduced automation in bacteriology like blood culture, mycobacterial culture and identification, where it is now possible to give results within a day from the specimen. This means that a person is given the most appropriate antibiotic for cure of their illness. In addition, looking for signatures of infection has like biochemistry made immunology and serology under go a sea change. Introduction of techniques like ELISA, immunoflouresence, chemiluminance, nephlometry has not only made the laboratory do tests on a miniature basis, but also faster. In fact, one of the triumphs of microbiology is the full characterisation of HIV virus from genome to tests within a short span of a few months.

Today, microbiology detects molecules from invading pathogens to identify them even before they establish themselves. The era of HIV\AIDS has changed technology faster and made diagnostic strategies more comprehensive where not only more sensitive methods are to be employed, but also the microbiologist needs to look for usual pathogens in unusual places.

Moleculear Biology

The discovery of synthesis of genes in a test tube has revolutionised medical diagnosis, making it possible to look for one single gene. This has not only touched infectious disease where PCR for HIV diagnosis is a household name, but has made giant strides in technology like Real Time PCR, NASBA etc where it possible to identify gene defects, absence of genes and mutations etc. This has opened up realm of medicine hitherto unheard and unexplored. The identification of SARS by this field occurred even before the virus could be identified or cultured.

Genetics

The genetics laboratory has moved from the realm of identification of gross morphologies of chromosomes to gene detection, variation mapping and identification. In this, realm the application of technology has made identification of diseases even before the couple plans to conceive.

Cell Culture and Cell Biology

Though the field of cell culture and cell biology is not really in the field of laboratory medicine it has started making inroads to culture of stem cells. These cells are capable of changing into any cell of the human body and opens up possibilities to repair tissues in the body which is either destroyed by disease or ageing. Though the strides in this field is recent, it promises to change the face of tissue regeneration.

All the above fields have been enriched by the use of technology and advancements in the field of biotechnology, electronics and human knowledge. Today, man is exploring the uses of telemedicine, space technology, digitisation where a doctor in a far off place could provide diagnosis, treatment and monitor the patient remotely. The transfer of images for diagnosis in histopathology, radiology is a step in this direction. This enables the use of experienced doctors to help in difficult clinical situations.

The next century may see patients being monitored from home, where sensors placed in their body measure blood sugar and transmit through the intranet to the hospital. This could be evaluated by expert systems and would react even before we have said Jack Robinson and injected or stopped release of insulin from a repository in the body. This brings us to a n important question: Would the change of technology make man redundant as a doctor? I would say that this would not occur at least in the time frame of the next millennium, but definitely it would change the way we practice medicine with mundane testing being available at the bed side along with decisions and management being done at home and only serious, demanding diagnostic dilemmas coming over to the hospital.

In this era of technological advancements, I would still say that the realm of the doctor providing a healing touch and a soothing influence will never be irrelevant as seen in patients counseled for HIV, where patients fight the deadly virus infections by a few tests, a little medicine and a lot of advice and moral support.

The writer is wih Manipal Hospital