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The future of computer-aided diagnosis in the laboratory.

Tuesday, 9 a.m., year 2082: it is time for my lab tests. I have felt tired lately. My skin is dry and itchy. My hair has turned brittle. I must rejuvenate again.

For 83 years I have gone to the clinical laboratory of my local hospital for tests. I am hungry from a 14-hour fast after a meal light in fat. I have been careful not to exercise or otherwise produce an outpouring of enzymes and chemicals that might confuse the smartest computer.

I insert my ID card with my medical history and test plan into the Visitor PC. The computer verifies that the tests requested are consistent with my diagnosis and determines how much blood must be drawn.

* Ancient history. In the 1990s, physicians wrote orders at the bedside on portable computers on on well-designed forms read at the lab by an optical scanner. Character recognition software identified printed letters, marks on specially designed multiple-choice forms, and handwritten letters as well as bar codes and electronic symbols.

The hospital added bar codes to patient ID bracelets in 1995. Portable bar code readers printed labels with IDs in bar codes instead of stamping a label from a plastic card. Later, patients' status was checked as they moved around the facility. No more patients lost behind curtains in the x-ray department! This system was discarded after patients at a long-term-care psychiatric institution exchanged bracelets with visitors and staff. The computer sent the patients home and locked in the visitors and staff. Nobody noticed anything for three months.

* Interaction with a PC. The lab computer speaks: "Good morning, Dr. Siguel. I hope your biochemical profile will provide the stimulus for a longer and happier life. What do we have today, some dry skin? Decreased neutrophil survival and mild anemia? Aha, a suspected abnormality in the manganese/titanium ratio. You may be catching a cold." I hate overly plesant chit-chat from machines.

Computer-controlled pressure cuffs adjust themselves around my arm and self-inflate to the correct pressure. Slowly a micro-needle is lowered through my skin as a light anesthetic mist, evaporating instantly, is sprayed. The blood is routed to prelabeled microcontainers and delivered to the laboratory.

I finally eat breakfast: imitation or biochemically recreated food. Most living beings were killed by population growth and the ecologic disaster of 2008-2053.

* Microbiology. Robotic systems accept specimen and send them through tubes and filters. Chemicals are extracted, concentrated, derivatized, and injected int the cartidge-HPLC-GLC-MS system.

A minor UTI is the source of my current pruritus on urination. The PC compares the spectral chromatographic and DNA patterns with those characteristic of specific microorganisms, identifies the mixture of bugs most likely to produce the contents of the specimen, and suggests an initial antibiotic and dose.

To verify the diagnosis, a culture will be incubated automatically by robots or remote-controlled arms. The result will be high reproducibility and low risk of contamination.

Antibodies are now available to test for thousands of microorganisms. Key byproducts of metabolism or reactions to microorganisms have been identified and can be measured quickly. As soon as an organism has been isolated, its three-dimensional structure is analyzed.

Computers identify target areas in the organism and synthesize molecules (similar to the old antibiotics) specifically designed to attack them. These molecules, which bear toxic substances, attach themselves to the organism and kill it.

Nevertheless, the lab director tells me, there is room for improvement. Often the match is imperfect and healthy cells are killed as well, along the lines of the old chemotherapy modules. On occasion an entire individual will be destroyed--an unfortunate side effect.

* Chemistry. The chemistry lab looks like a giant Timker Toy set. Slow-moving conveyor belts carry trays controlled by a map on a large computer screen. Human technicians program lab operations. Extensive training with joy-sticks and expertise in playing computer games are mandated by licensing boards. Cables, wires, and metal tubes are everywhere. Local PCs control most extraction-and-analysis procedures.

Phones provide test results when an appropriate code, similar to voide mail systems of the 1990s, is pressed. Test results are transferred to physicians' offices electronically.

* Blood work. My blood has been centrifuged, the components separated, and aliquots sent to processing stations. I already have the results of 280 enzymes, all the vitamins, 20 minerals, and roughly 500 other chemicals. Color profiles of sets of chemicals arrayed in hundreds of multidimensional diagrams are projected on a two-dimensional screen and a 3-D hologram. In fascination, I watch as the computer marks the biochemical processes inside my body that are out of tune.

When I was doing my residency in the 1980s, we wondered how to comprehend and interpret a profile with 30 results. Today, when laboratories can easily provide over 1,000 results, the computer does the wondering. It performs the analysis, interprets the results, and prints the diagnosis and treatment. A physician recently complained that she had become a messenger from computer to bedside.

I sit down before the multianalyzer and instruct it to display abnormal chemistries. The computer suggest therapies to modify the metabolic pathways and minimize abnormalities. Drugs, minerals, and vitamins are suggested. The "surgery" option is blank. I select several combinations. The computer displays the likely consequence of each therapy through "what if" analyses. I then presents the treatment with the fewest undesirable medical, economic, or social consequences, adapted according to the informed consent laws.

* Informed consent. All persons about to undergo medical treatment must be well versed in econometrics, biochemistry, and ethics. Each year we take the Patient Record Examination (PRE) and then reregister informed consent. For those who fail (>93%), a licensed trustee or guardian is assigned to make medical decisions. Laboratories, perhaps unduly concerned over 100,000 previous lawsuits charging failure to report and follow up abnormalities, now routinely provide each patient with the results of thousands of tests. Patients lacking adequate computer facilities to interpret these results at home are given time on PCs in the lab.

The system has not worked well. Ignorance of the law being no defense, attorneys imposed on the public a responsibility to know all the laws--a mere 1,000 volumes per state. Even in the 1980s, most lawyers, unable to grap the subtle differences between CPK isoenzymes, yelled "Heart attack!" every time somebody's CPKs were elevated.

Lab managers explain to patients, physicians, and lawyers the metabolic consequences of abnormalities and the pros and cons of alternative therapies. Informed consent forms for a typical test are only several hundred pages long. (There are over 100 million pages of appendices.) Everyone signs them; no one reads them. Life is too short, especially when you're sick.

Nobody had figured out a way for someone to read all those regulations in less than 2,400 years at a leisurely pace of 20 hours per day and 500 pages per hour. We are a nation of make-believe and euphemisms. The President had signed thousands of laws that she couldn't possibly read. Agencies issued and pretended to apply regulations that no one could follow and enforcers did not understand.

Each lab must now comply with 350 million pages of regulations. These are kept, with training programs, on tiny compact disks (CDs). Each CD stores millions of pages, including pictures, available for retrieval at a keystroke.

* Treatment. For my manganese eficiency, the computer suggests several alternatives, which I narrow down to manganese capsules or tea. I select the latter. The computer recommends 80 ml of decaffeinated tea per day.

My mild zinc deficiency is tricky. The computer suggests oysters, but warns that they contain toxic waste chemicals. I select zinc pills instead.

When the risks of toxic chemicals were entered tin the equation, the computer was programmed to state that eating food, drinking water, or breathing air was dangerous to one's health and to prescribe pills instead.

The FDO has ruled that any food used to treat medical problems is to be classified as a drug. I remember in 1992 when a doctor was fined $12,000 and his license suspended for three years because he had prescribed the former USDA-recommended diet supplemented by milk and red meat for a patient who was deficient in calcium and iron. He had failed to obtain an investigational new drug (IND) application for such use.

* Hematology. I wander into the hematology lab. In the '90, when excessive blood tests frequently required blood transfusions, labs started to use small tubes containing less than 1 ml of blood for CBCs.

Soon a complete cell count, plus an evaluation of the size, shape, and composition distribution of all major cell components, are displayed in multidimensional projections on the screen. (Such distributions became popular in the '90s when it became possible to display, print, and interpret results quickly on PCs.) No matter; all diagnosis is based on sophisticated mathematical analyses of patterns far beyond the comprehension of the average physician and printed along with suggested diagnosis and treatment.

* More PC talk. The results reveal a mild abnormality in the expected 3-D cell characteristics. I face the computer screen playing "What if?" with the alternative treatment options offered. I plug in corrections to my mineral definciencies and other suggestions from the chemistry analyses. The computer displays the expected results in cell characteristics.

The computer now explains to me that drinking 80 ml of decaffeinated tea per day would be too much. It recommends 50 ml augmented by selenium supplements daily. This baffling inconsistency is an indication that despite extraordinary advances in technology, medicine remains as much an art as a science.

Diagnosis and treatment aimed at correcting biochemical abnormalities (those related to substance concentrations) often produce results that are different from diagnosis and treatment aimed at correcting functional abnormalities (those related to cell function). The reason is that even 1,000 chemistries respresent an insignificant fraction of the millions of chemicals in the body. Chemistry and hematology analyses provide different windows through which to look at the body. Because both models are vastly simplified, their results are bound to diverge.

Ironically, with more test results available, physicians have become increasingly convinced that abnormal test results occur by chance rather than because of the presence of disease. They continue to treat every patient according to the disease they believe the patient ought to have. Lawyers derive considerable enjoyment and payment from uncovering abnormal test results that were not promptly followed by treatment.

* Lab changes. Structural descriptions and diagnoses are years ahead of practical applications. Debate continues about what causes specific shape abnormalities or variations in cell size and composition. Computer models can, however, accurately predict the age and life span of most cells, using information from DAN degradation, changes in enzyme composition, and other parameters.

Although diagnosis has taken a giant leap forward, prevention and treatment lag far behind. A fundamental reason is that most disorders are caused by environmental pollution and suboptimal eating patterns. The cumulative effects of megatons of toxic chemicals dumped on the earth show in all food supplies, air, and water, and nothing can be done about it.

Giant computer models integrate data to pinpoint metabolic problems or sources of contamination in the blood, precisely characterize cell shape and composition, identify and quantitate microorganisms, and predict the time of death and its cause. Diagnosis has reached its peak. We know what ails us and why.

Our greatest enemy has been ourselves. Misguided food processing, hypermanufacturing, wasteful leisure, and unlimited biochemical analysis have created a vast array of chemicals that cause most of the diseases diagnosed. Every facet of modern society has produced toxic waste that permeated the environment until it destroyed us. We no longer die of old-fashioned diseases and conditions such as pneumonia, diabetes, or starvation.

While the computer explains everything, we still die of obesity, alcoholism, and drug abuse or as the result of the complex interaction of millions of tiny chemicals that lead to irreversible physiologic changes. We wiped out a billion years of evolution in exchange for a few decades of overconsumption and irresponsibility.

In this way we mimic certain research laboratory rats of the 1960s. With electrodes implanted in the pleasure centers of the brain, they close electrical stimulation over food and starved to death . . . with pleasure.

Edward N. Siguel, M.D., Ph.D., J.D. is a senior scientist in the clinical nutrition unit at University Hospital, Boston University Medical Center.
COPYRIGHT 1991 Nelson Publishing
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Copyright 1991 Gale, Cengage Learning. All rights reserved.

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Author:Siguel, Edward N.
Publication:Medical Laboratory Observer
Date:Aug 1, 1991
Words:2054
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