EMERGING CHALLENGES IN DIAGNOSTIC

MICROBIOLOGY

NEED FOR NEWER TECHNOLOGIES

Dr.T.V.Rao MD

01-02-2016

Dr.T.V.Rao MD

Delivered as Guest Lecture as part of

the Dr K RajyaLakshmi oration at SVS
Medical College, Mahabubnagar
Telangana on the occasion of XIX th
Annual conference IAMM TS AP State
Chapter
01-02-2016

Dr.T.V.Rao MD

A Tribute to my Teachers Who Taught me

Microbiology
I am grateful to my Teachers
Dr ( Prof) B Raja Rao Garu
Dr ( Prof) Late Saroja Venugopal Madam
Dr ( Prof ) Ramani Madam
Dr ( Prof) Joga Lakshmi Garu
Dr (Prof ) Ramanamma Garu
Many others Who Taught me Microbiology
01-02-2016

Dr.T.V.Rao MD

Microbiology Moving from Past to Future

The long span of four hundred and fifty
years of microbiology has brought amazing
insight into the biology of microorganisms
and has also brought with it new challenges,
and close involvement with clinical staff in a
variety of acute and community settings to
effectively manage infections
01-02-2016

Dr.T.V.Rao MD

Microbiology Moving from

01-02-2016

Dr.T.V.Rao MD

Beginning of Diagnostic Microbiology

In the late 1800s, the realization that
identifiable microbes caused specific
diseases led to pathogens Specific medical
diagnosis. Although the time honoured
techniques of growing bacteria in broth or
solid cultures and staining and examining
them under microscopes are still important
today
01-02-2016

Dr.T.V.Rao MD

The real Good of the Past in

Diagnostic Microbiology
In the good old days, the
microbiology laboratory used
to be a labour intensive place
equipped with incubators and
microscopes. Microbiologists
were patient scientists waiting
at least 24 hours before their
isolated cultures were grown
enough for identification
01-02-2016

Dr.T.V.Rao MD

Laboratories are Evolving

Today, laboratory medicine
is developing at a rapid pace
and the microbiology lab is
having its own evolution
going on. Lab automation is
emerging and processes are
done faster than ever with
more standardized and
comparable tests.
01-02-2016

Dr.T.V.Rao MD

Microbiology in

st
21

Century

In the twenty-first
century, the clinical
microbiology laboratory
plays a central part in
optimizing the
management of
infectious diseases and
surveying local and global
epidemiology.
01-02-2016

Dr.T.V.Rao MD

Where we stand

Today

Most neglected and least

invested specialty
Reasons can be many

01-02-2016

Dr.T.V.Rao MD

10

Newer Adoptions in Microbiology

This pivotal role is made possible by the
adoption of Rational sampling, point-ofcare tests, extended automation and new
technologies, including mass spectrometry
for colony identification, real-time genomics
for isolate characterization, and versatile
and permissive culture systems
01-02-2016

Dr.T.V.Rao MD

11

SPECIMEN COLLECTION
whose duty it is ?
The specimen is the beginning. All
diagnostic information from the laboratory
depends upon the knowledge by which
specimens are chosen and the care with
which they are collected and transported.
Cynthia A. Needham
01-02-2016

Dr.T.V.Rao MD

12

A Simple question to Many Microbiology

Friends
How many Microbes we are identifying
How Good we are in Conventional Methods
to identify simple non fastidious Microbes
How many really measuring the Zone sizes
accurately when we are reporting Sensitivity
and resistance patters as per CLSI guidelines
01-02-2016

Dr.T.V.Rao MD

13

01-02-2016

Dr.T.V.Rao MD

14

What the Hospitals and Administrators

expect from Us
Todays microbiology labs are facing
growing workloads and the need to
produce results faster than ever before.
Labs are looking for new ways to
optimize lab processes and provide
quicker results; improve quality while
ensuring regulatory compliance
01-02-2016

Dr.T.V.Rao MD

15

Conventional Methods Continues to be main work

Since the 1960s, numerous ingenious

innovations have been introduced and used
in clinical microbiology laboratories.
Parenthetically, none of them allowed
microbiologists to abandon the dogma of
the pure culture technique,
01-02-2016

Dr.T.V.Rao MD

16

Molecular Biology in Infancy

Molecular biology
techniques promise to
revolutionize the
diagnosis of infectious
diseaseto date a
promise still in its
infancy
01-02-2016

Dr.T.V.Rao MD

17

Laboratory Medicine Under threat

Microbiology is No exception

Great questions to many

Microbiologists
How much Time we are spending in the
Laboratory

Who are doing the Bench work

Are laboratories equipped with minimal
requirements of infrastructure and Biosafety?
01-02-2016

Dr.T.V.Rao MD

18

NEED FOR AUTOMATION IN INFECTIOUS

DISEASES
Microbes are ever evolving with man we are
on the cusp of a dramatic change that will
sweep a wave of automation into clinical
microbiology laboratories. Threats faced by
ecological changes and ever growing misuse
of antibiotics for trivial conditions,
01-02-2016

Dr.T.V.Rao MD

19

Problems With Traditional Methods

Problems With Traditional Methods
Cultivation-based methods insensitive for detecting some
organisms.
Cultivation-based methods limited to pathogens with known
growth requirements.
Poor discrimination between microbes with common
behavioural features.
Failure to detect infections caused by uncultivated (e.g., novel)
organisms, or organisms that fail to elicit a detectable host
immune response.
Visual appearance of microorganisms is nonspecific.
01-02-2016

Dr.T.V.Rao MD

20

Problems With Traditional Methods

Examples of Failures With Traditional Approaches
Detection and speciation of slow-growing organisms takes
weeks
(e.g., M. tuberculosis).
A number of visible microorganisms cannot be cultivated
(e.g., Whipple bacillus).
Diseases presumed to be infectious remain ill-defined with
not detected microorganism (e.g., abrupt fever after tick
bite).
01-02-2016

Dr.T.V.Rao MD

21

NEED FOR MODERN METHODS

AUTOMATION

01-02-2016

Dr.T.V.Rao MD

22

Genotypic methods
The initiation of new molecular technologies in genomics and proteomics is
shifting traditional techniques for bacterial classification, identification, and
characterization in the 21st century toward methods based on the elucidation of
specific gene sequences or molecular components of a cell.

Genotypic methods of microbe identification include the use of :

Nucleic acid probes
PCR (RT-PCR, RAPD-PCR)
Nucleic acid sequence analysis
16s rRNA analysis
RFLP
Plasmid fingerprinting.
01-02-2016

Dr.T.V.Rao MD

23

Advantages of Automation
Known Advantages
Maximize resources and
automation of the lab to
improve efficiency
Greatly reduce or eliminate
errors, and re-work of redundant
processes
Train key personnel and staff on
LEAN principles and establish a
core knowledge of best practices

01-02-2016

Dr.T.V.Rao MD

24

SEPTIC SHOCK A PRIORITY

Let us think of septic shock as a top priority, at least
we receive 10% of the samples, we process are Blood
cultures and the number of specimens increase with
the expansion of ICU and MICU care, According to the
literature, the risk of death from septic shock
increases by over 7% with every hour that passes from
the onset of shock until the start of targeted therapy.
tools in clinical microbiology are primarily based on
techniques that evolved 30 to 40 years ago
01-02-2016

Dr.T.V.Rao MD

25

RAPID IDENTIFICATION SAVES

LIVES
A number of other
studies confirm the
urgency of rapid
identification of
pathogens and its
benefit to survival and
costs and the effective
targeting of
antimicrobial therapy,
01-02-2016

Dr.T.V.Rao MD

26

Clinicians start Empirical treatment

Physicians are forced to
deduce the presence of BSI
based on clinical symptoms,
which are often nonspecific.
Subsequently, antibiotic
therapy is initiated based on
clinical and epidemiologic
profiles rather than on

laboratory evidence.
01-02-2016

Dr.T.V.Rao MD

27

BacT/ALERT Culture Media BacT/ALERT Culture

media offers an ideal
environment for
recovering an array of
microorganisms,
including bacteria,
fungi, and
mycobacteria. 01-02-2016

Dr.T.V.Rao MD

28

Reliable Microorganism Recovery

BacT/ALERT Culture Media
provides a wide range of media
bottles to rapidly and reliably
recover an array of
microorganisms, including
bacteria, mycobacteria, fungi,
and yeasts from various sample
types. BacT/ALERT Culture
Media is FDA-cleared for blood,
sterile body fluids, and platelets,
and can detect 98% of isolates
within 72 hours.* 01-02-2016

Dr.T.V.Rao MD

29

WHO IS ACCOUNTABLE TO RUNNING THE

SYSTEM
1The physicians should give many clinical details why they wish to
culture blood, as automation is fraught with many errors if the
coordination fails between treating doctor and laboratory personal
the errors with automation are more expensive dangerous with loss
of valuable time and the purpose of automation is lost
2 All the requests should be identified with caring Doctor or nurse
responsible for treatment decision and better with active Mobile
contact number for faster communication in case of any growth as
the machine alerts every 10 minutes a valuable time is saved for
faster decisions
01-02-2016

Dr.T.V.Rao MD

30

WHO IS ACCOUNTABLE TO RUNNING THE

SYSTEM
3 The Medical Microbiologists should be well
know ledged to identify the contamination and
source to make the system running with
scientific efficacy
4 With experience I wish to say automation
needs more knowledge of Medical
Microbiologists or the matters will be
counterproductive in false identification of
contaminants
01-02-2016

Dr.T.V.Rao MD

31

WHO IS ACCOUNTABLE TO RUNNING THE

SYSTEM
5 A regular audit of the functioning and reporting both by
internal and external experts.
6 I wish who wish to run the Automation must read from
more at Bailey and Scot diagnostic microbiology available
in our libraries
7 Ill qualified and careless Microbiologists, and technicians
are more dangerous as the errors at many stages multiplies
faster than traditional methods of culturing leasing greater
misuse of Antibiotics
01-02-2016

Dr.T.V.Rao MD

32

(MALDI-TOF MS)
Spectrometry (MALDI-TOF MS) is a novel method for the direct
identification of pathogens in blood culture broths, with results
available within 2 hours. Although it does not provide antimicrobial
susceptibility data identifying the etiologic pathogen, followed by
antimicrobial susceptibility testing, is critical in the management of
BSIs, as delays in effective antimicrobial therapy can adversely affect
patient outcomes. MALDI-TOF MS has significant potential

over phenotypic methods, as it is able to detect bacterial

pathogens directly from blood culture broths reliably and
quickly
01-02-2016

Dr.T.V.Rao MD

33

VITEK MS
VITEK MS Mass spectrometry microbial identification
system An automated mass spectrometry microbial
identification system that uses Matrix Assisted Laser
Desorption Ionization Time-of-Flight (MALDI-TOF)
technology and a comprehensive database of clinically
relevant species for results in minutes Robust & accurate ID
with Advanced Spectra Classifier Seamless integration of
ID/AST results for optimized workflow Complete traceability
& flexibility 01-02-2016

Dr.T.V.Rao MD

34

Rapid & clear identification

VITEK MS is an innovative, automated microbial
identification system that uses MALDI-TOF (Matrix
Assisted Laser Desorption Ionization Time-of-Flight)
technology. In just minutes, this mass spectrometry
technology can provide clear identification at the
species, genus and family level. You can provide
clinicians with quick information to start appropriate
treatment, contributing to overall patient care and
outcomes.
01-02-2016

Dr.T.V.Rao MD

35

Rapid & clear identification

In just minutes, this mass
spectrometry technology
can provide clear
identification at the species,
genus and family level. You
can provide clinicians with
quick information to start
appropriate treatment,
contributing to overall
patient care and outcomes
01-02-2016

Dr.T.V.Rao MD

36

The Enigma of Tuberculosis

Nearly a third of the world's population is estimated
to be infected with Mycobacterium tuberculosis. This
enormous pool of latently infected individuals poses a
major hurdle for global tuberculosis (TB) control.
Currently, diagnosis of latent TB infection (LTBI) relies
on the tuberculin skin test (TST), a century-old test
with known limitations. Smear examination for Acid
fast bacilli continues to be Gold standard with many
limitations
01-02-2016

Dr.T.V.Rao MD

37

Limitations of RNTCP Program

However the word TB Continues to be least explored disease
the treatment in RNTCP as only National programme to
control tuberculosis to be challenged by many clinicians who
take care of patients however on many fronts the physicians
continue to have their own choices and on many fronts
empirical treatment continues and the researcher continue
to explore MDR tuberculosis as a threat to the many in the
society. Research on new TB diagnostic tools has been
accelerated over the last few years and the diagnostic
pipeline has been growing rapidly as a result
01-02-2016

Dr.T.V.Rao MD

38

TB Diagnostic Tools
Research on new TB
diagnostic tools has
been accelerated over
the last few years and
the diagnostic pipeline
has been growing rapidly
as a result

01-02-2016

Dr.T.V.Rao MD

39

Xpert MTB/RIF
Xpert MTB/RIF is an automated, cartridge-based
nucleic amplification assay for the simultaneous
detection of TB and rifampicin resistance directly from
sputum in under two hours. The technology is based
on the GeneXpert platform and was developed as a
partnership between the Foundation for Innovative
New Diagnostics (FIND), The test simultaneously
detects TB and rifampicin drug resistance (a reliable
indicator for MDR TB) in sputum.
01-02-2016

Dr.T.V.Rao MD

40

My Dear Young Microbiologists

Most people want to do excellent work. Apathy becomes a problem
when team members feel there is no solution or they have no voice
I wish you are the future leaders in Microbiology for next 40 years
hope you all wish for change to live in comfort,
Assess your role
Purpose of the speciality
Try Impress others with hard work and sincerity
If Medical People do not wish to work some body take you place ?

NEXT WHAT ?
01-02-2016

Dr.T.V.Rao MD

41

Emerging Pathogens: Challenges and

Successes of Molecular Diagnostics
More than 50 emerging and remerging pathogens
have been identified during the last 40 years. The
feasibility of applying molecular diagnostics to
dangerous, fastidious, and uncultivated agents for
which conventional tests do not yield timely diagnoses
has achieved proof of concept for many agents, but
widespread use of cost-effective, validated
commercial assays has yet to occur
01-02-2016

Dr.T.V.Rao MD

42

Molecular Assays Newer Emerging Trends in

Microbiology
Molecular assays have
become widely available for
diagnostic microbiology,
spurred by technological
developments and
commercial profit motives.
But questions arise when
new applications for
molecular testing are being
introduced. Can these tests
replace traditional methods?
01-02-2016

Dr.T.V.Rao MD

43

Are we Willing for Change

Can our current
laboratory professionals
be trained to perform
some of these highly
technically complex
assays? Will physicians
accept the results and
change practice
appropriately?
01-02-2016

Dr.T.V.Rao MD

44

Cost Versus Benefit

Are the decreased
turnaround time
and improved
sensitivity worth
the additional
cost?
01-02-2016

Dr.T.V.Rao MD

45

Beginning of Polymerase chain reaction

Newer technologies have transformed the field of
microbial diagnosis. Among the first emerging
epidemic diseases to be identified by one such
method was the hantavirus pulmonary syndrome, a
centuries old disease caused by an unknown
phlebovirus (Sin Nombre) that was discovered
unexpectedly in1993 by the application of a thennovel molecular genetic technique, polymerase chain
reaction(PCR).
01-02-2016

Dr.T.V.Rao MD

46

MOLECULAR METHODS IN DIAGNOSIS

The introduction of molecular methods will not only
depend on their performance for each individual
microorganism, but also on the clinical relevance of
the diagnostic question asked, the prevalence of the
clinical problem and whether the new methods are
added to the procedures in use or will replace them.
Therefore no general rules can be proposed, strategies
have to be elaborated for each infectious agent or
clinical syndrome.
01-02-2016

Dr.T.V.Rao MD

47

WHEN WE REALLY NEED MOLECULAR

METHODS ?
Molecular diagnosis is
most appropriate for
infectious agents that are
difficult to detect,
identify, or test for
susceptibility in a timely
fashion with
conventional methods.
01-02-2016

Dr.T.V.Rao MD

48

THERE IS AN URGENT NEED FOR

MOLECULAR METHODS IN
Strategies concerning the
use of molecular
diagnostic techniques for
the diagnosis of
Mycobacterium
tuberculosis, Chlamydia
trachomatis, meningoencephalitis syndrome
and respiratory infection
01-02-2016

Dr.T.V.Rao MD

49

Nucleic acid probes

Nucleic acid hybridization is one of the most powerful tools available for
microbe identification.
Hybridization detects for a specific DNA sequence associated with an
organism.
The process uses a nucleic acid probe which is specific for that particular
organism.
The target DNA (from the organism) is attached to a solid matrix such as a
nylon or nitrocellulose membrane.
01-02-2016

Dr.T.V.Rao MD

50

Nucleic Acid Probes

A single stranded probe is added and if there
is sequence complementality between the
target and the probe a positive hybridization
signal will be detected.

Hybridization is detected by a
reporter
molecule
(radioactive,
fluorescent,
chemiluminescent)
which is attached to the probe.
Nucleic acid probes have been
marketed for the identification of
many pathogens such as N.
gonorrhoeae.
01-02-2016

Dr.T.V.Rao MD

51

Advantages of Nucleic Acid Probes

Nucleic acid probes has many advantages over
immunological methods.
Nucleic acid are more stable at high temperature,
pH, and in the presence of organic solvents and other
chemicals.
This means that the specimen can be treated very
harshly to destroy interfering materials.
Nucleic acid probes can be used to identify
microorganisms which are no longer alive.
Furthermore nucleic acid probes are more specific
than antibodies.
01-02-2016

Dr.T.V.Rao MD

52

DIAGNOSTIC MICROBIOLOGY CHANGING FROM PHENOTYPIC

METHODS TO MOLECULAR METHODS

In hospital epidemiology, the use of such techniques has

already provided tests with exceptional discriminatory
power. Molecular techniques allow more efficient typing of
all pathogens, and permit discrimination between strains of
organisms that were previously phenotypically identical or
uncharacterizable. Currently, cost and complexity limit the
applicability of these techniques; however, they are likely to
be developed for routine laboratory use in the next decade,
and their impact will be considerable.
01-02-2016

Dr.T.V.Rao MD

53

EMERGING MOLECULAR METHODS

IN DIAGNOSIS

01-02-2016

Dr.T.V.Rao MD

54

NEW TECHNOLOGIES REAL TIME ASSAYS

The Real Time assays are proving to better technologies
1 Rapid
2 Quantitative measurement
3 Lower contamination rate
4 Higher sensitivity
5 Higher specificity
6 Easy standardization
Now a new gold standard for rapid diagnosis of virus infection in the
acute phase samples.
01-02-2016

Dr.T.V.Rao MD

55

WE HAVE NO POLICY TO IMPROVE THE

DIAGNOSTICS IN INDIA?
We in the country do not have any fixed guidelines or
acts how laboratories can improve unlike some of the
developed countries While ensuring accurate data is
the critical first step to technology implementation.
Faster time-to-results and the detection of disease at
an earlier stage enable patients to receive the
appropriate treatment more quickly. A closer link is
being forged between diagnostic tests and treatment
01-02-2016

Dr.T.V.Rao MD

56

Who can afford it?

Fluorescence microscopes, thermocyclers, qPCR
machines, hybridisation ovens, automated expert
systems, specialised reagents - these are the more
expensive requirements of the modern microbiology
laboratory. In some regions of the world uptake of the
new technologies has been slow. For resource-poor
areas, the obstacles can seem insurmountable
because significant funding must be allocated for
upgrading laboratory infrastructure and training of
staff as well as major equipment purchases
01-02-2016

Dr.T.V.Rao MD

57

Long way to go in Our approach

Because multidrug-resistant
gram-negative rods are
among the most important
causes of healthcareacquired infections today
and because well-studied or
commercial molecular
methods are not yet
available for their detection
01-02-2016

Dr.T.V.Rao MD

58

OUR VISION TO FUTURE DIAGNOSIS OF

INFECTIOUS DISEASES

With the ability to test for an unlimited number

of potential pathogens simultaneously, nextgeneration sequencing has the potential to
revolutionize infectious diseases diagnostics
In the microbiology laboratory, this technology
will likely replace the traditional one test, one
bug approach to pathogen diagnostics
01-02-2016

Dr.T.V.Rao MD

59

WHY WE MUST BE FAMILIAR WITH

MOLECULAR METHODS
In Many Developed countries several Diagnostic methods are
switched on to Molecular Methods.
No scientific journal is willing to accept or publish any
article without incorporation of Molecular Methods.
Antibiotic drug resistance is a growing concern, to the world,
unless molecular identification is performed on responsible
genetic mechanisms no effective scientific conclusions can
be drawn to contain the spread.
01-02-2016

Dr.T.V.Rao MD

60

Are we ignoring Anaerobes ?

01-02-2016

Dr.T.V.Rao MD

61

Tele Diagnosis

CDC helps in Digital diagnosis

The

CDC now offers tele diagnosis to help laboratories diagnose

malaria and other parasitic diseases. When laboratories are not
certain about identifying parasites on a slide, they can e-mail to
the CDC images of the suspected parasites. Experts then review
the images and discuss findings with the submitting lab within
only a few hours, allowing near real-time diagnosis as well as an
opportunity for training in microscopic diagnosis.

01-02-2016

Dr.T.V.Rao MD

63

A long parasite of 15 cm was extracted without

damage to the physical structure

An approximately 15
cm long filamentous
macroscopic
parasite was
extracted sent intact
in Normal saline, to
Microbiology

Histopathology sections and

Photomicrograph

As reported from CDC Atlanta USA

Based on the images, we agree this

is a female Dirofilaria (possibly D.

repens in India), as indicated by tall,
polymyarian musculature, external
cuticular ridges, and paired
reproductive tubes.

Documentation in Microbiology
WHONET is a Windows-based data
WHONET is a Windows-based
database software developed for the
management of microbiology
laboratory data and the analysis of
antimicrobial susceptibility test results.
The software developed for the
management of microbiology
laboratory data and the analysis of
antimicrobial susceptibility test results.

Data can be exchanged globally

To enhance local use of
laboratory data for guiding
therapy, assisting infection
control, characterizing resistance
epidemiology and identifying
laboratory testing errors; to
promote collaboration in
surveillance activities through
the exchange of data.
01-02-2016

Dr.T.V.Rao MD

68

Connects to the World through

WWW

These tools enable any

microbiology laboratory to put
its test results into a database
and conduct analyses to support
local infection control and
antibiotic use. Laboratories can
also upload files created by
WHONET, to feed into national
or other multi-centre
surveillance networks and to
inform drug policy. Such
surveillance programs are now in
place in many countries.
01-02-2016

Dr.T.V.Rao MD

69

Laboratory Automation Advanced

Beyond imagination
Laboratory automation has already made dramatic
changes to the way in which researchers approach
their work. It will clearly provide new tools for
increasing productivity in the future What is
ultimately possible seems to be limited only by the
creative genius of researchers working in the
laboratory to define their needs and companies
focusing on providing creative and user-friendly
solutions to those problems and challenges.
01-02-2016

Dr.T.V.Rao MD

70

Robotics Entering Diagnostic Laboratories

Advances to come include
programmable, automated work
stations that can perform a
multitude of tasks, extremely
sophisticated robotics that can
perform tasks once restricted to
humans, and artificial
intelligence systems on chips
that can learn from their
experiences much like ordinary
humans.
01-02-2016

Dr.T.V.Rao MD

71

Decreasing human Role

Some laboratories have even
enlisted the services of fully
functional robotic systems to
replace jobs once done manually
during an eight-hour shift into
procedures that require very
little human intervention and
operate (at least in theory) 24
hours a day, 7 days a week, 365
days a year. "
01-02-2016

Dr.T.V.Rao MD

72

World First for Malaria - mobile phone diagnosis

now available
xRapid is a world first in
mobile health, providing
automatic diagnosis of
malaria via an iPhone app. It
is the first commercially
available mobile app that
has the functionality to
quickly and accurately
diagnose a major disease.
01-02-2016

Dr.T.V.Rao MD

73

ARE WE READY FOR CHANGE TO

AUTOMATION ?

01-02-2016

Dr.T.V.Rao MD

74

THE FUTURE OF DIAGNOSTIC MICROBIOLOGY IS

CHANGING
The physical structure of laboratories, staffing
patterns, work flow, and turnaround time have all
been profoundly influenced by technical advances.
The implementation of nucleic acid amplificationbased molecular techniques provides complementary,
rapid, and on-demand diagnosis services. These
changes will continue, and lead diagnostic
microbiology inevitably to a modern discipline, which
can face many challenges in the future.
01-02-2016

Dr.T.V.Rao MD

75

Interesting quote on

AUTOMATION
Donald A. Norman University of California, San Diego

The automation is at an intermediate level of

intelligence, powerful enough to take over control
that used to be done by people, but not powerful
enough to handle all abnormalities. Moreover, its level
of intelligence is insufficient to provide the continual,
appropriate feedback that occurs naturally among
human operators. This is the source of the current
difficulties. To solve this problem, the automation
should either be made less intelligent or more so, but
the current level is quite inappropriate.
01-02-2016

Dr.T.V.Rao MD

76

How we can improve our Diagnostic

Microbiology

01-02-2016

Dr.T.V.Rao MD

77

THANK YOU ALL

WE WILL PROGRESS ONE DAY ?

01-02-2016

Dr.T.V.Rao MD

78