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Inside the Lab Digital and computational pathology, Precision medicine, Technology and innovation, Software and hardware

Erasing Pathology’s Borders

When you picture a pathology lab, what do you see? Perhaps you’re imagining stations for processing and preparing tissue samples, or racks of tubes containing blood to be examined, or even – in particularly advanced scenarios – a bank of computers with high-resolution monitors for viewing digital slides.

Although these are all standard sights in many laboratories, many pathologists and lab medicine professionals are not so lucky. For many of them, even simple staining facilities are a distant dream – and those who work in the most resource-limited settings are often desperate for assistance. That’s why, increasingly, these pathologists and laboratory staff are turning to digital pathology in its most basic sense.

They may use low-end smartphones to snap photographs of gross pathology or rely on DIY camera mounts to balance those phones on top of whatever microscope they’re lucky enough to have. They may fund their laboratories out of their own pockets when the allocated money runs out. They may post photos to social media to ask for expert consults because there are simply no specialist pathologists in their area. It’s a different world to the shiny new technologies many laboratory medicine professionals are familiar with – but people like Olaleke Folaranmi, Peter Carey, and Yuchun Ding are seeking to bridge the gap between the two worlds.

A Friend to All Pathologists

Yuchun Ding and his organization – X-WOW! – strive to open doors for pathologists worldwide

Michael Schubert interviews Yuchun Ding

Tell us a little bit about yourself…

I am an ordinary postdoctoral computer scientist. Since 2013, I have worked on whole-slide digital pathology image analysis using artificial intelligence (AI). One day, I asked myself, “Have I done something that has made a real difference in healthcare? How many lives have I saved? How many pathologists have I helped?” I was ashamed to admit to myself that the answer was zero.

My status as “a computer scientist with no experience in biology” was not helping me to change the answer to that question, so I decided to take a big step back and spend a little while observing what pathologists actually do. I have now been to the mortuary to watch a close-up autopsy at seven o’clock in the morning. I have been a “fly on the wall” observing the pathology workflow. I have even bought my own microscopes and staining kit to replicate at home what I’ve seen done in the lab. I’m not sure I would recommend this to other computer scientists, but I pricked my own fingers, stained the blood, and looked at it under the microscope to help me think about developing software from a pathologist’s point of view.

I’ve also done some unusual experiments such as staining colostrum (breast milk) after my second son was born and staining the red juice from medium-rare steak to find out what exactly is in it. You can find these experiments, and more,  on my Twitter page.

What exactly is X-WOW!?

Posting fun experiments on Twitter was only my first step. It helped me to understand what pathology is about; who the “celebrities” in the field are; and the differences between monocular, binocular, and trinocular microscopes. I also discovered that microscopes are expensive to buy and that not many people can afford them, especially in resource-limited settings.

Sharing is what makes a good pathologist. Being active in the pathology community for few months doesn’t turn me into a pathologist, but I can still share in a different way. A few days after my wife and I created X-WOW!, an organization with the goal of “making microscopes easier to access,” a microbiology student at a Nigerian university got in touch.

He said, “I am optimistic about a bright future by building a career in microbiology, but one must agree that it takes both hard work and learning with the right tools and equipment to gain full expert knowledge. At secondary school, while learning the basic concepts of microbiology (viruses, bacteria, fungi, and so on), I never got a chance to use a microscope (either compound or electron) – one of the most important tools for studying microorganisms.

The inadequacy or total lack of equipment and instruments here decreases students’ participation in science, and particularly microbiology.

“The study of microorganisms requires that we students conduct experiments using the microscope, discuss with one another, and get practically involved with our hands and eyes – but instead, we remained passive participants, expected only to listen, but not to see things for ourselves. The inadequacy or total lack of equipment and instruments here decreases students’ participation in science, and particularly microbiology. Having an awareness of African schools’ deficiencies and how they act as a setback to students’ involvement in microbiology, and wanting to create a solution to that problem, I am readily available to assist and also gain from this.” His comments basically mirrored the reasons my wife and I started the organization – and the main reason we named our (free) virtual microscopes after him. We want to help him achieve his dream of microbiology for all in Africa.

Because we are in the early stages of X-WOW!, we have thus far used our own savings and whatever donations we have received to make microscopes available to people who can bring ideas into reality. Although we are truly grateful to those who have supported us in the past, we know we shouldn’t ask for more from them; that’s why, after six months of hard work, we have now released our own commercial X-WOW! Manual Whole Slide Imaging System (1). This tiny device turns an ordinary microscope into a whole-slide scanner at one-twentieth of the cost of a high-end scanner. What makes it unique? We offer the lowest price we can, so that digital pathology is available to as many pathologists as possible – and we use the profits to fund more initiatives to support laboratory professionals in deprived areas.

We would also love to receive sponsorships to keep the work going long-term. We once received a donation from an entrepreneur who wanted to see his money bring to life projects in cancer diagnosis using digital technology. We believe there are more people out there who share the same dream, and we hope to connect with them to make it a reality.

What has X-WOW! achieved so far?

Since December of 2018, we have donated seven microscopes, including one converted to a whole-slide scanner. Let me tell you some of my favorite experiences.

First, I’ve always wanted to be a Santa, ever since I was a child. I don’t have a white beard (yet), but luckily, I do have a big belly. In December of 2018, one week after X-WOW! was born and two weeks before Christmas, I posted a tweet to give away a microscope. I wanted to make a child’s dream come true and, hopefully, to inspire a future pathologist. I even included some educational animal histology slides!

The event went really well and, two days later, we gave the microscope to a boy named Josh. This was actually a perfect choice, because his mother is a school biology teacher who can assist him in using the microscope properly. They even did an entire school project on hunting for tardigrades (water bears)!

Whole-slide imaging was a perfect solution, so I decided to upgrade their imaging system with a manual whole-slide scanning system.

The outcome of that first initiative encouraged me to keep it going. One day at work, I met a hematological pathologist who was providing remote consultation to a pediatric oncology unit in Malawi through microscopic images. However, half of the cases they sent were non-diagnostic; the image quality was poor and the fields of view were tiny. Whole-slide imaging was a perfect solution, so I decided to upgrade their imaging system with a manual whole-slide scanning system from a commercial partner. It cost so much less than an automated machine (under £5,000) – but, of course, even that was totally beyond the means of a small lab in Malawi, so I launched a fundraiser to buy the entire system.

Time was tight, because the British oncology team was planning to visit Malawi very soon; in the end, we bought the system before reaching our fundraising goal so that we could make sure they had it in time. Fortunately, a week later, we received a full donation and our story “hit the big time.” It featured on the news (2) and we were invited to write about our work for the July 2019 issue of the Royal College of Pathologists’ bulletin.

After the successful story in Malawi, I organized a pop quiz competition on Twitter as a little celebration and printed a lymph node T-shirt for a prize draw. The lucky winner was Tania, a Spanish pathologist. She loves it!

We also asked Finelia, a young cancer patient from Malawi, to paint a picture of her dream job. Her response? “I wish to become a police officer.” We took her dream back to the UK with us and used it to help explain our story and to spread awareness of the cancer diagnosis service available in deprived areas.

Finelia poses with a picture of her dream job.

Another one of our proudest moments was supporting Olaleke Folaranmi, a kindhearted Nigerian pathologist, to thank him for sharing great content on Twitter and to help him encourage African medical students to choose pathology as career.

How did that come about?

One day someone retweeted a post from Olaleke’s story. In it, he said, “I sacrificed everything possible to be here… that meant getting great quality images for #Pathology friends, colleagues & experts to view/comment on. All these were achieved at great personal costs: loans for microscope camera, mobile phone, PC, and expensive data subscription.”

I thought, isn’t that the greatest example of a good pathologist? That’s why I immediately decided I was going to help him. I had a chat with him privately and what triggered me most is when he said, “It is difficult to be different in this country. Most of my colleagues are leaving the country because of frustration. But I believe I can change pathology here in the future, and I can always use a personal microscope to encourage those close to my workplace (medical students) to decide on pathology as a career.”

It’s very rare to meet people like Olaleke and he deserved a present! I wanted to use the momentum generated by his story to encourage more people like him. Timing is important, so I ordered the microscope first thing in the morning and had it sent by express delivery so that it arrived less than two weeks later. I also setup a fundraising page to invite people to contribute to thank him for his great work – and we’ve managed to raise £120 so far!

What would you like to achieve next?

Digital pathology has a reputation for being exclusively for the “big, rich laboratories.” There are hundreds of thousands of labs around the world that need digital pathology to receive second opinions remotely and rapidly, but most of them can’t afford expensive machines that cost six figures. I’m currently working on an ambitious project to help the Caribbean islands go digital (3). One of the pathologists there told me, “It seems as though the small labs like us have been forgotten by those big companies.”

The dream is that pathologists from anywhere around the world can learn and make diagnostic decisions as a group digitally, remotely, and rapidly.

Ultimately, X-WOW! is trying to establish an inclusive ecosystem for pathology. The dream is that pathologists from anywhere around the world can learn and make diagnostic decisions as a group digitally, remotely, and rapidly to minimize malpractice. As a start, we can help small labs achieve whole-slide imaging at one-twentieth of the full cost, and we are prototyping a simplified lab information system (x-wow.org) that will be freely available to help pathologists in resource-limited areas submit, review, and share cases seamlessly across labs. It’s still in the early stages, but we would welcome any feedback that helps us improve.

Achieving such an ambitious dream requires us to obtain resources and financial support for system hardening, data security, and regulatory framework enrichment. In May, we approached a number of investors to seek sponsorship; unfortunately, they were more interested in seeing how we can make a profit before they help us. That’s understandable, of course, but it’s not really our focus at the moment!

What difference can digital pathology make in developing countries?

It’s a tricky question to answer. In most developed countries, the funds are sufficient, but strict healthcare regulations often delay the transition to digital pathology. In developing countries, on the other hand, the regulations are less strict – which means that, with enough sponsorship and training, labs can theoretically go digital rapidly at a large scale, making cross-country and international collaboration for remote diagnosis much quicker and simpler. Digital pathology would bridge the gap between independent labs; they could stop sending boxes of slides to the larger labs through parcel post for second opinions and people could start to sign out regardless of their location.

However, the unfortunate reality is that some of these countries have more than just a staff shortage. Some have no pathologists at all to look after a population of millions. Others have pathologists, but their labs have no internet access, digital storage, or computational power to transfer the digital slides – and even in those that do, power shortages are frequent occurrences. Some labs don’t even have the facilities to perform proper H&E staining. At Olaleke Folaranmi’s lab, for instance, their tissue processor stopped working. They have no funds to repair or replace it, and therefore no immunohistochemical staining, let alone digital pathology.

The number of pathologists suitable for domestic and cross-country collaboration around the world.

Recently, we realized that there are countless old or unwanted microscopes hidden in laboratory corners – often in perfect working condition, yet forced into “retirement” because the owners use other tools. That prompted us to start the Retired Microscopes Back to School Scheme (4). Our scheme helps place these microscopes in schools in deprived countries, so that those who believe they can change the world can have the opportunity to try. Our first donation, from Aleksandra Żuraw, is currently seeking a new home!

Pathologists, microbiologists, and even students who are seeking equipment, or who are finding a new home for their older devices, can get in touch with X-WOW! through our website (x-wow.com), our Twitter account (@X_WowCom), or by emailing us directly at admin@x-wow.com. It’s my hope that, in the future, we’ll be seen as a friendly neighborhood organization that pathologists in any situation can contact for assistance!

As well as creating X-WOW!, Yuchun Ding works as a post-doctoral computer scientist at the Interdisciplinary Computing and Complex BioSystems (ICOS) research group, and as a cancer bioinformatician at Newcastle Molecular Pathology Node (NMPN), Newcastle University, UK.

Acknowledgments: We thank all 35 people who have kindly donated to help us turn dreams into reality (5).

From Nigeria with Love

How technology and digital pathology can change the face of laboratory medicine in resource-poor areas

Michael Schubert interviews Olaleke Folaranmi

Tell us a little about yourself…

I am a senior anatomic pathology resident in Nigeria. I am currently in my sixth year and hope to conclude my training before the end of the year. I have always been in love with the microscope – ever since my exposure during my first degree in microbiology. I took a liking to pathology in my fourth year of medical school. The lecturers were serious-minded; they were always punctual and well-dressed; and they taught with an aura of authority. I am a naturally curious person, so pathology was appealing to me because it offers the detailed information that is necessary to manage patients appropriately.

Where do you practice pathology?

I train and practice in a tertiary-level hospital in Nigeria. The facilities are quite basic and noticeably lacking in modern equipment. Economic recession and the poor funding of healthcare over the years have taken a toll! My colleagues and I are primarily general pathologists and trainees; there are no provisions for specialist fellowships in the country because of the low overall number of pathologists. Our department offers services to all the medical and surgical specialties in the hospital, and we also take referrals from private health institutions in the city. Unfortunately, we are sometimes weighed down by our inability to make definitive diagnoses due to a lack of infrastructure for ancillary testing, such as IHC and molecular studies.

We are sometimes weighed down by our inability to make definitive diagnoses due to a lack of infrastructure for ancillary testing, such as IHC and molecular studies.

My presence on social media (you can find me on Twitter at @DrGeeONE) was borne out of the need to learn from specialists in well-developed countries – masters in their fields who can offer opinions on difficult cases and provide guidance. I also encourage younger colleagues and my own peers to consider investing time into broadening their knowledge through social media. Some of the cases I have shared in the past may have educated many (mostly younger) colleagues, particularly those that feature diseases exclusive to the tropics. For example, a few weeks ago, I shared a case of typhoid ileitis. I never imagined that many of my international colleagues would never have seen such a case before – a disease that is rampant in our part of the world due to poor sanitary conditions imposed by poverty. The feedback from this case was very encouraging and I hope to share many more of the unique challenges my country faces.

How does digital pathology affect your work?

Digital pathology in my present context means the sharing of digital images (using phone or microscope cameras) to showcase classical pathology cases or seek informal consults via social media. There was no such thing in my department when I started residency; back then, I took pictures of difficult cases with my phone so I could view the pictures while studying at home to try to “picture match” with photographs on pathology atlases. I stumbled upon pathologists on social media and, since then, I have been steadily investing in the knowledge and equipment to produce high-quality images to present for informal consults on social media.

Fortunately, my trainers permit me to seek informal consults on cases that are difficult for us to unravel. These interactions have definitely boosted the quality of our practice.

How did you encounter X-WOW! and Yuchun Ding?

I followed X-WOW! on Twitter (@X_WowCom) because the handle shares microscopic pictures. It was a stroke of luck that they came across my tweet on a thread where I was responding to the dictum, “The grass is always greener on the other side.” I was defending my opinion that there is no grass on the side of the fence where I am.

To explain why I felt this way, I offered a peek into all the struggles I put up with and the sacrifices I have made to get good pictures to share on Twitter. Over the years, I have taken out loans to purchase smartphones with high-quality cameras – not because I want a “fancy phone,” but so that I can produce great quality pictures. I tried DIY mobile phone adapters for the microscope, but they didn’t work out, so I eventually bought an adapter on AliExpress. Finally, I was able to get an Amscope microscope camera, which is what I use mostly for capturing my cases. I got a good computer and Adobe Photoshop software to edit my pictures – all in a bid to be excellent. I even learned how to take and edit good pictures from social media, thanks to Phillip McKee (@phmckee1948) and Jerad Gardner (@JMGardnerMD), the first social media teachers I ever knew.

I am extremely grateful to him [...] It’s my first personal microscope and I am treating it with the greatest respect!

You might find it hard to believe that I never linked Yuchun Ding to X-WOW! – not until he contacted me about this article. X-WOW! asked me how they could be of help in my efforts, and I mentioned that I would appreciate a microscope, because that was the next thing on my lab “wish list.” I am extremely grateful to him for shipping me a modern microscope. It’s my first personal microscope and I am treating it with the greatest respect!

It arrived barely a week ago, but I can be sure of one thing: it will definitely increase my educational efforts. Now, I can work from home to take pictures and share them, rather than having to go to work just so that I can create and access images.

What else is on your laboratory wishlist?

Like I said earlier, we operate at the most basic level you can imagine. My wishlist might seem simple to those with more sophisticated laboratories, but would contain key equipment:

  • A grossing table
  • An automatic tissue processor
  • A modern embedding station
  • A modern Hydra multi-head teaching microscope with a good camera
  • More microscopes
  • The basic equipment required to run an immunohistochemistry lab
  • And, lastly, maybe someday a mobile slide scanner – but, right now, that seems like a luxury!

Much of our existing equipment is old, unserviceable, or nonfunctional, including our microscopes. As a result, the most valuable tool we have is human resources. My colleagues’ – and my own – resilience, our desire to learn, and our need to make a difference in difficult situations is unrivaled.

What difference can digital pathology make in developing countries?

Based on my own time in the laboratory, I would say that digital pathology can bridge gaps in knowledge and experience between the underserved areas and the developed world in the form of specialist consults on difficult cases. In extreme cases where there are no pathologists at all in a given area, digital pathology can offer the “impossible” – bringing quality healthcare from thousands of miles away to meet those patients’ needs.

Pathology in resource-poor settings can be repositioned through foreign aid, collaborations, training via telepathology, and technical support. If pathologists and laboratories in resource-limited settings had more access to good equipment, good training, and good collaborations, I believe that we would be able to deliver stellar services. Thanks to organizations like X-WOW! and Associazione Patologi Oltre Frontiera (a “pathologists without borders”-style non-governmental organization), some African countries are already receiving the assistance they need.

I would like to send my gratitude to those who devote their time, money, and resources to teaching colleagues in resource-poor areas. My passion for pathology was rekindled by my daily interactions on social media – so thank you to everyone who contributes!

Olaleke Folaranmi is Senior Registrar at the University of Ilorin Teaching Hospital, Ilorin, Nigeria.

Pathologists Without Borders

Digital pathology can facilitate long-distance diagnosis and ease resource pressures

Michael Schubert interviews Peter Carey

How did you and your colleagues get involved with pathology in Malawi?

Liz Molyneux, a distinguished pediatrician, and her husband, a malariologist, lived in Malawi for many years. She set up and ran the pediatric malignancy unit in Blantyre until they retired. One of my pediatric oncology colleagues here in Newcastle, Simon Bailey, is originally from South Africa; as a trainee, he visited the unit and went on to collaborate with Liz for many years devising protocols for childhood cancers, in particular acute lymphoblastic leukemia (ALL) and Burkitt lymphoma. Together, they adapted existing protocols to make them realistically deliverable in a resource-challenged setting. Their approaches might be slightly less intensive than conventional western medicine, but they’ve made it possible to treat these diseases in settings that have no other options. Simon and Liz have also diligently collected data, reported their experiences academically, and demonstrated that these treatment regimens are safe and effective, given the challenges of the settings in which they are administered.

Simon would visit Blantyre once a year and return with boxes of slides. He would ask a friendly pathologist – usually me – to verify their diagnoses because they were writing up case series. We also performed immunocytochemistry and molecular tests on some of the material. Unfortunately, it was all retrospective. We only received slides once or twice a year, so we couldn’t offer clinically useful information in a timely manner.

There is a pathology laboratory in Blantyre, but the turnaround times can be variable, so the pediatric team has learned to spread blood films, make smears of fine needle aspirates (FNAs), and spread slides from bone marrow aspirates. They can even do Romanowsky stains on the ward by dipping slides into the staining solution. We’ve also taught several of them to take photomicrographs with a CCD still camera on top of a microscope, so they can send us representative slides of peripheral blood, bone marrow aspirate, and FNA films.

How does remote reporting work?

Initially, the team sent us emails with a few clinical details and a link to the slide images in Dropbox; I reviewed everything and gave them a report, including whatever helpful comments I had to offer. Because we could do it fairly quickly, it took off – and soon, we were receiving so many emails that they crashed into each other in our inboxes. That’s when we realized we needed a more intelligent system to cope with the workload and the generation of reports. My colleague Stephen O’Brien, a professor of hematology here in Newcastle, is internationally known as an expert in chronic myeloid leukemia, but locally also renowned as a bit of a computer geek. We got him to build us an interactive website – so now, the Malawi clinicians can enter demographic and clinical details into an electronic “request form” on the site. The form also attaches a Dropbox link to the images, creates a reporting worklist, and sends an automated email alert to indicate that cases have been entered for reporting. I can go in to add comments on the morphology, add diagnostic coding, and Simon can add a clinical comment with any management suggestions. The result is an integrated report populated with everybody’s contributions that gives the clinicians the health information they need and allows us to collect academic data as well.

We’re currently limited by file sizes and creaky Internet connections, but I think sharing whole-slide images will be feasible in the near future.

The limitation, from a pathological point of view, is that I’m guessing based on half a dozen images of fields selected by a clinician with no formal pathology training. The advantage is that I can form an opinion quickly – but the downside is that I might not see something I would have found if I’d searched the whole slide myself. Now, though, we’re approaching the era of affordable whole-slide scanning. We’re currently limited by file sizes and creaky Internet connections, but I think sharing whole-slide images will be feasible in the near future.

But with more material comes more work – and that’s where X-WOW! is helping. Yuchun Ding has two key innovations. First, an inexpensive “scanning” method that involves driving the microscope around the stage with the still camera on to form a composite image using clever software. And second, still in progress, AI software to look at and categorize individual cells. The latter has been done commercially for peripheral blood, but with an expensive standalone system that resource-limited laboratories can’t afford. Ding is working on affordable software to automate preliminary scan interpretation.

What is the pathology infrastructure like in Malawi?

There is a laboratory service in Malawi, but it lacks the resources on which western labs often rely. As a result, machines may break down and not be repaired, sample storage and preparation can be a challenge, and turnaround times are often slow. These challenges particularly impact tissue biopsies, so the pathologists and laboratory medicine professionals have come to rely largely on liquid material.

Although they do have a local laboratory, the staff at Blantyre appreciate our complementary service because we’re able to respond quickly when they don’t have time to wait. Previously, they had to make a lot of decisions purely on clinical data, but now, we can confirm when they’re doing the right thing, make recommendations when they need to change their approach, and flag specimens with too little material to make a definitive diagnosis.

Now that Liz has retired, the clinic at Blantyre is led by pediatric oncologist George Chagaluka. Staff are trained to acquire FNA specimens, bone marrow aspirates, and peripheral blood specimens, and to prepare material for pathological assessment. Simon and his team go out each year to refresh that training, and we’ve also provided them with a blood count machine that allows them to operate as independently as possible. It’s true that they have limited resources, but they’re overcoming that obstacle and maximizing their ability to use what they have.

How did you encounter X-WOW! and Yuchun Ding?

I met Ding when he was working with Chris Carey (no relation!), a hematologist with an academic interest in lymphoma. The two of them began to collaborate on software to look at images of lymphoma tissue, and that has blossomed into something larger. Ding came across the Microvisioneer software, which enables still camera “scanning” for far less than the price of a slide scanner. It was immediately clear that it would help resource-limited laboratories; although it’s more time-consuming for the operator, it captures a more comprehensive area of the slide. That way, pathologists doing remote reporting don’t have to worry about missing anything of diagnostic significance because it wasn’t represented in a few still photos of a slide.

I think full implementation will take some time. The staff at Blantyre already have the software, but they’re accustomed to taking still photographs, so they may need in-person training before they’re equally comfortable using the camera as a “scanner.” Hopefully, if a case arises in which we need to see more, they’ll try the new technique. In the meantime, we’re giving Ding lots of scanned images to build up his AI software, so that when we start receiving whole-slide scans regularly, they don’t consume all of our time. The goal is for the information increase to be offset by the new software.

What is the future of pathology in resource-poor areas?

Let’s say a new child comes to a western hospital with ALL. We might be able to look at a blood sample and say, “Here are cells compatible with a population of lymphoblasts” – but we would never make a diagnosis or start treatment without an immunophenotype and additional genetic data. In Malawi, they don’t have access to that information, so they treat based on what they can find out.

I think digital pathology is making a huge difference – particularly with the newfound ability to do whole-slide scans in resource-limited settings.

But on occasion, for particularly interesting patients, the staff at Blantyre have put a drop of blood onto blotting paper and sent it to us to extract DNA for molecular analysis – for instance, to find a Philadelphia translocation or a BCR-ABL or PML-RARA fusion. We’ve been able to bypass immunophenotyping entirely and go straight to molecular analysis, because the necessary material is potentially transportable and the technology works quickly. Immunophenotyping equipment is expensive and presents a training challenge, whereas material for molecular analysis can be transported far more easily and we can do the analysis from a distance. I think the biggest challenge in that arena will be transporting, extracting, and analyzing DNA in a timely fashion.

In the meantime, I think digital pathology is making a huge difference – particularly with the newfound ability to do whole-slide scans in resource-limited settings. An example that struck me recently came from pathologists doing remote reporting for China, where it’s not culturally appropriate to export human tissue beyond the border. If a Chinese pathologist wanted to consult someone in America, they couldn’t send a block and ask for an opinion. What they do have, though, is fantastic immunohistochemistry and slide preparation techniques – so they were able to do that locally, scan it, and send the scans to pathologists in other countries. In the end, reporting those scans was no different to reporting material obtained locally.

The problem is that many places have a shortage of trained expertise. If experts don’t have to move geographically to be useful, jobs become more attractive and they can even take several part-time positions in different locations to make up one full-time job. Digital pathology means that it doesn’t matter where you are geographically; you can still provide a top-quality service from a long way away. As long as you have people to acquire and stain the material, you can export everything else.

What else is on the “wish list” for a resource-limited laboratory?

In terms of hematology, the first thing you need is decent, reliable blood count information. Next, you need people skilled enough to prepare the material. They need to make good blood films, acquire and spread FNAs and bone marrow aspirates, make Cytospins of liquids, and stain reliably. Even in the UK, staining techniques vary considerably. I’m pleased with the staining machines our lab currently uses, but I remember tearing my hair out for several years, shouting up and down that I was getting better quality from Malawi via a few photographs than I was getting out of my own laboratory!

One day, I hope every lab will be able to pop slides into a box that does the job automatically in minutes.

The next big thing on the wish list is a better method of acquiring images. We’ve moved on from still photographs and are now encouraging the software-based “scanning” approach – but it’s still a bit clunky. One day, I hope every lab will be able to pop slides into a box that does the job automatically in minutes – first one slide at a time, and then with racks that accommodate multiple slides. Scanners are growing increasingly affordable, so it’s not out of the realm of future possibility.

What advice do you have for laboratorians in resource-limited settings?

It’s good to have trained people on the ground who can gradually improve the service. We can help with that by offering training positions. It’s increasingly difficult for people to obtain international travel funds, visas, and so on, so it’s vital to have enthusiastic local staff. They can pass on their knowledge to newcomers and ensure that the cycle of well-trained physicians and laboratory staff continues. That also ensures that they maintain the skill of preparing decent material; if you have to not only teach others how to do it, but also report it yourself, I find that it makes you care more about the quality of the material.

We’re running a service for a relatively small children’s facility, so we’ve been able to stay on top of the workload. However, when the same services are offered on a broader scale, or when we handle more data (for instance, by receiving whole-slide scans instead of single photographs), we will need much more manpower. That’s when we’ll need either the assistance of AI or more people reporting. Luckily, digital pathology means that we can give more people access to the diagnostic information – and it doesn’t matter where they are in the world. Anyone can chip in and help – and that’s the real power of digital pathology.

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  1. X-WOW, “X-WOW Whole Slide Imaging System” (2019). Available at: bit.ly/2yIjLDX. Accessed August 6, 2019.
  2. K Dickinson, “How Newcastle scientists can diagnose children with cancer in Malawi from 7,400 miles away” (2019). Available at: bit.ly/2H2axbd. Accessed June 19, 2019.
  3. X-WOW, “Amazing Stories: Working In Progress” (2019). Available at: bit.ly/2FJiD7g. Accessed July 1, 2019.
  4. X-WOW, “Retired Microscopes Back to School Scheme” (2019). Available at: bit.ly/2YQF9FI. Accessed August 6, 2019.
  5. X-WOW, “Hall of Fame” (2019). Available at: bit.ly/2Tcozen. Accessed August 6, 2019.

About the Author

Michael Schubert

While obtaining degrees in biology from the University of Alberta and biochemistry from Penn State College of Medicine, I worked as a freelance science and medical writer. I was able to hone my skills in research, presentation and scientific writing by assembling grants and journal articles, speaking at international conferences, and consulting on topics ranging from medical education to comic book science. As much as I’ve enjoyed designing new bacteria and plausible superheroes, though, I’m more pleased than ever to be at Texere, using my writing and editing skills to create great content for a professional audience.

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| Contributed by Thermo Fisher Scientific

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