1 00:00:00,000 --> 00:00:13,400 Thanks for joining us again at the Canadian Breakpoint, a Canadian infectious diseases 2 00:00:13,400 --> 00:00:17,680 podcast by Canadian infectious diseases physicians. 3 00:00:17,680 --> 00:00:23,300 I'm Summer Stewart, here again with Dr. Rupeena Purewal, pediatric infectious diseases physician 4 00:00:23,300 --> 00:00:24,920 in Saskatoon. 5 00:00:24,920 --> 00:00:30,520 In this episode, we welcome Dr. Marthe Charles, medical microbiologist and infectious diseases 6 00:00:30,520 --> 00:00:35,840 specialist from Vancouver, British Columbia, to discuss new advances in molecular diagnostics. 7 00:00:35,840 --> 00:00:37,840 Dr. Purewal. 8 00:00:37,840 --> 00:00:44,040 Hi, welcome to another episode of our podcast, the Canadian Breakpoint. 9 00:00:44,040 --> 00:00:46,840 Today we have a very special guest with us, Dr. Charles. 10 00:00:46,840 --> 00:00:53,760 Dr. Charles has completed an MD, MSc degree from the University of Montreal in 2010. 11 00:00:53,760 --> 00:00:58,480 Six years later, she finished her residency in medical microbiology and infectious diseases 12 00:00:58,480 --> 00:01:01,280 at the University of Alberta. 13 00:01:01,280 --> 00:01:05,280 Now she's the division head of the medical microbiology and infection prevention and 14 00:01:05,280 --> 00:01:09,700 control and Vancouver Coastal Health for the last five years. 15 00:01:09,700 --> 00:01:16,900 Her interest lies in more integrated diagnostics, increasing access and quality improvement. 16 00:01:16,900 --> 00:01:22,840 She currently oversees urogenital infections and molecular diagnostics at Vancouver Coastal 17 00:01:22,840 --> 00:01:24,040 Health. 18 00:01:24,040 --> 00:01:29,640 From an IPAC perspective, she's involved in laboratory assessment of self-disinfecting 19 00:01:29,640 --> 00:01:31,640 surfaces. 20 00:01:31,640 --> 00:01:32,640 Welcome Dr. Charles. 21 00:01:32,640 --> 00:01:39,680 It's a pleasure to have you on the podcast and I'm delighted to talk about some of these 22 00:01:39,680 --> 00:01:42,760 molecular methods and products. 23 00:01:42,760 --> 00:01:47,120 So obviously before we start, I would like to disclose that this is an informational 24 00:01:47,120 --> 00:01:51,920 podcast and we are no way endorsing a product. 25 00:01:51,920 --> 00:01:52,920 So thank you for being here today. 26 00:01:52,920 --> 00:01:55,560 Well, thank you so much for having me. 27 00:01:55,560 --> 00:01:59,880 I'm really excited about this opportunity to be able to talk. 28 00:01:59,880 --> 00:02:00,880 Great. 29 00:02:00,880 --> 00:02:02,240 So why don't we get right into it? 30 00:02:02,240 --> 00:02:06,480 Because I know a lot of our listeners are excited to hear about Biofire and different 31 00:02:06,480 --> 00:02:07,480 panels. 32 00:02:07,480 --> 00:02:12,360 So I think to give an introduction to everybody, I would like to see if you can just talk a 33 00:02:12,360 --> 00:02:18,240 little bit about some of the molecular based products that you're utilizing there in Vancouver 34 00:02:18,240 --> 00:02:20,960 and really the main differences between them. 35 00:02:20,960 --> 00:02:25,760 If you can touch on really from a lab perspective standpoint, it would be awesome. 36 00:02:25,760 --> 00:02:26,760 Okay. 37 00:02:26,760 --> 00:02:33,480 So I guess I'll probably start by saying that maybe I should disclose my concept of interest. 38 00:02:33,480 --> 00:02:41,320 So yeah, I'm part of the Bureau of Speakers for CFI, but this presentation is representing 39 00:02:41,320 --> 00:02:46,640 solely my own opinions and experience as a medical microbiologist at the Vancouver Coastal 40 00:02:46,640 --> 00:02:47,640 Health. 41 00:02:47,640 --> 00:02:52,880 So I think it's interesting really to have the perspective of the lab. 42 00:02:52,880 --> 00:03:00,640 So as you mentioned, I'm a medical microbiologist, but I'm also an infectious disease specialist. 43 00:03:00,640 --> 00:03:04,720 And I'm trying to kind of bring those two hats when I'm thinking about technologies 44 00:03:04,720 --> 00:03:07,840 that are being used in the lab. 45 00:03:07,840 --> 00:03:13,720 Before I start, I think it's important for people that are listening in on this topic 46 00:03:13,720 --> 00:03:19,880 that the molecular field has been for the longest time a really highly specialized area 47 00:03:19,880 --> 00:03:21,480 in the laboratory. 48 00:03:21,480 --> 00:03:28,280 So if you look at a lot of our various public health laboratories or reference laboratories, 49 00:03:28,280 --> 00:03:34,480 molecular diagnostic was normally a specific area in the laboratory while all of the people 50 00:03:34,480 --> 00:03:38,240 that were working there were a lot of people that have graduated studies. 51 00:03:38,240 --> 00:03:43,160 You know, you'll have like the masters, the PhDs and people that have a lot of training 52 00:03:43,160 --> 00:03:45,600 to be able to work in those facilities. 53 00:03:45,600 --> 00:03:53,260 So looking back in terms of molecular diagnostic, I think it's important to kind of mention 54 00:03:53,260 --> 00:03:59,960 like specific steps that are super important to be able to get to an answer at the end. 55 00:03:59,960 --> 00:04:04,960 I think everybody has now vivid memories of getting tested for COVID, for example. 56 00:04:04,960 --> 00:04:12,320 So if we take a sample that was coming from your nasal pharyngeal area, well, that sample 57 00:04:12,320 --> 00:04:19,200 doesn't just contain samples that are, I mean, material that is coming from viruses. 58 00:04:19,200 --> 00:04:20,880 You'll have a melting pot of stuff, right? 59 00:04:20,880 --> 00:04:25,800 So you'll have the human components, you'll have all of the bacteria that are part of 60 00:04:25,800 --> 00:04:26,800 our normal flora. 61 00:04:26,800 --> 00:04:32,160 I think we talk a lot about that, what is part of the microbiome of the nose, and then 62 00:04:32,160 --> 00:04:33,640 you'll have the viruses. 63 00:04:33,640 --> 00:04:39,880 So the first step that any sample that comes in the lab for molecular diagnostic would 64 00:04:39,880 --> 00:04:44,120 have to go through is what we call an extraction step. 65 00:04:44,120 --> 00:04:48,480 So what we want to do is really making sure that whatever material that we're working 66 00:04:48,480 --> 00:04:54,080 with is the material coming, the genetic material coming from the virus. 67 00:04:54,080 --> 00:04:59,760 So then what would happen is then once we know for sure that we have the genetic information 68 00:04:59,760 --> 00:05:04,880 coming from the virus, what you want to be able is to amplify that signal and then to 69 00:05:04,880 --> 00:05:06,600 be able to detect it. 70 00:05:06,600 --> 00:05:13,200 So as I said previously, you had a specific area in the laboratory that would do that, 71 00:05:13,200 --> 00:05:18,920 and all of those steps that I was talking about of extraction, amplification, and detection 72 00:05:18,920 --> 00:05:23,360 could have been done on various and different instruments. 73 00:05:23,360 --> 00:05:29,600 So I think today what we'll mostly focus on, it's the ability of having all of those steps 74 00:05:29,600 --> 00:05:39,000 within a black box and a super easy and fast way of detecting microorganism or pathogen. 75 00:05:39,000 --> 00:05:45,840 So I think the big players that we kind of hear about a lot would be like BioFire. 76 00:05:45,840 --> 00:05:50,960 So that's the instrument and the company is BioMaria. 77 00:05:50,960 --> 00:05:54,240 And then you have GeneXpert that people might have heard about. 78 00:05:54,240 --> 00:05:59,880 GeneXpert is the instrument, but it's the company C-Feed. 79 00:05:59,880 --> 00:06:04,560 Other players that people might or might not have heard about would be things like Roche, 80 00:06:04,560 --> 00:06:08,280 that's the big company, and the instrument that they have is Liat. 81 00:06:08,280 --> 00:06:15,000 And then Kyagene is a little bit like of a later player in the multiplex diagnostic sphere 82 00:06:15,000 --> 00:06:16,840 with the Kyastat. 83 00:06:16,840 --> 00:06:20,080 So those are the instruments that we have right now. 84 00:06:20,080 --> 00:06:25,560 We call them black box because all of those steps that I've previously described are happening 85 00:06:25,560 --> 00:06:30,440 without any intervention from the laborer or the technologist. 86 00:06:30,440 --> 00:06:34,760 So they all happen without us being involved in the process. 87 00:06:34,760 --> 00:06:35,760 Wow. 88 00:06:35,760 --> 00:06:41,320 It's amazing that such a detailed process. 89 00:06:41,320 --> 00:06:48,360 And I'm sure from a lab perspective standpoint, that cuts down a lot of time for technicians 90 00:06:48,360 --> 00:06:52,200 as well and turnaround time as well, I would imagine. 91 00:06:52,200 --> 00:06:54,560 Oh, no, for sure. 92 00:06:54,560 --> 00:07:02,000 Those type of instruments are a devil-edged sword in a sense because as a diagnostician, 93 00:07:02,000 --> 00:07:06,960 we want to be able to see what's happening and to be able to also troubleshoot. 94 00:07:06,960 --> 00:07:12,640 But now it's completely out of our control really because all of the quality aspects 95 00:07:12,640 --> 00:07:16,960 are taken into account by the instrument itself. 96 00:07:16,960 --> 00:07:25,920 So it's quite fascinating that we were able to automate and miniaturize all of those parts 97 00:07:25,920 --> 00:07:33,400 in a way that it makes it way, way much easier and easily accessible, not only for the clinicians, 98 00:07:33,400 --> 00:07:36,160 but also for the lab artisan. 99 00:07:36,160 --> 00:07:40,640 And I know in the past, you've mentioned that like respiratory panels, for instance, would 100 00:07:40,640 --> 00:07:44,440 be kind of the most commonly used, just like what we talked about with COVID. 101 00:07:44,440 --> 00:07:49,480 And I think lots of people are kind of familiar with respiratory samples. 102 00:07:49,480 --> 00:07:53,800 So what other, like we'll definitely go into, I think, all the details of that because I 103 00:07:53,800 --> 00:07:58,120 know you've done a lot of research in that area as well, because it is the most commonly 104 00:07:58,120 --> 00:07:59,120 used panel. 105 00:07:59,120 --> 00:08:04,680 But in terms of other panels, what's being offered right now? 106 00:08:04,680 --> 00:08:07,080 Oh my God, there's so many. 107 00:08:07,080 --> 00:08:13,160 So if we look at the BioMaria product with BioFire, and I think that's funny because 108 00:08:13,160 --> 00:08:18,920 a lot of the clinicians these days are phoning the lab and they're like, I want a BioFire. 109 00:08:18,920 --> 00:08:21,280 And for me, my answer is always like, which one? 110 00:08:21,280 --> 00:08:22,280 Yeah. 111 00:08:22,280 --> 00:08:24,280 Which, what are we looking for here? 112 00:08:24,280 --> 00:08:25,560 Yeah, which one? 113 00:08:25,560 --> 00:08:29,760 Because I think people are not aware that there's a lot of different panels that are 114 00:08:29,760 --> 00:08:32,960 available for BioMaria at this point. 115 00:08:32,960 --> 00:08:34,520 So there's the pneumonia. 116 00:08:34,520 --> 00:08:41,440 So we're talking about lower respiratory pathogens, and they also have one for that are more upper 117 00:08:41,440 --> 00:08:44,080 respiratory tract type of infection. 118 00:08:44,080 --> 00:08:46,680 They also have GI panel. 119 00:08:46,680 --> 00:08:50,400 They have a meningitis panel, the ME panel, they call it. 120 00:08:50,400 --> 00:08:52,200 They have a blood culture ID. 121 00:08:52,200 --> 00:08:54,600 So that's from positive blood culture. 122 00:08:54,600 --> 00:08:58,240 Then you can put it into that panel that goes onto the BioFire. 123 00:08:58,240 --> 00:09:03,840 And I'm also interested to see that they also have what would be like for a joint infection, 124 00:09:03,840 --> 00:09:07,040 but I didn't have the pleasure yet to be able to work with that one. 125 00:09:07,040 --> 00:09:12,960 But it's just to show that please don't call your lab saying that you want a BioFire because 126 00:09:12,960 --> 00:09:15,320 there's so many different panels that are available. 127 00:09:15,320 --> 00:09:20,280 So it's always more helpful to really be clear about what you're looking for. 128 00:09:20,280 --> 00:09:25,800 If you're looking at GeneXpert, I'm not going to name all of the panels that they have because 129 00:09:25,800 --> 00:09:27,480 they have more than five. 130 00:09:27,480 --> 00:09:32,400 But things that you probably have heard is that they'll have like the COVID-2-AB-RSV 131 00:09:32,400 --> 00:09:33,760 panel. 132 00:09:33,760 --> 00:09:40,840 They have cartridges for all sorts of things like from C. diff, neuro, gyne, so STI testing 133 00:09:40,840 --> 00:09:44,080 on the GeneXpert, C. diff testing on the GeneXpert. 134 00:09:44,080 --> 00:09:49,760 So they have a quite big array of cartridges that are available for testing. 135 00:09:49,760 --> 00:09:55,480 And then in terms of the BioFire panels, so let's say the REST panel, what are we looking 136 00:09:55,480 --> 00:09:56,480 at? 137 00:09:56,480 --> 00:09:59,560 So obviously the type of specimen is going to depend on the type of panel and what we're 138 00:09:59,560 --> 00:10:01,060 looking for. 139 00:10:01,060 --> 00:10:06,480 But what are some of the turnaround times that people are looking at? 140 00:10:06,480 --> 00:10:09,760 And what does this really cost for the lab? 141 00:10:09,760 --> 00:10:11,760 That's my big question. 142 00:10:11,760 --> 00:10:12,760 Yeah. 143 00:10:12,760 --> 00:10:13,760 Okay. 144 00:10:13,760 --> 00:10:20,840 So we can talk about the differences between the various panels that are available, but 145 00:10:20,840 --> 00:10:23,880 I think, I guess I'll just tell you the price. 146 00:10:23,880 --> 00:10:31,600 So depending where you are in Canada, I think the pricing might change depending on the 147 00:10:31,600 --> 00:10:33,440 contract that you have with those companies. 148 00:10:33,440 --> 00:10:37,680 But normally it's in the hundreds of dollars. 149 00:10:37,680 --> 00:10:42,760 And the reason why we mentioned this, it's quite significant because for the longest 150 00:10:42,760 --> 00:10:48,640 time in the molecular area, we use what we call lab-developed tests. 151 00:10:48,640 --> 00:10:55,920 The lab-developed tests are often super easy to establish in Canada in the sense that if 152 00:10:55,920 --> 00:11:00,780 you have your set of primers and then you have your reagent for your real-time PCR, 153 00:11:00,780 --> 00:11:07,800 so it's easy in terms of it wouldn't be really costly compared to hundreds of dollars for 154 00:11:07,800 --> 00:11:11,440 a cartridge on a multiplex panel. 155 00:11:11,440 --> 00:11:17,800 So on the ABI, because that's the real-time PCR that we use here, often a lot of the tests 156 00:11:17,800 --> 00:11:24,360 that we would do would be on the magnitude of less than 20 or $10 per patient. 157 00:11:24,360 --> 00:11:25,360 Yeah. 158 00:11:25,360 --> 00:11:26,360 So a huge difference. 159 00:11:26,360 --> 00:11:28,320 So it's significant, right? 160 00:11:28,320 --> 00:11:37,480 So the approach that we took here at my laboratory was to really try to have a laboratory stewardship 161 00:11:37,480 --> 00:11:41,800 in a sense to try to really make sure that the test that we're doing is providing the 162 00:11:41,800 --> 00:11:46,680 answers that the clinician required to take the best care as possible for their patient 163 00:11:46,680 --> 00:11:47,680 population. 164 00:11:47,680 --> 00:11:48,680 Yeah. 165 00:11:48,680 --> 00:11:49,680 And I think that's really important. 166 00:11:49,680 --> 00:11:55,560 When we talk a lot about stewardship in the clinical world, but I think kind of taking 167 00:11:55,560 --> 00:12:00,960 that into account and from a lab perspective standpoint is really creating that awareness. 168 00:12:00,960 --> 00:12:06,400 And sometimes when I'm a clinician, so when I'm wearing the clinician hat, you don't think 169 00:12:06,400 --> 00:12:07,640 about these things. 170 00:12:07,640 --> 00:12:12,280 You really are just trying to find the answer because the answer is going to help your patient 171 00:12:12,280 --> 00:12:19,520 get better or the answer is going to help give us an answer to better treat the patient. 172 00:12:19,520 --> 00:12:25,240 And we always think of it more from a stewardship standpoint in terms of antibiotic use. 173 00:12:25,240 --> 00:12:31,680 And I know that especially with the respiratory panel, you've done some work also in research 174 00:12:31,680 --> 00:12:33,820 around this area. 175 00:12:33,820 --> 00:12:37,560 So probably changing the gear a little bit because I know that we've talked a little 176 00:12:37,560 --> 00:12:44,320 bit about the costs and some of the, I guess, advantages and disadvantages of this, but 177 00:12:44,320 --> 00:12:50,120 really going into what clinicians, the reason that we are ordering these panels, what is 178 00:12:50,120 --> 00:12:54,200 some research that you, and do you want to talk a little bit about your research around 179 00:12:54,200 --> 00:12:58,880 how you've seen these respiratory panels help us in the clinical world? 180 00:12:58,880 --> 00:12:59,880 Yeah. 181 00:12:59,880 --> 00:13:05,600 So here at our laboratory, I think the panel which we had the most experience with was 182 00:13:05,600 --> 00:13:09,960 the respiratory panel, so the RP1 at the time. 183 00:13:09,960 --> 00:13:16,280 So when I joined the lab, one of the research that I was able to participate in was about 184 00:13:16,280 --> 00:13:23,240 the utilization of biofire respiratory panel for the BMT, so the bone marrow transplantation 185 00:13:23,240 --> 00:13:30,160 unit and the impact that the utilization of such equipment would have on infection control, 186 00:13:30,160 --> 00:13:33,160 but also on antimicrobial stewardship. 187 00:13:33,160 --> 00:13:39,920 So we know that that population has a tendency to present with high-grade temperature or 188 00:13:39,920 --> 00:13:46,000 fever, and it's always kind of the concern about, well, is it part of their evolution 189 00:13:46,000 --> 00:13:50,080 of their disease or is it because of an infection? 190 00:13:50,080 --> 00:13:56,360 And if it's an infection, is it due to viruses when you're in the respiratory viral viruses 191 00:13:56,360 --> 00:13:57,520 season? 192 00:13:57,520 --> 00:14:03,520 So what we were able to show, and for people that are curious and want to go and read about 193 00:14:03,520 --> 00:14:09,440 it, we have an article titled Biofire Film RA Decreases Infection Control Isolation Time 194 00:14:09,440 --> 00:14:13,280 by Four Days in ICU, BMT and Respiratory Rewards. 195 00:14:13,280 --> 00:14:19,760 So this was published by Dr. Wong and all, so I was one of the contributors to that study. 196 00:14:19,760 --> 00:14:22,240 But I think the title will kind of say it. 197 00:14:22,240 --> 00:14:27,920 We were able to show that the utilization of the biofire, despite the upfront cuts to 198 00:14:27,920 --> 00:14:33,040 the lab, had downside effect in the sense that we were able to reduce the isolation 199 00:14:33,040 --> 00:14:34,600 time for those patients. 200 00:14:34,600 --> 00:14:39,560 And we know that having patients in isolation is often problematic in terms of the quality 201 00:14:39,560 --> 00:14:44,480 of the care that they're getting because often for the nursing staff, it's easier to keep 202 00:14:44,480 --> 00:14:50,120 the care for a lot of people that you have to dawn and off precautions for. 203 00:14:50,120 --> 00:14:56,280 So that's just an example of how an equipment in the laboratory has a direct impact on the 204 00:14:56,280 --> 00:14:59,200 care that patients are getting on the ward. 205 00:14:59,200 --> 00:15:03,680 So I think that study was really good and it kind of helped us also build a business 206 00:15:03,680 --> 00:15:08,920 case and show value for an instrument that would be used in the lab. 207 00:15:08,920 --> 00:15:15,560 The only caveat that I would put there is that it made a difference as long as the laboratory 208 00:15:15,560 --> 00:15:19,520 was using this instrument as a stat instrument. 209 00:15:19,520 --> 00:15:25,120 And we'll talk about it maybe a bit later about the impact of having those type of equipment 210 00:15:25,120 --> 00:15:26,120 in the lab. 211 00:15:26,120 --> 00:15:30,600 It's only true if I'm able to act on the sample right away. 212 00:15:30,600 --> 00:15:36,240 So during that study design, what we had done is like all of those samples that were coming 213 00:15:36,240 --> 00:15:42,360 from ICU, BMT, and the respiratory wards had to be processed within one hour of receipt. 214 00:15:42,360 --> 00:15:48,800 So then the fact that the instrument is so quick, you can really capitalize on that because 215 00:15:48,800 --> 00:15:50,960 we were putting it on the instrument right away. 216 00:15:50,960 --> 00:15:57,840 So I guess what I'm trying to say is if the wards collect the sample and doesn't send 217 00:15:57,840 --> 00:16:03,560 it to the lab, or if the lab received the sample and don't put it on the instrument 218 00:16:03,560 --> 00:16:08,440 right away, then you lose the benefit of having an instrument that is really quick. 219 00:16:08,440 --> 00:16:09,440 Definitely. 220 00:16:09,440 --> 00:16:11,800 So those are some of the things. 221 00:16:11,800 --> 00:16:16,100 And sometimes in the clinical world, as opposed to when we're doing some of the research, 222 00:16:16,100 --> 00:16:19,800 we can sometimes find those discrepancies too. 223 00:16:19,800 --> 00:16:27,020 Because sometimes with clinical, there's like delay for collection, there's delay for multiple 224 00:16:27,020 --> 00:16:29,800 reasons for the sample to get to the lab. 225 00:16:29,800 --> 00:16:34,200 Probably also depends on the number of samples that are coming in. 226 00:16:34,200 --> 00:16:39,560 And so hence why we always kind of talk about lab stewardship and really understanding, 227 00:16:39,560 --> 00:16:42,280 are we sending the sample for the right reasons? 228 00:16:42,280 --> 00:16:47,160 And is this going to make the difference because we don't want to burden our lab colleagues 229 00:16:47,160 --> 00:16:48,160 either. 230 00:16:48,160 --> 00:16:50,520 Yeah, no, good point. 231 00:16:50,520 --> 00:16:56,040 And I also like what you mentioned about, it's also knowing the specimen type that you're 232 00:16:56,040 --> 00:16:57,040 sending. 233 00:16:57,040 --> 00:17:05,200 Because sometimes if you don't have the conversation with your microbiologist in the lab, then 234 00:17:05,200 --> 00:17:06,640 you don't have that information. 235 00:17:06,640 --> 00:17:13,280 But of all the instruments that we have in the lab, some can or cannot process certain 236 00:17:13,280 --> 00:17:15,920 specimen type. 237 00:17:15,920 --> 00:17:23,720 So what I'm trying to say here again is that if the only sample that you can collect on 238 00:17:23,720 --> 00:17:28,160 one of your patients is a tracheal aspirate, well, it might not be compatible to be put 239 00:17:28,160 --> 00:17:34,380 on your biofiber and therefore you're not getting the result as fast as you were hoping 240 00:17:34,380 --> 00:17:35,380 to get it. 241 00:17:35,380 --> 00:17:36,380 Right? 242 00:17:36,380 --> 00:17:39,640 So you have to change the methodology to process that sample. 243 00:17:39,640 --> 00:17:41,560 But something else to keep in mind. 244 00:17:41,560 --> 00:17:46,400 And that kind of brings me to the second paper that we've done in collaboration with the 245 00:17:46,400 --> 00:17:53,400 BioFire, which was the utilization of bronchoscopy samples and try to put that on the BioFire 246 00:17:53,400 --> 00:18:01,440 and see that the performance was still fairly good, but not as good as we were hoping it 247 00:18:01,440 --> 00:18:02,440 to be. 248 00:18:02,440 --> 00:18:08,520 So right now for us, we're not yet putting BALs, for example, on the BioFire, but it's 249 00:18:08,520 --> 00:18:14,520 a conversation that we would have with the clinicians in terms of how strong is their 250 00:18:14,520 --> 00:18:18,960 pre-test probability that they think that there's a viral infection going on. 251 00:18:18,960 --> 00:18:25,160 And then knowing the performance on the test, we would decide if we would go that way or 252 00:18:25,160 --> 00:18:26,160 not. 253 00:18:26,160 --> 00:18:27,160 Right? 254 00:18:27,160 --> 00:18:30,320 So just for our knowledge, for the listeners as well, the best sample right now would be 255 00:18:30,320 --> 00:18:32,520 your nasopharyngeal sample. 256 00:18:32,520 --> 00:18:33,520 Yeah. 257 00:18:33,520 --> 00:18:41,160 So on the respiratory panel, on the BioFire, the best sample would remain to be the nasopharyngeal 258 00:18:41,160 --> 00:18:42,160 squad. 259 00:18:42,160 --> 00:18:43,160 Okay. 260 00:18:43,160 --> 00:18:48,000 And then also just because we have listeners that are clinicians, but we also have pharmacists 261 00:18:48,000 --> 00:18:52,160 and we have nurses kind of from all across the world. 262 00:18:52,160 --> 00:18:58,280 So just to kind of let them know what type of organisms and pathogens are we detecting 263 00:18:58,280 --> 00:19:02,000 with like, for instance, the respiratory panel, just to name a few. 264 00:19:02,000 --> 00:19:03,000 Okay. 265 00:19:03,000 --> 00:19:06,680 So the respiratory panel will have like your regular steps. 266 00:19:06,680 --> 00:19:12,840 So you'll find the flu, A, B, RSV, you'll have the COVID. 267 00:19:12,840 --> 00:19:20,320 In terms of the other viruses, it has the ability of detecting human metonymovirus, 268 00:19:20,320 --> 00:19:23,760 rhino enteropara influenza as well. 269 00:19:23,760 --> 00:19:31,600 But it has also the ability of detecting other organisms depending which BioFire, if you're 270 00:19:31,600 --> 00:19:36,320 on the pneumonia panel versus the RP2 panel. 271 00:19:36,320 --> 00:19:40,240 I'm just going to provide the information for the RP2. 272 00:19:40,240 --> 00:19:45,400 So the other organism that I was thinking about was, for example, certain bacteria, 273 00:19:45,400 --> 00:19:51,760 the bordetella paraparctis, the media pneumoniae and mycoplasma pneumoniae. 274 00:19:51,760 --> 00:19:59,400 And then also all of the other human coronaviruses that were known prior to COVID were also part 275 00:19:59,400 --> 00:20:01,680 of the RP2. 276 00:20:01,680 --> 00:20:06,720 And then for the pneumonia panel, that would also include like strep pneumoniae homophilus, 277 00:20:06,720 --> 00:20:08,800 it'll be able to detect those as well. 278 00:20:08,800 --> 00:20:09,800 Yep. 279 00:20:09,800 --> 00:20:18,360 If we look specifically at the pneumoniae one, so yeah, so it's 33 target. 280 00:20:18,360 --> 00:20:24,160 And that one would have like stuff more like streptococcus, biogenes, pneumoniae, even 281 00:20:24,160 --> 00:20:25,840 some acinetobacter. 282 00:20:25,840 --> 00:20:31,000 And the part that I think is also interesting about the pneumonia panel is the ability of 283 00:20:31,000 --> 00:20:34,560 detecting some antimicrobial resistance gene. 284 00:20:34,560 --> 00:20:39,920 But again, this one is not a panel that we had the opportunity or luxury to be able to 285 00:20:39,920 --> 00:20:46,120 use at my laboratory, but those would be some of the perceived like perks of having that 286 00:20:46,120 --> 00:20:47,120 panel. 287 00:20:47,120 --> 00:20:48,840 That would be fantastic. 288 00:20:48,840 --> 00:20:49,840 Yeah. 289 00:20:49,840 --> 00:20:51,680 But in its own way, right? 290 00:20:51,680 --> 00:20:55,880 So sometimes there could be pros and cons to technology as well. 291 00:20:55,880 --> 00:20:58,080 And some of these molecular methods are super sensitive. 292 00:20:58,080 --> 00:21:02,440 So I know in the past, you and I have had multiple discussions about biofire versus 293 00:21:02,440 --> 00:21:03,520 gene expert. 294 00:21:03,520 --> 00:21:09,000 And I know you want to talk a little bit about and tell the audience kind of the differences 295 00:21:09,000 --> 00:21:14,840 between that, because even me as an infectious disease physician, I could tell you that I 296 00:21:14,840 --> 00:21:19,760 may not know all the differences, including kind of what the sensitivity specificities, 297 00:21:19,760 --> 00:21:24,200 the CT values, we always talk about these numbers, but I love to hear it from a lab 298 00:21:24,200 --> 00:21:25,200 expert. 299 00:21:25,200 --> 00:21:26,200 Okay. 300 00:21:26,200 --> 00:21:32,760 Well, I would say that, you know, when you look at the clinical performance or the laboratory 301 00:21:32,760 --> 00:21:36,800 performance of the two assays, like it's a PCR assay. 302 00:21:36,800 --> 00:21:42,960 So their sensitivity specificity from a laboratory perspective would be above the 95%. 303 00:21:42,960 --> 00:21:43,960 Right. 304 00:21:43,960 --> 00:21:50,200 And I think they're pretty similar in that regards in terms of sensitivity of the assay. 305 00:21:50,200 --> 00:21:54,520 To walk you through the differences between the two, what I would say is if we start with 306 00:21:54,520 --> 00:22:00,640 CIFID, CIFID is a multiplex panel, but it's limited target. 307 00:22:00,640 --> 00:22:01,640 Okay. 308 00:22:01,640 --> 00:22:06,680 So as I mentioned, they have a lot of different cartridges that you would have to build up 309 00:22:06,680 --> 00:22:08,040 on. 310 00:22:08,040 --> 00:22:15,040 But in terms of, if we just speak about respiratory panel, they have this combo of flu A, B, R, 311 00:22:15,040 --> 00:22:16,280 S, V, and COVID. 312 00:22:16,280 --> 00:22:22,760 So one of the advantage is that it would specifically answer your question because they have also 313 00:22:22,760 --> 00:22:25,240 a cartridge that is COVID only. 314 00:22:25,240 --> 00:22:26,240 Okay. 315 00:22:26,240 --> 00:22:30,880 So I feel like it's a bit closer to what a clinician with duty would think about like, 316 00:22:30,880 --> 00:22:32,720 well, is this influenza? 317 00:22:32,720 --> 00:22:35,360 Then you order a gene expert and you will get your answer. 318 00:22:35,360 --> 00:22:37,000 It's pretty straightforward. 319 00:22:37,000 --> 00:22:40,280 From a laboratory perspective, it's really, really easy to use. 320 00:22:40,280 --> 00:22:45,760 As a matter of fact, it's one of the rare multiplex assays that is Health Canada approved 321 00:22:45,760 --> 00:22:48,280 to be used as a point of care assay. 322 00:22:48,280 --> 00:22:51,160 And we've seen that during the pandemic as well. 323 00:22:51,160 --> 00:22:53,440 It is quite fast. 324 00:22:53,440 --> 00:22:58,120 So for the respiratory panel that I was telling you about, it can provide an answer within 325 00:22:58,120 --> 00:23:00,480 35 to 40 minutes. 326 00:23:00,480 --> 00:23:05,360 And then it used some end fluorescence in terms of detection. 327 00:23:05,360 --> 00:23:09,960 But it also has the ability of providing you a CT value. 328 00:23:09,960 --> 00:23:16,400 And then overall, it might be a bit cheaper than the Biofire if we're just talking about 329 00:23:16,400 --> 00:23:20,200 the respiratory panel in terms of the cost to the lab. 330 00:23:20,200 --> 00:23:25,360 But if we look at the Biofire, this one, as I mentioned, is syndromic and it has more 331 00:23:25,360 --> 00:23:30,320 than 20 targets if we're talking specifically about the respiratory panel. 332 00:23:30,320 --> 00:23:36,120 It's also easy to use, but there's no CT available on the Biofire. 333 00:23:36,120 --> 00:23:44,120 Okay, so it's a real, completely real black box in the sense that you cannot see how strong 334 00:23:44,120 --> 00:23:47,880 or low of a signal was detected by the instrument. 335 00:23:47,880 --> 00:23:49,600 But it's quite sensitive. 336 00:23:49,600 --> 00:23:53,800 I've mentioned the five panels that they have also, and it's just that it takes a little 337 00:23:53,800 --> 00:23:54,800 bit more time. 338 00:23:54,800 --> 00:23:58,880 So it's just a bit over an hour to get the full panel result. 339 00:23:58,880 --> 00:24:05,480 I also think that the Biofire kind of brings an ethical conundrum or conversation because 340 00:24:05,480 --> 00:24:06,960 it's a syndromic approach. 341 00:24:06,960 --> 00:24:13,480 So I think we've been accustomed to do an assessment of your patient, come up with your 342 00:24:13,480 --> 00:24:19,240 diagnosis and then try to have the diagnostic support your hypothesis. 343 00:24:19,240 --> 00:24:25,520 But in this case, you might have been thinking about influenza, you're sending me the sample, 344 00:24:25,520 --> 00:24:33,920 you're asking for a Biofire, but I'm testing for 22 other organisms that you have not requested. 345 00:24:33,920 --> 00:24:41,320 So I feel like it's a good ethical conversation in terms of bioethics and what do you do with 346 00:24:41,320 --> 00:24:42,320 that? 347 00:24:42,320 --> 00:24:46,960 And some people would say, well, you only have to report what the clinician has requested. 348 00:24:46,960 --> 00:24:52,540 But what if it's positive for something that the clinician has not requested? 349 00:24:52,540 --> 00:24:54,520 Can you really hide that information? 350 00:24:54,520 --> 00:24:59,720 Yeah, and that's the thing with all of these reports, I think, is that you can tell us 351 00:24:59,720 --> 00:25:00,720 more. 352 00:25:00,720 --> 00:25:06,880 But for any of these respiratory panels, you usually get this line list of pathogens and 353 00:25:06,880 --> 00:25:09,640 then it'll just say positive or negative. 354 00:25:09,640 --> 00:25:16,360 And then taking that into your clinical context, I think, can be actually quite challenging 355 00:25:16,360 --> 00:25:20,720 because a lot of them have similar presentations. 356 00:25:20,720 --> 00:25:27,080 So we're talking about the exact same patient, but you could have multiple viruses. 357 00:25:27,080 --> 00:25:31,840 And something that I deal with in my clinical world is obviously I'm a pediatrician, so 358 00:25:31,840 --> 00:25:37,560 pediatric infectious disease, we're going to see a lot of respiratory illnesses. 359 00:25:37,560 --> 00:25:43,960 And with PCR testing, although it's great, molecular methods give us a quicker result, 360 00:25:43,960 --> 00:25:46,160 we also see those long lasting effects. 361 00:25:46,160 --> 00:25:50,320 So six weeks prior infections are being detected as well. 362 00:25:50,320 --> 00:25:55,000 So you also have to, as a clinician, take into context, like, is this a previous infection 363 00:25:55,000 --> 00:25:57,040 or is this really my acute illness? 364 00:25:57,040 --> 00:26:01,640 And relying on that, and then let's say I take off antibiotics because I think this 365 00:26:01,640 --> 00:26:08,080 is what's going on, is that harmful or problematic in that clinical case? 366 00:26:08,080 --> 00:26:12,320 So I think it can be challenging, definitely from our perspective too, but I can't even 367 00:26:12,320 --> 00:26:15,740 imagine at least I have the clinical context. 368 00:26:15,740 --> 00:26:20,920 And so from your standpoint, being on the lab side of things, and you do both sides, 369 00:26:20,920 --> 00:26:27,320 so obviously right now I'm giving you the lab hat, but being on the lab side of things, 370 00:26:27,320 --> 00:26:30,820 it's challenging because you don't get all of that information. 371 00:26:30,820 --> 00:26:35,400 You're not fully involved from like day one with the case, you know, and so you get really 372 00:26:35,400 --> 00:26:37,200 what we place on the requisition. 373 00:26:37,200 --> 00:26:39,480 Yeah, no, it's a good point. 374 00:26:39,480 --> 00:26:41,160 Yeah, it's like anything, right? 375 00:26:41,160 --> 00:26:45,640 The same way that when you see your patient, you come up with your differential and the 376 00:26:45,640 --> 00:26:50,920 laboratory, we also come up with a differential based on the very limited information that 377 00:26:50,920 --> 00:26:51,920 we get. 378 00:26:51,920 --> 00:26:59,920 So if people could only remember one thing, I guess, from anything that I said today is 379 00:26:59,920 --> 00:27:03,360 get a good relationship with your laboratory and provide more information. 380 00:27:03,360 --> 00:27:08,840 The same way that when you send a requisition form to diagnostic imaging, you would provide 381 00:27:08,840 --> 00:27:11,480 with a little bit of a history. 382 00:27:11,480 --> 00:27:13,480 It's the same thing for microbiology, right? 383 00:27:13,480 --> 00:27:21,080 So a history can go a really long way in microbiology and helping us find what you're looking for. 384 00:27:21,080 --> 00:27:27,960 Because the reality is people think that the laboratory will find whatever is in your sample, 385 00:27:27,960 --> 00:27:30,320 but that is not how the lab is made. 386 00:27:30,320 --> 00:27:36,960 The lab is made to identify the common causes of issue for the syndrome that you're talking 387 00:27:36,960 --> 00:27:39,860 about or the sample type that you're providing. 388 00:27:39,860 --> 00:27:46,200 So if you're looking for a zebra, it's always better to get in touch with your medical microbiologist 389 00:27:46,200 --> 00:27:49,960 and let them know that you're looking for a zebra. 390 00:27:49,960 --> 00:27:53,960 So I think that would be a big, big message. 391 00:27:53,960 --> 00:27:59,160 The other thing that I'll always use as an example is it's always also important for 392 00:27:59,160 --> 00:28:04,400 the clinician to understand the different technologies that we're using in the lab. 393 00:28:04,400 --> 00:28:10,560 And we try to have this dialogue with our clinician in a sense that we provide comments 394 00:28:10,560 --> 00:28:14,200 with our reports so you know what we've tested your sample for. 395 00:28:14,200 --> 00:28:19,440 And sometimes, I don't know, as a labartician, we feel like we're misunderstood or not fully 396 00:28:19,440 --> 00:28:20,440 read. 397 00:28:20,440 --> 00:28:27,480 So the best example would be, I think I've told you that story, but I kind of like that 398 00:28:27,480 --> 00:28:28,480 story. 399 00:28:28,480 --> 00:28:33,960 It kind of shows us how all those molecular assays are fantastic to look for the bread 400 00:28:33,960 --> 00:28:36,720 and butter stuff. 401 00:28:36,720 --> 00:28:39,800 And also, I'll tell you about the strength of a story. 402 00:28:39,800 --> 00:28:42,240 So I use that story with the resident a lot. 403 00:28:42,240 --> 00:28:50,820 So the story goes as follow, and you can also Google it because it's a true story. 404 00:28:50,820 --> 00:28:55,380 It's about a family that was presenting with rice water diarrhea. 405 00:28:55,380 --> 00:29:04,360 So for anyone who is ID trained or has interest in ID, if I tell you rice water diarrhea, 406 00:29:04,360 --> 00:29:06,760 there's a diagnosis that comes in mind right away. 407 00:29:06,760 --> 00:29:07,760 Exactly. 408 00:29:07,760 --> 00:29:12,960 So I'm not giving the punch just right. 409 00:29:12,960 --> 00:29:17,480 I'll keep it quiet over here too. 410 00:29:17,480 --> 00:29:22,800 So that sample was sent without a story to the laboratory, and then a molecular testing 411 00:29:22,800 --> 00:29:26,920 was done, and it came back negative, no pathogen found. 412 00:29:26,920 --> 00:29:33,640 So of course, we normally get involved when things are not fitting or it's not the result 413 00:29:33,640 --> 00:29:34,640 that we're expecting. 414 00:29:34,640 --> 00:29:37,600 So that's when the conversation happened. 415 00:29:37,600 --> 00:29:43,040 But we could have saved time and managed those patients differently if that conversation 416 00:29:43,040 --> 00:29:44,040 happened earlier. 417 00:29:44,040 --> 00:29:50,920 So what I was describing earlier on was a case of cholera in a family. 418 00:29:50,920 --> 00:29:57,720 So it's just an example of you can have a molecular assay that detects cholera, but 419 00:29:57,720 --> 00:30:02,760 a cholera that is found all over the world, but not the one that you have locally. 420 00:30:02,760 --> 00:30:03,760 Exactly. 421 00:30:03,760 --> 00:30:04,760 Yeah. 422 00:30:04,760 --> 00:30:08,880 And I think we've discussed that a lot during the pandemic, the whole conversation about 423 00:30:08,880 --> 00:30:15,120 variant, but in the bacterial world, you also have different serotypes, for example. 424 00:30:15,120 --> 00:30:20,800 So it's important for a labartician to also know the limitation of their technology. 425 00:30:20,800 --> 00:30:28,920 But from a physician seeing patient perspective, I think it's also always important to keep 426 00:30:28,920 --> 00:30:38,360 the story in mind and bring the clinical diagnostic combined together and see if it makes sense. 427 00:30:38,360 --> 00:30:44,040 And so in this case, you weren't able to pick up that specific strain on the serotype, and 428 00:30:44,040 --> 00:30:47,080 that's what the PCR was negative for? 429 00:30:47,080 --> 00:30:48,320 That's why. 430 00:30:48,320 --> 00:30:51,000 So the PCR was a multiplex. 431 00:30:51,000 --> 00:30:58,160 It had the ability of detecting, you know, LTOR, so one of the cholera that we normally 432 00:30:58,160 --> 00:30:59,160 see. 433 00:30:59,160 --> 00:31:00,160 Yeah. 434 00:31:00,160 --> 00:31:06,000 But then it seemed like we had a different one in BC, and the primers would not attach 435 00:31:06,000 --> 00:31:11,800 to the genetic information of the one that was local to us. 436 00:31:11,800 --> 00:31:16,440 It's just another example of, you know, the history at the end of the day and the clinical 437 00:31:16,440 --> 00:31:19,520 examination of your patient still makes a difference. 438 00:31:19,520 --> 00:31:24,280 It's not because the PCR said it's negative that what you're saying is not infectious, 439 00:31:24,280 --> 00:31:25,280 right? 440 00:31:25,280 --> 00:31:26,280 Right. 441 00:31:26,280 --> 00:31:29,880 Yeah, and I actually deal with this, you know, often because people will come in and they 442 00:31:29,880 --> 00:31:37,920 have respiratory symptoms, looks like a viral upper respiratory tract infection, and the 443 00:31:37,920 --> 00:31:43,480 PCR respiratory panel comes back negative, and families will always ask, but I don't 444 00:31:43,480 --> 00:31:44,480 understand. 445 00:31:44,480 --> 00:31:49,720 We said they have a virus, but the thing to like, we always try to educate our families 446 00:31:49,720 --> 00:31:55,280 as well and also teams that we work with as, you know, being a consultant is that you don't 447 00:31:55,280 --> 00:31:58,520 always get the answer for which virus it is. 448 00:31:58,520 --> 00:32:01,640 You have to be looking for those specific viruses that are on there. 449 00:32:01,640 --> 00:32:08,040 Now, if it's a different strain or it didn't pick up, it could be, I mean, there's multiple 450 00:32:08,040 --> 00:32:09,040 reasons, right? 451 00:32:09,040 --> 00:32:15,920 We talked about specimen type, we talked about, you know, the lab, like the technology itself, 452 00:32:15,920 --> 00:32:16,920 right? 453 00:32:16,920 --> 00:32:22,040 And in the end, we also have to remember that it is obviously no longer, you know, it is 454 00:32:22,040 --> 00:32:23,920 a machine-based test. 455 00:32:23,920 --> 00:32:32,320 And so things can be, you know, not as streamlined as sometimes when it's done by hand, right? 456 00:32:32,320 --> 00:32:38,800 And so because it's done quick, that's fine, but it's also machines can make mistakes. 457 00:32:38,800 --> 00:32:42,680 And so there could be lab errors, there could be specimen errors as well. 458 00:32:42,680 --> 00:32:47,480 And so I always try to, but really important is that you don't have to detect all viruses 459 00:32:47,480 --> 00:32:51,480 because I think it goes back to your cholera story is, you know, sometimes you don't pick 460 00:32:51,480 --> 00:32:55,400 up the strain or this, the variant or the serotype. 461 00:32:55,400 --> 00:32:59,640 So I think that's something that we should all remember as clinicians. 462 00:32:59,640 --> 00:33:04,760 In terms of, I know we talked a little bit about the advantages and disadvantages of, 463 00:33:04,760 --> 00:33:09,560 I know specifically you've worked a lot with the BioFire respiratory panel. 464 00:33:09,560 --> 00:33:14,080 Is there anything that comes to your mind that would be, that we didn't talk about today 465 00:33:14,080 --> 00:33:19,240 that would be an advantage or disadvantage that you would want our listeners to remember? 466 00:33:19,240 --> 00:33:20,240 Yeah. 467 00:33:20,240 --> 00:33:24,680 So, I mean, I think we covered a lot of the various aspects. 468 00:33:24,680 --> 00:33:30,400 So if I have to summarize the disadvantages, I mean, we kind of talked about the fact that 469 00:33:30,400 --> 00:33:33,320 the cost could have been a bit prohibitive. 470 00:33:33,320 --> 00:33:39,760 I think there is some pressure on the laboratory to really be quick at handling those samples, 471 00:33:39,760 --> 00:33:40,840 to put it on the instrument. 472 00:33:40,840 --> 00:33:45,760 So that's pressure on us if we want to be able to show the value of those faster and 473 00:33:45,760 --> 00:33:46,760 around time. 474 00:33:46,760 --> 00:33:51,600 But then related to that, you had mentioned the amount of samples that are coming in the 475 00:33:51,600 --> 00:33:53,460 lab at the same time. 476 00:33:53,460 --> 00:33:58,720 But the reality is a lot of those instruments like the, the GeneXpert or the LIAT or the 477 00:33:58,720 --> 00:34:04,320 BioFire, they're limited in terms of how many samples can they run at the same time. 478 00:34:04,320 --> 00:34:12,600 So on average, they're all below 20 sample per hour compared to our routine in-house 479 00:34:12,600 --> 00:34:15,200 PCR or real-time PCR. 480 00:34:15,200 --> 00:34:18,960 Those can do hundreds of samples within three hours. 481 00:34:18,960 --> 00:34:22,840 So I think that's something else to keep in mind in terms of the low throughput that those 482 00:34:22,840 --> 00:34:24,440 instruments have. 483 00:34:24,440 --> 00:34:30,560 And then I think lastly, it's really like all of the too many targets maybe that might 484 00:34:30,560 --> 00:34:34,920 not be relevant to certain patient population that we're providing. 485 00:34:34,920 --> 00:34:38,840 So that could be perceived as a disadvantage and an advantage. 486 00:34:38,840 --> 00:34:43,340 And then in terms of advantages from a laboratory perspective, you know, I started off this 487 00:34:43,340 --> 00:34:48,160 conversation by telling you, well, the people that work in molecular diagnostic have to 488 00:34:48,160 --> 00:34:51,360 be like highly, highly trained. 489 00:34:51,360 --> 00:34:55,240 To use those black boxes, you don't need to be highly trained. 490 00:34:55,240 --> 00:34:59,680 Like often the manipulation of those cartridges are super easy. 491 00:34:59,680 --> 00:35:05,840 So we can have that step being done by people that are not like the most trained people 492 00:35:05,840 --> 00:35:07,880 in our laboratory. 493 00:35:07,880 --> 00:35:12,560 And other advantages, I mean, I'm in Vancouver, you know, real estate is a real problem. 494 00:35:12,560 --> 00:35:17,440 So a lot of those instruments have a really small footprint. 495 00:35:17,440 --> 00:35:22,160 So I think it's an advantage and it can also be interfaced with your LIS. 496 00:35:22,160 --> 00:35:25,240 So that makes it even faster for reporting. 497 00:35:25,240 --> 00:35:29,840 So yeah, there's a lot of pros, a lot of pros and a little bit of cons. 498 00:35:29,840 --> 00:35:30,840 Yeah. 499 00:35:30,840 --> 00:35:33,440 I think that's a good, great summary of that. 500 00:35:33,440 --> 00:35:35,740 So what is, what's the future then? 501 00:35:35,740 --> 00:35:36,740 So what are we looking at? 502 00:35:36,740 --> 00:35:42,060 Like, are we, are you validating, is your lab validating additional biophier panels 503 00:35:42,060 --> 00:35:43,060 right now? 504 00:35:43,060 --> 00:35:45,440 And what's kind of the new thing that's out there? 505 00:35:45,440 --> 00:35:46,440 Yeah. 506 00:35:46,440 --> 00:35:47,600 So good question. 507 00:35:47,600 --> 00:35:52,320 I think there's a lot of conversation about what's going on in the world of molecular 508 00:35:52,320 --> 00:35:53,320 diagnostics. 509 00:35:53,320 --> 00:35:57,080 So, I mean, the multiplex panels are super interesting. 510 00:35:57,080 --> 00:35:59,080 I told you about the pneumonia panel. 511 00:35:59,080 --> 00:36:04,040 That's something that we will most likely want to be able to play with. 512 00:36:04,040 --> 00:36:10,120 And then the sample type, the fact that it's putum and BL that's like major and makes sense. 513 00:36:10,120 --> 00:36:17,040 So, but that would be probably in the future the same way with the, sorry, the joint fluid 514 00:36:17,040 --> 00:36:18,040 samples. 515 00:36:18,040 --> 00:36:19,040 Yeah. 516 00:36:19,040 --> 00:36:24,600 So I think that's going to be super interesting because we know that joint fluid from a smear 517 00:36:24,600 --> 00:36:30,880 when you do the ground smear, it's not super sensitive, but if we have the ability of having 518 00:36:30,880 --> 00:36:38,220 a multiplex PCR or a multiplex black box that allows you to do early detection, it would 519 00:36:38,220 --> 00:36:42,520 make a complete difference in terms of management of those or atopation. 520 00:36:42,520 --> 00:36:43,520 Right. 521 00:36:43,520 --> 00:36:45,160 So I think that's exciting. 522 00:36:45,160 --> 00:36:47,080 Yeah, definitely. 523 00:36:47,080 --> 00:36:51,120 In terms of timeline that are approaching a bit faster for us. 524 00:36:51,120 --> 00:36:53,680 So we're interested in looking into the GI. 525 00:36:53,680 --> 00:36:58,520 So we've done our validation for the GI panel and we're about to go live with that. 526 00:36:58,520 --> 00:37:01,960 So that should be for, you know, this summer. 527 00:37:01,960 --> 00:37:06,040 And then we're also looking into the meningitis panel. 528 00:37:06,040 --> 00:37:07,040 Right. 529 00:37:07,040 --> 00:37:14,160 So I think that also makes quite a big difference if we're able to detect early on any cases 530 00:37:14,160 --> 00:37:15,760 of meningoencephalitis. 531 00:37:15,760 --> 00:37:18,240 Yeah, exactly. 532 00:37:18,240 --> 00:37:23,320 I think from a clinician standpoint, all of this sounds like great because there's a lot 533 00:37:23,320 --> 00:37:29,440 of times when you, you know, it's challenging, especially like being in Saskatchewan, we 534 00:37:29,440 --> 00:37:36,320 have a lot of remote communities and sometimes patients are very, very ill. 535 00:37:36,320 --> 00:37:40,800 And so receive antibiotics prior to arriving at our center. 536 00:37:40,800 --> 00:37:45,880 And so for me, the advantage of getting, for instance, like a PCR, at least if they've 537 00:37:45,880 --> 00:37:50,900 had multiple courses of antibiotics prior to arriving, it can at least help me narrow 538 00:37:50,900 --> 00:37:54,240 down even from an antibiotic standpoint. 539 00:37:54,240 --> 00:37:55,240 Right. 540 00:37:55,240 --> 00:37:59,200 And so, and also kind of figure out what is the most common pathogen. 541 00:37:59,200 --> 00:38:05,600 Like we always kind of takes away that guessing game that sometimes makes clinicians a bit 542 00:38:05,600 --> 00:38:11,640 uneasy, I would say, if that's the right term. 543 00:38:11,640 --> 00:38:17,760 So you did talk a little bit about the BCID panel, which is that currently validated? 544 00:38:17,760 --> 00:38:20,080 Like you guys are using that there? 545 00:38:20,080 --> 00:38:25,280 So we had a chance to work with it and validated it. 546 00:38:25,280 --> 00:38:29,440 But the thing, you know, it's always a balance. 547 00:38:29,440 --> 00:38:36,960 The same way that when we see patients, you're always trying to figure out like how much 548 00:38:36,960 --> 00:38:43,440 any type of management choices you take, how much would it impact your patients? 549 00:38:43,440 --> 00:38:46,040 So it's the same in the laboratories. 550 00:38:46,040 --> 00:38:54,200 So for us, because our volume of positive blood cultures were so high, so I'm at Vancouver 551 00:38:54,200 --> 00:38:59,680 Coastal Health, so we provide service for more than 12 healthcare centers. 552 00:38:59,680 --> 00:39:03,080 So we have a fair amount of blood cultures coming in. 553 00:39:03,080 --> 00:39:09,560 And on average, we can have like anywhere between 15 to 20 positive blood culture a 554 00:39:09,560 --> 00:39:10,560 day. 555 00:39:10,560 --> 00:39:18,320 So trying to put that on the instrument in terms of volume will make it for us impossible 556 00:39:18,320 --> 00:39:19,880 to also do respiratory. 557 00:39:19,880 --> 00:39:23,800 So we had to make a choice. 558 00:39:23,800 --> 00:39:26,760 So we had to decide like, what's more important for us? 559 00:39:26,760 --> 00:39:30,600 Is it to get an answer quickly on the respiratory side? 560 00:39:30,600 --> 00:39:35,040 Or do we think that the gain that we would do on the blood culture would make such a 561 00:39:35,040 --> 00:39:36,640 big difference? 562 00:39:36,640 --> 00:39:43,640 So because of the infection control components related to respiratory viruses, we decided 563 00:39:43,640 --> 00:39:51,480 to go that route because we were fairly quick at identifying the organism on the blood 564 00:39:51,480 --> 00:39:52,480 culture. 565 00:39:52,480 --> 00:39:57,800 So the first thing that you have to keep in mind is that on the blood culture, it could 566 00:39:57,800 --> 00:40:00,800 be anything and everything. 567 00:40:00,800 --> 00:40:07,520 The BCID panel is limited to a set numbers, right? 568 00:40:07,520 --> 00:40:14,360 So the moment it doesn't identify your organism, you just delayed by one hour if you weren't 569 00:40:14,360 --> 00:40:15,760 already on top of it. 570 00:40:15,760 --> 00:40:21,520 So we felt like with our workflow, it made more sense to dedicate the instrument on their 571 00:40:21,520 --> 00:40:22,520 respiratory panel. 572 00:40:22,520 --> 00:40:24,200 Yeah, and that's fair. 573 00:40:24,200 --> 00:40:30,080 I think we're also practicing in an era where we have Malditov and other technologies. 574 00:40:30,080 --> 00:40:35,040 And so previously when we just had biochemical tests, I think it was more challenging and 575 00:40:35,040 --> 00:40:36,640 we wanted quicker identification. 576 00:40:36,640 --> 00:40:43,760 But I think a lot of times with that MRSA select plates is a lot of technology that's 577 00:40:43,760 --> 00:40:50,000 already come through that's making it easier for clinicians, especially those practicing 578 00:40:50,000 --> 00:40:53,320 in an area where they are using this constantly. 579 00:40:53,320 --> 00:40:59,560 But I think you're bringing up a super valid point in a sense of epidemiology and population 580 00:40:59,560 --> 00:41:04,120 is super important in terms of those decisions that you take in the lab. 581 00:41:04,120 --> 00:41:11,520 My conversation with you might have been different if 60, 70% of my people that had positive 582 00:41:11,520 --> 00:41:13,760 blood cultures were Staph. 583 00:41:13,760 --> 00:41:18,400 And then maybe 50% or 30% of them were MRSA. 584 00:41:18,400 --> 00:41:23,360 So it would make such a big difference to be able to use BCID because it would have 585 00:41:23,360 --> 00:41:24,960 a direct impact right away. 586 00:41:24,960 --> 00:41:29,600 But that's not really my situation right now in terms of the patient population that we're 587 00:41:29,600 --> 00:41:31,680 providing care for. 588 00:41:31,680 --> 00:41:37,080 So yeah, it didn't make total sense at the time to go that route. 589 00:41:37,080 --> 00:41:38,080 Yeah, fair. 590 00:41:38,080 --> 00:41:41,520 And I think, yeah, that's one thing about ID, right? 591 00:41:41,520 --> 00:41:45,240 It's infectious diseases, different everywhere. 592 00:41:45,240 --> 00:41:51,240 You cross the border and it's like a provincial border and you're facing with different diseases, 593 00:41:51,240 --> 00:41:56,040 different conditions, different demographics and the epidemiology is very different. 594 00:41:56,040 --> 00:42:00,640 So I think it's important to always, I think one of the things that I've learned is that 595 00:42:00,640 --> 00:42:06,640 there's a lot of technology out there and there's a lot of things that we'd want our 596 00:42:06,640 --> 00:42:07,680 labs to be doing. 597 00:42:07,680 --> 00:42:14,800 But I think having that conversation as clinicians with the labs, microbiologists and having 598 00:42:14,800 --> 00:42:18,840 that close connection, that's I think really, really important because you can bring up 599 00:42:18,840 --> 00:42:24,120 these types of topics and ideas and really understand it from, we obviously just want 600 00:42:24,120 --> 00:42:28,720 the answer, but who's providing us the answer, that also depends, right? 601 00:42:28,720 --> 00:42:34,800 We need to figure out what the rationale is behind having one panel versus the other using 602 00:42:34,800 --> 00:42:38,240 gene expert over another respiratory panel, that type of thing. 603 00:42:38,240 --> 00:42:40,840 So you bring up a very, very valid point. 604 00:42:40,840 --> 00:42:44,960 That's why it's great having somebody who's in the field, in the lab and the clinical 605 00:42:44,960 --> 00:42:45,960 world. 606 00:42:45,960 --> 00:42:52,440 So is there anything you would want our listeners, I know you mentioned before a couple of key 607 00:42:52,440 --> 00:42:57,800 points, is there anything else you have a burning desire to tell your listeners from 608 00:42:57,800 --> 00:43:03,960 a lab perspective standpoint that something that they should do and follow and would be 609 00:43:03,960 --> 00:43:07,680 helpful for our lab colleagues? 610 00:43:07,680 --> 00:43:14,680 I mean, I'm going back to what I said earlier, I mean, having a history, really, really helpful. 611 00:43:14,680 --> 00:43:21,920 So if you guys can provide more clinical information, we'll be better at supporting the team that 612 00:43:21,920 --> 00:43:24,280 is seeing the patient, that's for sure. 613 00:43:24,280 --> 00:43:28,720 And I think having conversation with your laboratory as well, trying to understand what 614 00:43:28,720 --> 00:43:33,880 kind of technology are being used can also help you be better at the job that you're 615 00:43:33,880 --> 00:43:34,880 doing. 616 00:43:34,880 --> 00:43:40,440 So knowing the limitation of the instrumentation that you're using is also key. 617 00:43:40,440 --> 00:43:43,640 Well, that's a very, very valid point. 618 00:43:43,640 --> 00:43:48,240 And I think a lot of our listeners are going to enjoy this episode because we don't talk 619 00:43:48,240 --> 00:43:54,080 a lot about diagnostic methods and what's new in the lab world. 620 00:43:54,080 --> 00:43:58,560 So I'm excited to have you on our podcast today. 621 00:43:58,560 --> 00:44:04,760 So thank you so much for taking the time and this great opportunity for us to learn a little 622 00:44:04,760 --> 00:44:09,600 bit of, you know, the different technologies and molecular methods that a lot of us are 623 00:44:09,600 --> 00:44:13,880 probably already using and don't even realize some of these details and points. 624 00:44:13,880 --> 00:44:14,880 So really appreciative. 625 00:44:14,880 --> 00:44:16,880 Oh my God, thank you so much. 626 00:44:16,880 --> 00:44:18,360 It was a lot of fun. 627 00:44:18,360 --> 00:44:19,840 So my pleasure. 628 00:44:19,840 --> 00:44:20,840 Perfect. 629 00:44:20,840 --> 00:44:21,840 Thank you so much. 630 00:44:21,840 --> 00:44:24,440 Have a great day. 631 00:44:24,440 --> 00:44:28,120 Thank you, Dr. Purwall, and a special thank you to Dr. Charles. 632 00:44:28,120 --> 00:44:29,440 Thanks for joining us. 633 00:44:29,440 --> 00:44:36,080 If you've got a topic suggestion, please email us at thecanadianbreakpoint at gmail.com or 634 00:44:36,080 --> 00:44:39,760 get ahold of us on Twitter at CA Breakpoint. 635 00:44:39,760 --> 00:45:00,160 See you again soon at the Canadian Breakpoint.