 Yes, it was. So thank you so much, Michelle, for inviting me. And it's a pleasure to talk to you. And I was, as you see, a professor of pathology here. But now that I'm working for Cepheid, I'm hoping that this doesn't sound too much like a commercial. So I'm trying to make it as subjective, objective as possible. But please realize that there is a conflict of interest here because I work for the company. And part of what I'll be talking about because Michelle asked me to do that was to talk about this test. But first, we have to talk about tuberculosis. And for those of you who aren't familiar with the world problem of tuberculosis, let me just give you a few facts. And a lot of the most recent data come from every year the World Health Organization publishes Global TB Control. And this is the most recent one that just got published about two months ago. So the good news is that the global burden of TB is actually dropping. And so it's about 1.2 billion people, a fourth of the population, as of the most recent data. And the last time I looked at this, it was a higher number of people and about one third of the population of the world who is infected with tuberculosis. Now, being infected does not necessarily mean you have disease. 8.8 million new cases of TB in 2010, including and one of the highest rising numbers of people are those with HIV AIDS, particularly in Southeast Asia, Eastern Europe, and Sub-Saharan Africa. And in 2010, fewer people died from TB than did in 2009. And that was about 1.5 million people, including a third of a million who were the HIV-co-infected people. And that equates to 3,800 deaths a day. This is the second biggest cause of death of infectious diseases in the world and a major problem in the world to which not enough resources have been devoted over the last few years. And in 2010, the largest WHO, MDR, which stands for Multidrug-Resistant TB, survey reported the highest rates ever of MDR TB with peaks up to 28% of new TB cases in some settings of former Eastern bloc, Soviet Union, Azerbaijan, and countries like that. So here's a brand new map of incidence or not incidence, prevalence of TB per 100,000 population in last year. And these numbers, the dark green, greater than 300 people with TB per 100,000 population. And what you can see is that their concentrations are here in Africa and some parts of Southeast Asia, but the numbers in China are pretty high as well. And the only reason they're not more darker green is because China has such an enormous population that the percentage is lower, the prevalence is lower per patient population. But you can see that all these numbers are pretty high. And even in the US, in a lot of Central South America, we have zero to 24, we have some numbers, two and three per 100,000 in the US that would be compared to greater than 300 per 100,000 in some parts of Asia, Africa. And Haiti, here, is pretty high as well. Well, what about multidrug resistant TB? The proportion that WHO reported last year was an overall high in those high redder countries here of 18%. And in a moment, you're going to see that that was an underestimate of the truth. So these numbers indicate proportion of multidrug resistance among TB cases, the dark red is greater than 6%, the next color brown is 3% to 6%, et cetera. And then there are places with no data. So this is Greenland of interest. There's actually some hotbeds of TB and multidrug resistant TB among the Native American Inuit type populations right around the bottom of Greenland. So although there are no data reported for that country, there's actually our high pocket of MDR and TB in that country as well. What about the XDR, the extreme drug-related TB? These are patients who have organisms that cannot be treated but with combinations of first and second line drugs. They need to be placed in a hospital given intravenous drugs for six months to a year and longer. And there's XDR TB in almost all these countries that are red and it's growing in areas where there was MDR TB because it is poor control of multidrug resistant TB that leads patients to become infected with the XDR TB because they don't take their drugs. The drugs are difficult to take. They make you feel ill. And so those patients then develop resistance of their existing organisms that go on and become extremely drug-resistant TB. And you probably heard in the news about the TDR TB, the totally drug-resistant TB, which was first isolated in Mumbai, India. But now we're beginning to see it moving around. And there have been a couple cases in northern Europe as well from people who have moved from India to northern Europe with TDR. Now, I wanted you to realize that the WHO estimate was low. And this is based on a Lancet publication that just came out five days ago or so. And they looked in eight countries and sent almost 1,300 isolates from patients to the CDC where the CDC did the definitive drug susceptibility testing. And what they found was that 44% of those isolates from eight countries showed resistance to at least one of the second line drugs. And that 6.7% had XDR TB. So these are pretty frightening numbers. And they're frightening to us here in the US and to other developed nations because patients with these organisms come here, they visit people from here, go there and visit their relatives and bring these organisms back. So it's not just a problem of developing world, although it's developing world where we need to control it. Now, how do we diagnose TB in the developed world, in our laboratory? So some of you may recognize, I hope you do, Niaz Benai, the current director of the microbiology lab here at Stanford. He is working in our biolaminer safety cabinet, wearing an N95 protective mask. And he's doing TB diagnosis. So here's the sputum from the patient. And what we do is we add sodium hydroxide to kill off the organisms that are not TB and allow the TBs to remain. And then we use a buffer to kill off the activity of the sodium hydroxide so it doesn't totally kill the TB. We concentrate and spin down that sample that's now been what we call decontaminated and then concentrated. And in order to do that, we need a floor level refrigerated centrifuge because the high speed that we spin that thing at heats it up and you don't want to heat it up and kill the bugs. And then we have this pellet down here of concentrated acid fast organisms from the original sputum. And what we do with the pellet is we add some growth in enhancing chemicals to it. And we place it in these tubes, which are put into an automated instrument called a midget. It's a liquid broth system. We also put some of that pellet onto solid agar media. And we put some of it onto a smear on a glass slide that we then stain and look for acid fast. So once it goes into the liquid medium, it incubates for anywhere from four to eight weeks, at which time the culture becomes positive. Now, every sample that we get in the laboratory here or in the developed world or in any country high level laboratory, they have to examine the smear. And we have to stain the slides and we use either a zeal nilson stain, which is a fuchsin-based stain, basic fuchsin-based stain. The bugs look red against a blue background. Or we can use a fluorescent stain, which is a nonspecific fluorescent stain for the sterols and the cell wall of the AFB. And that's called oremine or oremine rotamine. It takes a skilled person three to five minutes each to look at this slide. And remember, this is already concentrated from the original sample. In the developing world, they don't do any of that concentration stuff that I just went through. Most diagnosis, if it's made at all, is made using a direct smear from the sputum directly onto a slide and looking at it. So it's not concentrated. And number two, people in the developing world, technologists aren't so skilled. Number one, and they're not so motivated to sit and look at these slides for the three to five minutes it would take to actually detect if there were rare numbers of acid fast organisms in the sample. In Cambodia, where our NGO works, we have to incentivize the local techs $2 US each just to read the smears as opposed to looking at them and calling them negative or positive. So diagnosis in developing world is a far cry from what I'm just showing you here. Another problem with this is that these acid fast here that you see in the picture could be any mycobacteria. They could be avium intracellularia. And there's a lot of that in the respiratory tracks of patients in the developing world. It could be mycobacterium cologne or Kansas acid or anything. You can't tell by looking which organism it is. Now there are problems with diagnosing pediatric TB. Kids and patients with HIV share some of these characteristics, which is they don't have cavatary disease. And in order to get the organisms into the sputum that you cough up, a patient has to have an area of organisms that have cavitated in the lung, and that cavity opens up into a bronchial or some part of the bronchial tree. And then that gets coughed up and you can see it. Well, if you just have diffuse disease in the lung parenchyma and no cavity where the thing is being available into the sputum, the respiratory secretions, you're not going to be able to detect it in the sputum. And there's really no other way to diagnose active pulmonary disease. So even if they did have cavatary disease or they were coughing up organisms in their respiratory secretions, you can't get a kid to spit that stuff into a cup. They will swallow it. And so what we do is we use a surrogate respiratory sample by waking them up early in the morning and pumping the contents of the gastric contents of the stomach out and looking for it there, since they've been swallowing it all night long. Or we induce them, aerosol induce them. And that's very difficult with children and hard to obtain. And so culture-confirmed childhood TB, for example, in one study that I looked at, was about 62%. So you're going to miss 40% of children who are infected with TB. And that's very similar to the situation in HIV-AIDS patients, where they just don't develop cavities. So as I said, in the developing world, most diagnosis is made by direct smears. And the sensitivity is anywhere from 15% to 60% compared to culture. WHO, in that 2011 document that I mentioned at the beginning, asserts that eight of the 22 high-burden countries, there are 22 countries in the world that have super high levels of the greater than 300 per 100,000 patients, eight of those did not meet the benchmark of one microscopy center per 100,000 population. And among the 36 countries in the 26, 22 high-burden and 27 high-MDR multidrug-resistance TB-burden countries, 20 had less than a benchmark of one laboratory capable of performing cultures and drug susceptibility testing per 5 million population. So this is basically saying, and the truth is that something like 96% of the patients who are at risk for TB in these high-burden countries are not getting any kind of laboratory diagnosis. Physicians may be treating them based on guesses or based on history, but not based on actual laboratory data. So once you grow the organism, so here is a mycobacterium tuberculosis colony growing on Lowenstein Jensen, which is a medium used throughout the world often. You see it's very rough colony. You have to dilute this colony, disperse it in a liquid, make dilutions, and then place it on, in this case, augur media containing different antibiotic concentrations to determine if the organism is susceptible or resistant to the antibiotics that you want to treat it with. And so this is what we call the augur dilution method. This is the classic method. And then the newer method is in a liquid broth. Again, the midget machine. But now we've placed our dilutions into liquids containing various concentrations of the antibiotics, put them back in the machine, and wait another week or two weeks for them to grow in the control and then compare to the liquid containing antibiotics to make sure that they are susceptible or resistant. And strangely enough, after you've done all this phenotypic in vitro testing, those results are inconsistent. And they may not actually match the genotypic results or the patient outcomes. So I'm going to show you a very interesting paper that was published in 2009 looking at four different methods of determining antibiotic susceptibilities for TB. So this was the LJ proportion on a medium that's green and is made out of potatoes and eggs, which is what a lot of developing world people are able to make. Middlebrook, which is a clear auger, the one I showed you the picture of, auger proportion method. The radiometric method, which is a previous liquid culture method no longer available in US. And the midget system, which is the current liquid culture method I showed you. And what you see here is this is the ratio of MIC to critical concentration. And all the ones above the line would be called resistant. And all the ones below the line would be called susceptible. And each one of these columns is a different isolate from a patient. And what you see is that it depends on what method you're using, whether you're going to call it a resistant or a susceptible strain. Well, this has huge implications when you're going to subject a patient to six months to a year of highly toxic drugs in combination if it depends on what method you use, whether you're going to give them that drug yes or no. So this is a problem with tuberculosis today. So how are people doing it using the new generation molecular methods? So the Hain test, GTMD, genotyping mycobacterium drug test, was WHO endorsed about five or six years ago. It's a very high complexity test that's done only in some national reference labs throughout the developing world. It's not even done in the developed world. In the US, it's not FDA-cleared, so we don't have it. But the way it works is that you take the original sample, the sputum. You extract DNA from it using a manual extraction method, like a kaogen column. You amplify it using PCR, polymerase chain reaction. And then you take the amplified supernatant and you overlay it over filter paper strips in which oligonucleotides of various mutational areas on the gene sequence of mycobacteria have been laid. And then you add color reagent to detect it, incubate it, and take a look at the band pattern visually. So it's high skill required. It's subject to contamination because you're opening up a PCR-amplified tube and pipetting it into a well, a micro well like this, a strip well, and then incubating and looking at the pattern. And so then the pattern is subject to the subjectivity of the reader. So they have some controls up here for mycobacterium tuberculosis so that if you have TB, you'll get a positive band here. And then they have a series of mutant segments that are in the ribosome polymerase B region of mycobacterium tuberculosis where rifampin resistance occurs. So if there's mutations there, they will show up as rifampin resistant. And then they had two sections of genes where isoniazid, the other major drug, resistance occurs, the CAT G locus and the INHA locus. And all of these different patterns would indicate resistance. And if you didn't have those bands, you'd have a wild type. Or if you have the band, you have various definitions of wild type versus resistance. For the RPOB mutants, the system works quite well. The sensitivity for picking up true resistance based on phenotype is about 96%. But for the two different INH mutants, it's not that great individually. But when you put those things together, you do get better results. I'll show you in a moment. So here are actual pictures of actual strips. And as you can see, there are some pretty pale bands and maybe a band, a plus minus band once in a while. So they're somewhat subjective and very, very difficult and takes all day, which means that they are sent to a central laboratory, maybe one in every country or not even, maybe to a supernational lab somewhere, and then batched and done maybe once a month, maybe once a week if you're lucky. The gene expert, which is the Cepheid product, was revealed to the world in September of 2010 in a paper that was published in the New England Journal by Catarina Boehm from FIND, the Fund for Innovative New Diagnostics, which, with a lot of Gates Foundation money, worked with the company Cepheid to create this test. And I'll show you how it works in a moment. But the way that you perform the test is you take the sputum from the patient, you add by eyeball a certain amount of a buffer reagent to it, you shake it up on the bench, wherever the bench may be, it could be in some smear microscopy lab in the middle of Uganda. And then you use a pipette with a line on it to put about two milliliters into this cartridge. And then the cartridge is barcoded into the machine. And in less than two hours, about 70 minutes, the machine will give you a readout on a computer that says, MTB detected, high, low, moderate, et cetera, rifampian resistance detected or not detected. So it's a pretty simple process. The technology would be considered moderate complexity here in the US, which means nurses can do it, laboratory technicians can do it, clerks can do it, et cetera. So this was introduced in 2010. The instruments core is this module where the cartridge goes in. And all of the sample extraction, PCR amplification and detection occurs in this module. And the modules can be placed into any size machine. So there's a little one unit one, which is about this big. And you could put it in your backpack and take it out into some village. There's two units, four units, eight over eight, 16. And then there's this giant infinity thing, whoops, which can do more than 2000 tests per 24 hours. These things have been installed in South Africa and some of the big national labs. India is going to be placing these in a number of different provincial laboratories. And rich places like Dubai are using them routinely for TB testing. So I want to tell you a little bit about how the test works, just so you're aware. This is a cutaway of the cartridge. It has freeze dried beads, which contain all the reagents necessary for PCR, the primers, the probes, the enzymes, et cetera. And it has a plunger down the center that moves liquid from different reservoirs into other reservoirs. And on the back here is the ampule where the PCR occurs. I'm gonna show you a movie, how this thing happens, hopefully if it works. And then down here is an interface between the module and a sonic horn, an ultrasound. So when the organisms get fixed down on a filter at the bottom of that cartridge, they get sonicated, that breaks them open and allows the DNA to be released and then amplified. So let's see if the movie runs. Okay, so here's the cartridge. Like I said, it's about so big and we're gonna take it apart. It's got all kinds of different parts and all the different reservoirs. And the plunger's down here in the center and the cap goes on. And now it's got all the reagents, liquid and dry on board. The sample goes in the hole on top into the first reservoir. And then the sample gets washed. There's a bunch of computer generated algorithms within the cartridge that manage how it works. It's called the assay definition file. And everything goes into the center and then gets pushed out through different holes as the whole thing rotates. So here now the organisms from the sputum are affixed on the filter. There's glass beads in here as well as buffer reagent. The ultrasonic horn will eventually come up. It's gonna be washed through the filter a couple of times to get rid of potential inhibitors in the sample. And then the horn comes up and bangs the glass beads against the bugs, opens them up and releases the DNA which then gets sucked into another reservoir. The reagent beads get added and the first round of PCR is gonna occur. So here the reagent beads get dissolved. There are all kinds of quality controls built in here so that if any step fails, the whole thing stops. So the first round of PCR here is going to amplify the entire 81 base pair region of the RPO gene where all those mutations occur. So it's actually a hemi nested or a nested type PCR in this cartridge. And then it gets the second bunch of reagents are dissolved into it. It gets pushed back out into the amplify tubule and the second round of PCR occurs and it's interrogated using six colors to look for amplification of the different sections. And one of the keys to breaking this force of anthrax which is what this whole thing was developed for is this sonication and it works really well to break apart the very hard outer mycolic acid bound shell of mycobacteria tuberculosis. So the system works like this. Here's the 81 base pair area. There's the sequences and there are floors that cover overlapping five of the different areas all of which 96% of the mutations that confer rifampin resistance occur. So if you have four bound, they're wild type and you'll get four PCR reactant curves with four different colors up here. And if you have all five of them, you'll get five and that would be a wild type. The six colors for an internal control for inhibition and amplification. And so if you have only three or only four, then you know there's a mutation somewhere in there. You have TB but you have rifampin resistance. So does that make sense to you how it works? Okay. And it's molecular beacons. So interestingly enough, as I told you before, the mutations may not match the phenotype that you get from doing the drug dilution. So in this case, the midget system had 52 patients which were INH and resistant but rifampin susceptible. But the gene expert called four of those patients rifampin resistant. And when they went back and looked at those four patients, three of those four had treatment failure and one of them died. So all four of them were true rifampin resistance missed by the midget system. And the expert results actually match the clinical outcomes better than the phenotypic liquid culture results. That may not always happen but it's one of the problems that we have to deal with with TB. So WHO took all the data from the system that had been done. There were over 7,000 patients studied by FIND in six different countries. I'm not showing you those data, they're kind of old. I'll show you new data. And they endorsed this test for the initial diagnostic test for individuals suspected of MDR or HIV associated TB next to microscopy recommended for children and even just to use one sputum instead of what we use in this country, which is three. Because the sensitivity of detecting one patient from one sample is above 90%. It's now about 95% sensitive for detecting TB with one sample. And for smear negative samples, which is really important, it's over 70% sensitive. So all those patients who were smear negative but later came up positive on culture that might have been lost to follow up or had more serious consequences waiting for the culture results are detected, many of them 70% using the system. So this is what Michelle's probably more interested in is how's it doing now? So this is the rollout of the gene expert cartridges used and one of the reasons this is important is because the company negotiated with WHO and Unidade to give high burden, low resource countries a super cheapo price. So in the United States, the test is gonna cost 70 bucks or something like that. In developing world, the test cost $17 at this time. But just last month, you may have seen an announcement that Gates Foundation, Bill Gates, has agreed to underwrite dropping the cost to under $10. So now each cartridge is less than $10 for the high burden, low resource world. And there is a website on the WHO website which is called the MTB RIF rollout website. And in January 2011, these are all the countries that had it, which is like six. And just now in second quarter, 2012, all of the blue countries have gene experts ordered and the yellow ones don't count because they're not high burden, low resource countries. So you can see that many countries now have the system in place using this, what we call differential or low high burden pricing system. And I pulled a couple slides from some recent presentations. So this is from Wendy Stevens who's the head of the National Priority Program's National Health Lab, South Africa. South Africa is the number one poster child for this system. They are, they procured more than 50% of all the tests that have been sold for the high burden world at this time. And they've rolled it out to every one of their smear microscopy stations and they've stopped doing smears basically and they're just using a gene expert. And within the first quarter of the time, they've detected MTB at least doubled for early diagnosis of implementation, 17% positive versus 8% by smears. Their rifampin resistance looks very well compared to culture and they doubled the national coverage since the pilot in 2010. There have now been cost effectiveness studies published showing that it is cost effective even at the $17 price, which was pretty pricey at the time. And there are new studies showing that if this continues to be rolled out in high burden countries that we're looking at dramatic reductions in tuberculosis over the next five to 10 years that would never have occurred if this kind of technology had not been available. So here's a cost effectiveness study that was published in Plas Medicine last year. And I don't think I'll go through the whole thing for you, but it was based on three countries, Uganda, which had a high HIV, low multi-drug resistant population, India, which is low HIV, low MDR, and Africa, South Africa, high HIV, high MDR. And they looked at the willingness to pay by each country's baseline for the aversion of disability adjusted life years or dailies. I'm sure you've heard of those things. And they looked at smear positive prevalence, et cetera, to figure out how well the thing did. And here are what the curves look like. So each of these curves are if you did gene expert instead of smear and the lower darker curve is if you did gene expert on top of smear and it looks at the ICER's incremental cost effectiveness ratios and basically every one of them is above the threshold where the country was willing to pay to a vert one tuberculosis case. And so it's really good. It adds cost on the front end and it saves cost on the back end. And the conclusions of this paper were that the experts likely to be more cost effective than smear microscopy and clinical diagnosis. And if it's maintained as it is, expert has the potential to substantially increase TB case detection. And now we have some new mathematical models of based on actual real world interventions in South Africa that it will do that. And that's very exciting for people like me. Now another aspect of this test is the rapidity of the result compared to current system and the portability. So it's available now being sent out to district health centers. Now these guys, if any of you have worked overseas, you know that these people travel to get their tests done maybe for a day or two from their village. They have to take away from childcare, their other kids. They have to stop working in the fields, whatever they're doing to get there, to get their lab tests and they get it done and then they leave. And they may or may not ever be found again to deliver their results and meantime they're spreading disease to their family and cohorts back in their own village if they are positive. So if you put the system on a van or have it locally available at the district health center, while they're still there, you can give them the answer and start them on their drugs. And so the question of this Lancet paper that was published last year was, could those local health centers that really have no skills that never did TB testing before actually learn to use this instrument? And so what they did was they took two sites, a site where they introduced smear reading and the gene expert together at the same time. So this is a local clinic where nobody had done any lab, nothing. And then they took a very experienced smear lab and established the gene expert there and trained them. And these are the sensitivity compared to culture and what you see is that the new guys learning smear, their sensitivity for smear was pretty poor but even the reference lab smear compared to culture was only 42% which remember I told you HIV patients and children et cetera, the smear's not that great but the gene expert sensitivity to culture 87% and even in the very established smear lab they were only 56% positive with their smears and the gene expert about the same. So that shows that people without any prior lab experience or training can be trained to do this test well and as well as anybody else can do it. Now how well does it work? This is a big meta analysis that was published in I think in 2010 looking at a number of different sites, all different papers that were done and these are the sensitivity and the specificity and what you see is the sensitivity hovers in the about 90% range and up for most sites and the specificity is basically really great because there just aren't very many false positives with that whole five molecular beacon system. This was published in Lancet last year looking at case detection rate increased by greater than 30% but this is the key thing. This is the proportion of cases detected and this is days. So this is 90% of cases detected within the first two days here using the gene expert. If you sent the samples off to be done in a midget liquid culture system you get up to 100% since that's the gold standard and you get that at about 35 days and if you look at microscopy, your sensitivity is lower but it's fast, it's equally fast as a gene expert but if you look at solid culture you get 89% of the patients at greater than 100 days. It's pretty pitiful that these patients are waiting for those results or never get them or die before they get them and this smaller graph on the inside is actually the positive patients where it looks even worse. By the time they get their drug sensitivity test it's over 120 days and they're still only getting maybe 80% of them or something like that. So it's a major difference in time to positivity. So in 2012, WHO reviewed it and basically came up with a statement that added value to conventional methods was significant. The quality of the evidence was moderate but desirable versus undesirable effects highly favorable, et cetera. So it really put a stamp of approval on their previous endorsement. Now one of the beauties of this system is you can use it on samples other than respiratory and here's a meta-analysis from a whole lot of different things. Tissue, spinal fluid, gastric, stool, et cetera, urine. And what you see is that somewhere above around 80% sensitivity and some samples work really well, others don't work so well, but nevertheless it can be used for other things. So now we have them on vans, mobile vans. Here's a gene expert in the back of a van. They used to do smears there so they had a laminar flow safety cabinet and now you don't need it because for this you don't need a safety cabinet. You can do it on an open bench. And they even bring patients in by showing movies on the side of the van at night so that they have something to look at. They'll show health movies first and then they'll show a more fun kind of movie to keep the patients happy. And in Tanzania there was one called the Tututester in Cape Town, South Africa. And what they've found now as published by Catarina Boehm is that this is the validation and implementation stage of time to treatment and with smear positive, culture positive patients, it's not too different, but with smear negative, culture positive patients, the gene expert brought that right back down to what it would be for smear positive, culture positive. And for multi-drug resistant patients, the gene expert is gonna work just as well because we detect that rifampin resistance at the same time we detect the tuberculosis. Whereas the routine kind of test, this is the routine kind of test, which would be the Hain test. And the reason it takes so long, which is average days, something like 80, is because it's sampled, sent somewhere else and then batched and run in some giant laboratories somewhere. So there's a website if people are interested for the high burden work. It's called Cepheid Cares. And that's it on TVN. Michelle asked me to say something about the next test coming along for this platform. So I thought I would just briefly mention to you that the Chlamydia trachomatis nicere gonorrhea cartridge is CEIVD, so it's being used in Europe and everywhere else in the world and it's currently in the FDA now. So this is an old poster about sexually transmitted infections. This is sexist, it's from the 1940s, you know? Exactly, it's a terrible poster. But we have an answer for this problem. And this is the US from CDC and what you see is that Chlamydia is going up for males and females, but nicere gonorrhea is actually kind of dropping down, but that doesn't mean it's gone. So we want a molecular test to detect both Chlamydia and gonorrhea. We use molecular tests now in the US, it's a standard, but we batch them. Do you know that our laboratory at Stanford only runs them once a week? If you went into student health and you were worried about STD, you're gonna wait a week to get your answer, whether you have it or not. This thing takes an hour. So it's a stable design, it works, it's random access, et cetera. And it has collection vial and again, you just put the sample like a swab into here. One of the beauties of it is a self-collected vaginal swab, so that's gonna be great where there's no doctor, the woman can just collect her own. And she does a better job actually than an endocervical swab collected by a physician under speculum exam. And then you can just put the sample into the cartridge and run it. And these are preliminary data, well, from the CEIVD product, and you can see that for urine's males and females, the sensitivity and specificity for both Nigeria and Chlamydia are really, really great. And for female swabs, endocervical and self-collected, the sensitivity and specificity are really, really great. So the bottom line is that the nucleic acid amplification testing that we've been promising for more than 20 years is finally available for everybody, it can be done. It's the standard, not just in US, but overseas. And my boss likes to say what works in the third world works on the third shift. And you're benefiting from that here at Stanford because this is the system being used to test C difficile here in the hospital core lab. So we have a one hour stat turnaround time for clostridium difficile from liquid stool and that's using the same system. And these kinds of results improve patient care and save money. And this is training that we did on the gene expert in Panampen, Cambodia, where there's probably now 12 or 15 instruments being used for TB diagnosis. That's it, thank you. So I'm happy if anybody has any questions. And the second question is, how do you still get around the gastric aspect for children? Do you do it on school because there's been a lot of people that have stool in children? Yeah, so sustainability is an issue in developing the world for everything. You go there and you visit a lab and there are instruments in boxes that were never opened. There's instruments sitting there and reagents that expired three years ago that were never used. It is a huge issue and I'm with you 100% on that. And one of the reasons that one of the things we're working on with this system is something called remote calibration. It's going to be rolled out in South Africa. So it's not only that through the cloud we're going to be able to look at the systems and monitor their performance. They're going to be monitoring all the internal controls, plus how many tests were done, plus how many positives and negatives were done. And if we see problems, we can earmark that particular laboratory for intervention before something horrible happens. So that's going to be rolled out this year. And the remote calibration will allow laboratories to do their own calibration. They won't have to have a maintenance person come visit them once a year to swap out the modules if they don't need to be swapped out. But I think administrative oversight is key in every introduction of technology. And that's one thing South Africa is really doing well is they have hordes of people who are responsible for this thing and trained to do it. And I agree with you, it always is going to be an issue. And I don't know how well it will continue to work. But we've had these systems out. The one in Mumbai, India, has been there for like five years. It's never had a problem. It just turns out results. There are very few moving parts in the thing. It's not like these big robotic instruments that we use in the United States. It's very simple concepts. And so they don't seem to break down as easily as they used to. But we do have distributors everywhere, and WHO, UNIDADE, is committed to keep these things up and running. I can also tell you that in Cambodia, remember, I told you we have to incentivize techs two bucks to read a smear. They love running these things. They stay late, which is unheard of because they all have another job where they actually make enough money to live on. They stay late to finish the run because they love getting the results and feeling in control of them. So it's really a cool thing. So the second question was about children. We have a lot of studies. David Alland at Robert Wood Johnson School in New Jersey is one of the developers of the TV assay. And he has several NIH-funded projects looking at spinal fluid, gastric aspirates, and stool to optimize the use of this system. So we're looking at magnetic beads for concentrating new organism, NEOS. And Rob Lowe, our global fellow at Stanford Pathology Lab, is looking at the use of a magnetic bead to try to concentrate the tuberculosis organisms in these kind of more difficult samples. But we don't have the answer yet. And the problem with stool and gastrics is the numbers of TB in there is low compared to the volume. And this thing can accept 2 mils. And that's how we run spinal fluid. We throw 2 mils of spinal fluid right into the cartridge. That's more than any other molecular test. Mostly you put in 20 microliters or something into any amplification. This pushes through a lot more. It's still a problem. And there are a lot of people working to try and optimize it. Other comments or questions? Yeah. Yeah, what you do is you can have a solar battery and fill up a small battery off the solar battery and then run it. Or you could run it off of a car battery. We've set it up off of boat batteries. For Greenland, I think we're going to actually be sending a boat down around the coast and running it off of a boat battery. It doesn't need much oomph. And it only has to run for 70 minutes before it's finished its run. Obviously, there's a capacity issue there. If you have a four unit, you've run four and 70 minutes. You're done. But we have a small laboratory in Uganda where a very enterprising young technician guy set up a solar panel on the roof of his little hut and has it running down into some kind of battery. It looks like a Rube Goldberg device. But it's running being an expert there. So yeah. Yeah? I'm wondering how golden is the gold standard of a liquid culture? It's better than solid culture. So it's probably as good as it gets, except for, say you're a patient and you're taking antibiotics and your bugs are somewhat degraded but not killed. Then the culture may be negative, but the molecular test may be positive. So what we don't know is if the bugs are totally killed and the antibiotic is working well, the molecular test may be positive because dead bugs amplify the same as live. So we have several projects working on looking. There's, I don't know if you know, there's a clinical path to new TB drug regimens, CPTR group, and they have a moxifloxacin study remox. And then there's something called 29x where they're looking at rifapendine versus rifampin to try to shorten the time to treatment. And we're running gene experts periodically looking at the cycle threshold numbers to see if we can determine earlier than in liquid culture whether increasing cycle thresholds, which indicates fewer organisms, is actually indicative of activity of the antibiotics. So we're looking at that. We're looking at integrating some kind of DNA inhibitor into the DNA before we amplify something like PMA or EMA, and they will intercalate with DNA. So if you run a gene expert and then use this stuff and run it again, only dead organisms won't amplify. And you'll be able to look at the live versus dead organisms, but it is an issue. And the same as with those phenotypic versus genotypic tests for resistance, who's right? You're gonna have to go look at patient clinical outcomes. And with liquid culture, the longer you're on an antibiotic, the more degraded the bugs are, but still maybe could recover in liquid culture, the longer it takes the culture to grow. Well, we stop it at eight weeks. We don't keep going. If we kept going maybe to 12 or 14 weeks, maybe some of those damaged bugs would suddenly grow, but there's a practical limitation to what you can do. So I don't think there's a true, true answer at this moment. I think patient outcomes is gonna be the answer and we love to have those kinds of studies done. Thank you. The preceding program is copyrighted by the Board of Trustees of the Leland Stanford Junior University. 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