issue 603 | july 2013 - association of clinical biochemists

In this issue

BiochemicalEndocrinology

WorkforceSurvey 2013

TenderingHavingNegativeImpact onPathologyServices

Appreciationto NeilFormstone

The Association for Clinical Biochemistry & Laboratory Medicine | Issue 603 | July 2013

ACBNews

About ACB NewsThe Editor is responsible for the finalcontent. Views expressed are notnecessarily those of the ACB.EditorDr Jonathan BergDepartment of Clinical BiochemistryCity HospitalDudley RoadBirmingham B18 7QHTel: 07973-379050/0121-507-5353Fax: 0121-507-5290Email: [email protected]

Associate EditorsMrs Sophie BarnesDepartment of Clinical Biochemistry12th Floor, Lab BlockCharing Cross HospitalFulham Palace RoadLondon W6 8RFEmail: [email protected]

Mr Ian HanningDepartment of Clinical BiochemistryHull Royal InfirmaryAnlaby RoadHull HU3 2JZEmail: [email protected]

Dr Derren ReadyMicrobial DiseasesEastman Dental HospitalUniversity College London Hospitals (UCLH)256 Gray’s Inn RoadLondon WC1X 8LDEmail: [email protected]

Mrs Louise TilbrookDepartment of Clinical BiochemistryBroomfield HospitalChelmsfordEssex CM1 5ETEmail: [email protected]

Situations Vacant AdvertisingPlease contact the ACB Office:Tel: 0207-403-8001 Fax: 0207-403-8006Email: [email protected]

Display Advertising & InsertsPRC AssociatesSundial Court, Unit 4 - Ground FloorBarnsbury LaneTolworthSurrey KT5 9RNTel: 0208-337-3749 Fax: 0208-337-7346Email: [email protected]

ACB Administrative OfficeAssociation for Clinical Biochemistry &Laboratory Medicine130-132 Tooley StreetLondon SE1 2TUTel: 0207-403-8001 Fax: 0207-403-8006Email: [email protected]

ACB PresidentProfessor Eric KilpatrickDepartment of Clinical BiochemistryHull Royal InfirmaryAnlaby RoadHull EH17 7QTTel: 01482-607-708Email: [email protected]: @ACBPresident

ACB Home Pagehttp://www.acb.org.uk

Printed by Swan Print Ltd, BedfordISSN 1461 0337© Association for Clinical Biochemistry &Laboratory Medicine 2013

ACBNews

General News page 4

Current Topics page 6

Practice FRCPath Style Calculations page 11

Meeting Reports page 12

Letters page 19

An Appreciation page 20

ACB News Crossword page 21

Situations Vacant page 22

Issue 603 • July 2013

The monthly magazine for clinical science

Issue 603 | July 2013 | ACB News

Front cover: Rick Jones, Nikki Williams and Steve Goodall at this year’sFocus Fringe

EuroLabFocus

The Patient &Laboratory MedicineLiverpool, UK • 7-10 October 2014

Launch IF AntibodyTest MHRA AlertDeterioration in the activity of affected lotsmay lead to false negative results outside ofthe manufacturer’s claims for performance(61.2% sensitivity). A false negative couldresult in a delay in diagnosis or treatment ofvitamin B12 malabsorption. Laboratoryinternal quality control systems may not detectthis deterioration. Orgentec have pointed toaffected lots: 24723031 and 24723945.This lot has also shown a deterioration inactivity in a recent UK NEQAS Haematinicsdistribution. The action you should take: donot use devices from the affected lot; considerthe need to review previous negative resultsfrom tests performed using the affected lot;and where results are inconsistent with theclinical picture, samples should be retestedwith a different lot number. It may benecessary to arrange for repeat samples.For further details, or to request replacementstrips for retesting, contact: Ms Louise Knight,Launch Diagnostics Ltd, Tel: 01474 876 402Email: [email protected] �

4 | General News

ACB News | Issue 603 | July 2013

Sudoku

Lastmonth’ssolution

General News | 5


ConsultantClinical ScientistAppointmentsThe ACB strongly supports the use ofaccredited Royal College of Pathologistsassessors in the appointment process of anyconsultant grade clinical scientist (AfC Bands8c, 8d and 9). Employing authorities arerecommended to seek the advice of one ormore national assessors, both on theagreement of the job description for thepost and on the calibre and suitability ofcandidates.Further guidance is available through the

College website at:http://www.rcpath.org/workforce/medical-workforce/consultant-clinical-scientist/ �

Michael ThomasAssessor Lead for Clinical Biochemistry

Policy On Letters toACB NewsWe have a clear editorial policy on ACB Newswith regard to publishing letters where thewriter does not want their name published.We are prepared to do this as long as thewriter(s) are happy to give their names to theACB News Editor and the content is felt towarrant a name and affiliation beingwithheld.This month a reader, who is also a

senior practising member of the profession,has wanted to speak out about tenderingand the impact on services and ACB Newsis happy to publish this without namingthem. �

We have previously reported in detail onthe proposed tendering process in the East& West Midlands (ACB News 594, 595, 598,599 – all available on www.acb.org.uk).Clearly things are not going entirely toplan and there is now considerablediscussion and conjecture about what ishappening behind the scenes.

Some Clear Facts . . .

The proposed three-lot tender had a PQQresponse phase that closed on 1st March 2013.The bids were assessed and a number ofbidders contacted and told they wouldproceed to the Invitation to Tender (ITT),commencing May 2013. This deadline was notmet and indeed a second deadline of the endof June has also been missed. Bidders havebeen told that the ITT will now be issued bythe end of July, and the deadline for receipt oftenders extended to mid-October.During the last few months there have been

several communications with NHS Trustproviders of Pathology services asking foradditional information. This has includedworkload figures and also questions designedto give an impact assessment on providers ifthe tender means that they no longer offerpathology services to Primary Care.Analysis of the Strategic Projects Team

website also sees some interesting changes.Certainly marketing communication activityhas been curtailed and Richard Dolby, whobecame Commercial Manager for theTransforming Pathology Programme in August2012, has moved on. Richard was, for a shorttime, a key public face for the process,speaking at events such as the Health ServiceJournal meeting in London last autumn.Richard is now working with the TransformingPathology Partnership (TPP), the hub and

spoke model which includes seven Trusts in theEast of England, centred on Addenbrooke’sHospital.

Why the Delays?

A number of sources suggest that now theCCGs have taken over there are questionsbeing asked about the desirability ofcontinuing the process. One GP member of aCCG board has told ACB News that there aremany other much bigger issues to consider,explaining: “GP Board members arequestioning why this tendering is occurringwhen they are happy with the way theirPathology services are provided, but GPmembers are in the minority on the Board”.Another source has suggested that CCGs

who feel they currently get excellent value arenot happy that the cost of their pathologyservices may actually increase substantially dueto tendering. Certainly we are aware thatsome provider Chief Executives have beencontacted by CCGs who are looking to pull outof the process before it moves on to the nextstage

Detrimental Impact on PathologyThere are many signs that the tender processand the delays and uncertainty are having adetrimental impact on pathology provision.One Trust told ACB News that a detailedbusiness case requested by their local CCG forintroducing BNP testing is now “on hold untilafter the tendering process is complete”.A number of laboratories are experiencingserious situations with staffing and this is inpart put down to the tendering and all theuncertainty that it is bringing within theworkforce. This is impacting on the ability tooffer out of hours services, and one laboratoryreports that managers are having toparticipate in the out of hours rota.

6 | Current Topics


Midlands Tendering DelaysCompromising PathologyServicesBy our Central England Correspondent

Burton Hospitals has recently issued a noticeto award a five year contract for the hospitalbased pathology once the East and WestMidlands tendering process is completed.However, this potential opportunity issomewhat compromised with the statementthat “the Authority is engaged indiscussions…to join a RegionalAlliance...therefore there can be no guaranteeof award in this procurement exercise”.One has to ask what the commercial sector

are thinking of all this. Assurances that theEast & West Midlands tender process wouldrun to time made last February have alreadybeen broken. Commercial companieslooking to enter or increase their marketin UK pathology are spending millions ofpounds on tender preparation and clearly thisbrings considerable pressure for the processto proceed in some way. The negativeimpact of the three Leicester CCGs pullingout of the process before the PQQ processbegan sounded alarm bells to some lastFebruary.

Pathology Experiment . . . Uncertain

Outcome & Political DimensionThe impact at a professional level is clear withlaboratories that previously worked welltogether now very guarded on how theyinteract. There is evidence that wastefulduplication of specialist services is beingre-introduced as part of the jockeying forposition. Attracting staff to the Midlands towork in pathology has never been easy andthe uncertainty that tendering has broughtonly makes this harder. Whether it proceeds ornot, the impact of the uncertainty it hasintroduced is now a serious managerialchallenge for an increasing number of Trusts.So, it is very much “watch this space”.

The public outcry in Essex over the East ofEngland pathology tendering was surprisingand had a significant impact. One has towonder how the current delayed process willsit politically with a coalition government thatwill soon be turning its attention to thebuild-up to a general election and looking toplease, rather than annoy, potential voters. �

Current Topics | 7


The ACB Office maintains a database fromwhich the ACB Workforce Advisory Committee(WAC) compiles workforce statistics. In recentyears this has been supplemented by “Lost,New & Vacant post” surveys, the first beingperformed in 2006 and subsequently in 2007,2009 and 2010. The 2006 survey showed thenumber of lost posts was exactly balanced bynew jobs created, a situation that has not beenrepeated since; all subsequent surveys haveshown that more posts were being lost thancreated and the only differentiating factor isthe rate at which those posts were lost.In early 2013, the survey was repeated due

to the perception that the situation hadprobably not improved. The survey was sent to181 ACB members, of which there were 91responses (50.2% response rate, down onprevious rates of ~75%). The general datacontained within detailed the current status of580 Clinical Scientist/Chemical Pathologist staffmembers. This accounts for 74% of theestimated total workforce (not inclusive of SpRstaff), as determined from ACB workforce datacollected in January 2013.Of the 91 respondents, 46 (50.5%) reported

that there had been no change to theirworkforce in the preceding two years. TheTable below illustrates the main findings ofthe 2013 survey, and presents data from 2010for comparison. This covered the preceding 2year time period; lost was defined as “vacantfor >6 months and not advertised”, whilevacant was defined as “remaining unfilled >3months after being advertised”.

Where posts were lost, respondents wereasked to state the AfC band and the reasonthe post was lost. It will come as no surprisethat band 8 and 9 comprised the most posts,although there were 11 band 7 posts lost too.However, the reasons for higher grade postspredominating are reflected by the fact thatmost were lost due to re-structuring to lowerpay bands. Figure 1 illustrates the comparisonbetween surveys for the loss of posts.

As illustrated in Figure 1 above, the mainreason posts were lost in 2010 were due tofinancial constraints, however, conversion to alower pay band was the main factor in 2013.Although varied, reasons provided for

vacant posts mainly reflected either a lack of

8 | Current Topics


Workforce Survey 2013Adrian Miller, Chair, ACB Workforce Advisory Committee

Figure 1. Reasons for lost posts in 2010 and 2013

Lost, New and Vacant Posts in 2013 Compared with 2010

Lost 47 78New 37 30Vacant 18 14

Net effect -10 -48

2013 Survey 2010 Survey

suitable candidates (higher band posts) orshort, fixed-term contracts possiblydiscouraging people from applying (Band 6& 7). This is supported by anecdotal evidencethat trainees are choosing to leave theprofession rather than take on a temporarycontract in the hope that another opportunitywill present itself in the interim.

Trainee Losses

The current survey shows that, whilst there isstill a net loss of posts, the severity haslessened compared with previous surveys.The data also show a change in the factorsinfluencing changes to the workforce, possiblyreflecting an active drive to maintain posts atlower pay bands while consolidatinglaboratory medicine into “Blood Science”departments.Although not reflected in this survey, a

worrying development in laboratory medicineis the number of trainees who choose to leavethe profession near the end of their trainingbefore their contract expires. Trainees leavingthe profession is not a new phenomenon,WAC data has previously demonstrated anattrition rate between 10 and 20%. However,a recent poll of Regional Tutors has shownthat, in the past 2 years, 12 Biochemistrytrainees have left to pursue other careers dueto a lack of progression opportunities. This ontop of data showing that, in September 2013,25 trainees are at risk of being lost to theprofession if they can’t obtain a substantivepost in the interim. The problem is not limitedto Biochemistry; Clinical Microbiology andImmunology are suffering from a similar fate.This presents a great deal of waste in timeand resources, as well as the negative humanimpact. It seems self-defeating to invest somuch in a workforce who, due to lackof progression opportunities, aren’tsubsequently utilised and allowed to make

what would undoubtedly have been a positivecontribution to the profession.

Professional Brain Drain . . .Or Refreshing New Blood?

A concern also raised by the survey is thedegree of expertise and level of experiencethat are seemingly being squeezed out of theprofession. Whilst WAC is grateful to anyonewho has strived to maintain a post through re-banding, evidence suggests that previousincumbents of such posts are being lost to theprofession, whilst relatively inexperiencedpeople are taking their place. A case in point isone Trust in England who replaced 3 Band 8posts (combined experience of previousincumbents >100 Biochemist Years) with 3Band 7 posts (combined experience ofsuccessful candidates ~15 Biochemist Years).While fully appreciating that we can’t havethe best of both worlds, as a profession wemust be aware of this “Brain Drain” andensure that measures are taken to maintainthe breadth and depth of knowledge ofClinical Scientists by actively supportingparticipation in any beneficial trainingopportunity.Finally, for any workforce planning to be

effective we need good workforce data.There is a current drive by the College, DoHand Health Education England (HEE) toimprove the quality of workforce data, so as tofacilitate improved staffing, education andtraining planning in the new NHS landscape.The ACB has received praise from manyquarters in the past about the quality of ourdata and, whilst it is viewed as exemplar bythe College compared to other professions’,it is by no means perfect. To help with this,it would be appreciated if ACB Memberswould ensure their details on the ACB website(and in their local ESR) are as accurate aspossible please. Thanks. �

Current Topics | 9


10 | Current Topics


A media workshop organised by Sense AboutScience and sponsored by the Association forClinical Biochemistry was recently held in theUniversity of Glasgow. This full day eventintroduced early career researchers to ‘thegood, the bad and the ugly’ aspects of dealingwith the media. Speakers from both sides ofthe fence were invited to ensure awell-rounded discussion.‘Science and the Media’ was first on the

agenda. This session included talks fromexperienced members of the scientificcommunity. The discussion focussed on therole of science and scientists in the publicdomain and what happens when things gowrong. Dr Eleanor Gilroy from the JamesHutton Institute spoke of her work ‘undoingthe damage’ the media has caused regardingthe public’s perception of genetically modifiedcrops. Professor Miles Padgett from theUniversity of Glasgow gave a positive accountof his experience with the media. TV and radioappearances over the years have allowed himto promote his research to as wide an audienceas possible. His advice to young researcherswas: be prepared, know your facts and viewthe media as a means of promoting your work.

Working with JournalistsProfessor Sergio Della Sala from the Universityof Edinburgh warned of the misuse of themedia and commented that the scientificcommunity may be contributing to themisrepresentation of science announcements.He emphasised the importance of knowingyour facts and discouraged the release of pressstatements on ‘what you are about to do’rather than ‘what you have done’ and ‘whatyou have found’. Group work allowed furtherdiscussion of the topics of the day as well as achance to interact with young researchersfrom various scientific backgrounds.The afternoon session gave the journalists an

opportunity to fight back. The audience

gained an insight into the difficulties and timepressures faced by both newspaper and TVjournalists. Peter Ranscombe from TheScotsman encouraged young scientists toapproach journalists directly to get their voiceheard. Julie-Anne Barnes from the Daily Mailurged the audience to provide clear andconcise information to ensure that theirresearch is not ‘lost in translation’. The BBCScotland’s Health Correspondent EleanorBradford explained that direct quotes fromrelevant sources are a key component ofbreaking news stories. She emphasised thatthese quotes do not necessarily have to comefrom the most senior member of aDepartment and that young researchersshould not be afraid to engage withjournalists early on in their career.The last session of the day provided

guidance on how early career researchers canget involved and ‘Stand Up for Science’.Ross Barker, the Media Relations Officer atthe University of Glasgow, explained the workthat he does bridging the gap betweenresearchers and journalists. He encouraged theaudience to work with press officers topromote their work to the general public.Jaime Earnest, a Voice of Young Science (VoYS)representative, and Victoria Murphy fromSense About Science urged the audience tocomment on ‘bad science’ and to ‘ask forevidence’ when scientific claims are made inthe media. There was an introduction to thework the VoYS network does and informationon how early career researchers can getinvolved.

Go On – Get InvolvedThe workshop provided useful hints andtips on the successful communication ofresearch to the scientific community andbeyond. For more information on the VoYShow to get involved visitwww.senseaboutscience.org/voys �

Standing Up for ScienceMedia WorkshopGemma Gallacher, Southern General Hospital, Glasgow

Practice FRCPath Style Calculations | 11


An HPLC mobile phase is normally prepared by mixing 27 mL methanol and 20 mL acetonitrilewith 153 mL of ammonium acetate buffer. You only have 120 mL of buffer. How much methanoland acetonitrile would you add in order to prepare the maximum amount of mobile phase?

This is a simple exercise in proportionality – as taught in primary school!

153 mL buffer requires 27 mL methanol

therefore 1 mL buffer requires 27 mL methanol153

and 120 mL buffer requires 27 x 120 = 21.2 mL methanol (to 3 sig figs)153

Similarly 153 mL buffer requires 20 mL acetonitrile

therefore 1 mL buffer requires 20 mL acetonitrile153

and 120 mL buffer requires 20 x 120 = 15.7 mL acetonitrile (to 3 sig figs)153

Deacon’s ChallengeNo 146 - Answer

Question 147It has been suggested that a simple delta-check using serial plasma creatininemeasurements be used to detect acute kidney injury (AKI). If the within-subject biologicalcoefficient of variation (CV) for plasma creatinine is 5.0% what minimum analytical CV isrequired to detect a percentage increase in plasma creatinine of 20% with 95% certainty?

P(%) 10 5 2 1 0.2 0.1

z 1.65 1.96 2.33 2.58 3.09 3.29

FRCPath, Autumn 2012

The Royal College hosted a joint meeting withthe ACB on biochemical endocrinology on asunny day in early March. A balance of lecturesand interactive teaching sessions providedmany learning points to influence clinical andlaboratory practice.Dr Graham Beastall began with an update

on the work of the International Federation ofClinical Chemistry towards the standardisationof thyroid function tests (TFTs). Despite beingpart of routine laboratory services for over 30years, method-dependent differences remainsignificant. Dr Beastall highlighted the impactthis has on public confidence in the use of TFTsto diagnose and manage thyroid disease. Thedifferences between standardisation(achievable for free thyroid hormones) andharmonisation (applicable to TSH) wereexplained. Recalibration would improveconcordance across methods, but alignment tothe conventional reference measurementprocedure for free T4 (fT4) would involve asignificant shift in reported fT4 values. WhileTSH harmonisation may be ‘coming soon’, thefuture for free thyroid hormonestandardisation remains less certain.

Reference Intervals for Thryroid Function

Dr Julian Barth then asked the question,‘What are abnormal TFTs?’ and set the scenewith a show of hands to highlight that only aminority of the audience were usinglocally-generated reference intervals. Dr Barthshowed that nationwide variation in TSHreference intervals cannot be fully explainedby differences in assay performance, andpopulation values follow a remarkably similardistribution across multiple methods.Harmonisation of TSH reference ranges shouldtherefore be achievable, however, the mostclinically relevant upper-limit-of-normalremains controversial. The data suggestedharmonisation of fT4 reference ranges is likely

to be particularly challenging with currentbetween-method differences.Professor Richard Andersen gave an update

on the clinical utility of measuring anti-Müllerian hormone (AMH) in women. Heexplained that much of the evidence for its usestems from studies in assisted reproduction,and it is not yet certain whether AMH canfulfil its potential as the ‘crystal ball’ of femalereproduction. AMH is an effective biochemicalpredictor of response to ovarian stimulation,and is also an independent marker for theoverall success of assisted reproduction cycles.This has promoted its reputation as a markerof ovarian reserve, so it was interesting tonote that high AMH levels are in fact linked toa delayed time to pregnancy in healthy youngwomen, which may reflect patients withpolycystic ovarian syndrome (PCOS).Furthermore, although there is a link betweenAMH and age at menopause, wide variabilitylimits its use in predicting menopause forindividuals. Improvements in assayperformance will be required if AMH is to beused routinely in this area.

Vitamin D in Chronic Disease

Professor Bill Fraser and Professor NaveedSattar then discussed some of the ‘knowns’and ‘unknowns’ of vitamin D deficiency,emphasising the lack of convincing evidencefor a causal role in many chronic diseases.They reminded us that many vitamin D ‘facts’often seen in the press are based onassociation studies, and there are moremeta-analyses than randomised controlledtrials in this area. We were shown how thebasis for commonly-accepted treatment targetlevels is controversial, and reminded of thepotential risks of high-dose supplementation.Professor Fraser showed data demonstratingthat parathyroid hormone (PTH) levels varywidely with vitamin D concentration,

12 | Meeting Reports


RCPath & ACB Meeting onBiochemical EndocrinologyDavid Church and Olivia Bacon, Addenbrooke’s Hospital

illustrating the problem of using PTH as asurrogate marker for vitamin D status. VitaminD requests continue to increase and many areinappropriate. It was useful to hear that aguidance document from the NationalOsteoporosis Society/Institute of Medicine willsoon be available for circulation in primarycare.After lunch, attendees were given electronic

voting handsets for an interactive session onhyperandrogenism and PCOS led byDr Danielle Freedman. Diet and lifestyleshould be considered the mainstay oftreatment for PCOS, as illustrated by a case ofmarkedly raised testosterone (confirmed bytandem mass spectrometry) and hirsutism in afemale which improved dramatically followingweight loss. We were reminded of the linkbetween PCOS and hyperinsulinism, and thatmetformin can help regulate menstrual cycles.Dr Claire Higham then gave an update on

the current best treatments for acromegaly,and pointed out the dependence onstandardised growth hormone and IGF-1

assays for assessing response, with currentchanges to IGF-1 assays being a particularconcern. There was a further interactiveclinical case session, with Dr Kevin Deans andDr Freedman presenting a case of ectopicACTH-driven Cushing’s syndrome and a case ofprimary hyperparathyroidism in pregnancy,respectively.The day ended with a debate, ‘This house

believes that the future of hormonemeasurements lies with tandem massspectrometry, not immunoassay’, withDr Sandra Rainbow speaking in favour of,and Dr Richard Chapman against, this motion.The room was almost equally split on the issueat the start, and remained so after twoinformative talks.This was an excellent update on current hot

topics in biochemical endocrinology. The issuesdiscussed highlighted the importance of assayperformance in clinical decision-making andemphasised the role of the laboratory inguiding rational test requesting and in leadinginitiatives towards result harmonization. �

Meeting Reports | 13


Albeit briefly, Spring was in the air on whatwas the first scientific meeting of the year forACB Scotland. Held under the shadow ofStirling Castle in the historic city of Stirling,the ‘brooch that clasps the Highlands andLowlands of Scotland together’, the meetingwas devoted to matters of the heart andlaboratory informatics.

Sensitive Heart TestingThe day began with an informativepresentation from Dr Nick Mills (EdinburghRoyal Infirmary) outlining recent researchduring the implementation of a highsensitivity troponin I (hs-TnI) assay. Heprovided evidence that use of hs-TnI with alowering of the diagnostic threshold from0.2 ng/mL to 0.05 ng/mL was associated with a29% increase in diagnosis of myocardialinfarction (MI) and subsequent improvementin morbidity and mortality in patients withacute coronary syndrome (ACS). It was shownthat patients with TnI concentrations between0.05 and 0.19 ng/mL have the worst clinicaloutcomes and are at greater risk of a furthercardiac event compared to those with a TnIless than 0.05 ng/mL or greater than 0.2ng/mL. When the diagnostic threshold isreduced to 0.05 ng/mL there is a decline in therisk of death and recurrent MI from 39% to21% potentially due to increased referrals forspecialist advice and treatment.Implementation of the high sensitivity assay

and the diagnostic reclassification of patientsare associated with improved clinicalmanagement, including increased specialistreferral, coronary angiography and anti-platelet therapy, fewer deaths, and feweradmissions with recurrent MI.The consensus statement on the universal

definition of MI recommends that an increase

in plasma troponin concentration above the99th centile of a normal reference populationis used to confirm the diagnosis, irrespective ofwhether the coefficient of variation is lessthan 10% at this concentration. This wouldidentify more patients with ACS at risk ofrecurrent MI and death and would increasethe diagnosis of MI by 47%. Dr Mills indicatedthat gender-specific thresholds less than 0.05ng/mL may be helpful in identifying morefemale patients with ACS. He concluded bydiscussing these gender-specific differences inhs-TnI measurements and the ongoing BHFHighSTEACS trial investigating this.

Heart FailureDr Bernie Croal (Aberdeen Royal Infirmary)described the use of BNP and NT-proBNP in thediagnosis and monitoring of heart failure.These have a high negative predictive valueand can be used in the assessment ofsuspected chronic heart failure. He describeda pilot study carried out in NHS Grampianmeasuring NT-proBNP in patients withsuspected heart failure as a decision-point forreferring patients for echocardiogram.Using a cut-off of 400 pg/mL, 52% of patientsavoided an echocardiogram. Furthermore,20% of patients had an NT-proBNP greaterthan 2000 pg/mL and were prioritised for anurgent echocardiogram.Despite the apparent advantages to be

gained by implementing NT-proBNP, Dr Croalacknowledged the difficulties in obtainingfunding for the introduction of newlaboratory tests in the current financialclimate. He highlighted the importance ofevaluating any new test by looking at itsefficacy (i.e. can it work?), effectiveness(i.e. does it work?) and efficiency (i.e. is itworth it?) to build a defensible business case.

ACB Scotland SpringScientific Meeting - The Heartand Laboratory InformaticsRebecca McCann, Kirkcaldy & Laura Willox, Glasgow



Dr Kevin Deans (Aberdeen Royal Infirmary)concluded the morning’s discussions with anentertaining overview of cardiac risk factorswith respect to “where we are” and “wherewe are going”. This took us from risk scoringsystems to the current available evidenceregarding use of specialised lipids andinflammatory biomarkers in determiningoverall risk and need for treatment. Overall,the morning session provided an interestingupdate on some of the progress being madewith current and novel cardiac biomarkers.

Laboratory InformaticsThe afternoon began with a look at theimplementation of TrakCare in NHS Lothianby Dr Sara Jenks (Edinburgh Royal Infirmary).TrakCare, a healthcare information system,was introduced eight years ago to NHS Lothianas a pilot site and is currently being rolled outto five additional NHS Health Boards acrossScotland, serving approximately 70% of theScottish population. Dr Jenks gave acomprehensive overview of the functionalityof the TrakCare system and, interestingly,a user’s perspective of some of the problemsand advantages encountered with its use.By considering some of the difficultiesencountered when using TrakCare, she gavean insight into some of the factors that shouldbe considered when building a TrakCare system,how important it is to get small details rightfrom the start and the importance of laboratoryinvolvement in the setting up process.

Primary Care OrderingJim Allison (Aberdeen Royal Infirmary)continued the theme with an account oflaboratory Order Communications in PrimaryCare within NHS Grampian. A great numberof benefits both to users and the laboratoryhave been realised with its recentintroduction, which has eased the requestingprocess and provided a ‘quantum leap’ in thequality of requests received by the laboratory.This has had a knock-on effect in improvingthe workload management within thelaboratory.Both of these presentations enlightened

what can be quite a ‘dry’ subject-area andhighlighted the importance of laboratoriesbeing involved as much as possible in an ITproject from initial planning discussions toretaining control and input into aspects of theordering and reporting system e.g. creatingtest names, developing order sets andoptimising the display of results and commentsto users.The day came to a close following an

overview and update from Charlotte Fifield(Glasgow Royal Infirmary) and Kelly Smith(NHS Lothian) on the progress being made inScotland with regards to Pathology Harmonyand the Clinical Portal, which is a ‘virtual’electronic patient record that can be accessedacross the various Health Boards in the Southof Scotland. �





The ACB Northern Ireland and Ireland meetingwas held this year in the Elliott Dynes Building,a former Care of the Elderly Unit, in the RoyalVictoria Hospital in Belfast. Chair for themorning session was Dr Peter Sharpe(chairman of the NI section), who welcomedattendees from both sides of the border.

Network or No Network?

Jennifer Welsh, chair of the NI Pathologynetwork since 2010, provided a conciseoverview of the NI pathology network.This was officially launched on 20th October2009 and progress has been made onstrengthening our culture of evidence-basedpractice. This includes a regional screeningprogramme for familial hypercholestero-laemia. In December 2011, the DHSSPSNIreleased the ‘Transforming Your Care’document which was a review of local healthand social care. Jennifer highlighted theimportance of being mindful of this release,particularly recommendation 78, regardingimplementation of the pathology network, toensure that the interest in pathology ismaintained. Prior to this publication, theboard had no clinical members. Networkdecisions are made for the greater good andChemical Pathologist Michael Ryan is now thenetwork’s clinical lead. Positive news fortrainee scientists is that a new fund for theirtraining has been supported by the ChiefMedical Officer. When the network isprioritising potential projects, from the currentlist of 44, the aim is to reach a consensusamongst people actually delivering theservices.

Why is this Blood Glucose so Low?

Next was a highly instructive talk from GwenWark, Director of the peptide laboratory inGuildford. Her subject was insulin and theinvestigation of hypoglycaemia. She remindedus to think of proinsulin, as some tumours onlyproduce this precursor peptide. The mainclinical indication for measuring insulin levels

is in the work-up of hypoglycaemia, but it isbeing increasingly being requested in patientssuspected of being insulin resistance. TheJCEM guidelines from 2009 are the port of callfor those who would like further elaboration.Drugs, alcohol and critical illness are commoncauses. If both insulin and C peptide areelevated in hypoglycaemia, then the aetiologyis narrowed to sulfonylureas or insulinoma.To avoid confusion, it is crucial to clarifywhether the reference interval is for a healthyor a hypoglycaemic population. The bloodglucose is essential to enable resultinterpretation and she always measuresC peptide concurrently to check the source ofthe insulin. It can be helpful for insulin assaysto be less specific as tumours can produce100% insulin, 100% proinsulin or a mixture.ELISA can provide a quantitative result forproinsulin. The mainstay of insulin analysis,however, is the immunoassay and insulin wasactually the first substance measured by thismethod. Failure to appreciate the hook effectcan lead to falsely low results. Haemolysis isunfortunately a big problem as peroxisomeprotease, found in erythrocytes, degradesinsulin, but not C peptide. The enzyme’sactivity is much lower when frozen.Gwen presented some case scenarios,which illustrated various clinical pitfalls whenconsidering possible causes of hypoglycaemia.For instance, enzyme assays should be able todetect animal as well as human insulin.She also reminded us to consider the potentialaccess to insulin, e.g. a healthcare worker ordiabetic pets.

Help with Those Tricky Thyroid Results

There followed an illuminating presentationon unusual thyroid results, by local Trainee inEndocrinology, Dr Helen Wallace.She presented a case of thyroid hormoneresistance, an autosomal dominant condition,affecting only one in 50,000 live births. This isa rare condition where free T4 is elevated andTSH is normal or elevated. Next came a similar

Full of the Joys of SpringGiles Aldworth, Belfast



pattern, but with a different explanation. Thistime a TSHoma, showing a typically bluntedresponse in the TRH test. The patient’s resultsnormalised after treatment with pituitarysurgery. The final case was one of amacroadenoma presenting with bitemporalhemianopia, with post-op blood resultsindicative of primary hyperthyroidism. Thislady had been receiving enoxaparin for thetreatment of recent multiple pulmonaryemboli. Enoxaparin interferes with proteinbinding, thereby increasing free T4. TSH maybe an unreliable indicator in somebody withpituitary surgery.

Kidneys are Important Then . . .

Clinical scientist Peter Auld was up next,discussing the introduction of a scoring systemfor that oft neglected medical emergency,acute kidney injury. The idea is to highlight toclinicians results for which immediate action isrequired, but without “crying wolf”. Aboutone in five of all acute hospital admissionssuffer from this condition, which kills 200times more people than MRSA. The NCEPOD2009 report observed that only 50% of AKIpatients receive good care. Last November,there was a consensus conference at RCPEdinburgh, which emphasised that 12,000 livescould be saved a year, given optimal care. TheMDRD reversal technique was highlighted asan estimate of a patient’s baseline creatinine.A 10 day pilot study was performed in the RVI,which found 13 episodes of AKI, one of whichhad been missed by clinical staff. The pilotallowed improvement of the initial e-alertsystem, to ensure better visualisation. Thesystem has the potential to reduce morbidityand mortality. NICE have recently releaseddraft guidelines for consultation and in thewords of Donal O’Donoghue, “Don’t let themdie from AKI”. Why not download the LondonAKI app today?

Hypertension: Not Just Essential!

Marguerite MacMahon stimulated us with theutility of mass spectrometry in evaluatinghypertension. It has greater specificity thanthe more widely used immunoassay and canhandle complex mixtures, so many compoundscan be measured in just one run. It is slower

than immunoassay however, and requiressignificant sample preparation, for exampledilution or protein precipitation. A quarter ofthe Western population are hypertensive,meaning endocrine causes are more commonthan you might think. Mass spectrometry ismuch better at detecting catecholaminemetabolites than immunoassay and this ismore important than whether the sample wasplasma or urine (a useful 2013 discussion canbe found in Clinical Chemistry).Methoxytyramine, a marker of metastaticphaeochromocytoma, can also be measured.Urinary free cortisol can boast 100% recovery,with a turnaround time of only 2 days, and animpressive intra- and inter-assay CV of only3%. Finally, aldosterone and renin can also bemeasured and it is noteworthy that primaryhyperaldosteronism confers a highercardiovascular mortality when compared tothose with similar blood pressure.

To Screen or Not to Screen?

Next Jennifer Cundick talked about neonatalscreening. First she reminded us that the classicWHO screening criteria of Wilson and Jungnerwere not designed for neonates. Next came ahistory of neonatal screening locally, startingwith PKU screening in 1969, hypothyroidism in1981 and CF in the early 1980’s (cf 2005 for

Mike Ryan with Ellie Duly



remainder of UK). The introduction of tandemmass spectrometry at the tail end of the lastcentury led to a quickening of pace. MCADDscreening came in August 2009. She suggestedconsidering the combined prevalence ofinherited metabolic disorders whenconsidering the utility of neonatal screening.Food for thought was provided in the exampleof the benign condition histinidaemia, whenpatients were subjected to the significant risksof liver biopsies for little perceived benefit?

A Condition in its Screening Infancy

Screening for the autosomal recessivecondition sickle cell anaemia was introduced inNorthern Ireland in March 2012 (England: 2001and Scotland: late 2010) and we were given asuccinct overview of the story so far by GarethMcKeeman. Over 25,000 children have beenscreened to date and a case has yet to befound. The clinical consequences of thiscondition occur due to the hypoxicpolymerisation of HbS leading to painfulvaso-occlusive ischaemia. The method used ision-exchange HPLC, with the more positivelycharged measurands eluting later. Variants areconfirmed by isoelectric focussing. 18 SCcarriers have been found and 9 HbD carriershave been found; of note D-Punjab is the only

clinically significant variant. When consideringthe merits of screening, one must alwaysweigh up cost versus equality.

It is Time to Fight for ObesityTreatment

The educational components of the dayfinished with a bang, with the inimitablepresentational style of Dr Michael Ryan. Hewarned us of the rising prevalence of obesityand stated that it is the most significant healthproblem of this century. BMI is a tool prone toerror in individuals with higher than averagemuscle mass. It must not be glossed over thatobesity increases the risk of many cancers andincreases the risk of death and cardiovasculardisease. Abdominal obesity has been relativelyignored, when compared to its more popularcousins of smoking, diabetes andhypertension. If a person weighs 100 kg andthey manage to shed 10 kg, their risk of deathfalls by over 20%. Dr Ryan believes that apathological relationship with food is the rootcause and reminds us that excess calories arestored as triglycerides. Blood markers ofcalorie overload include GGT, triglycerides,LDL, HDL and CRP. The ubiquitous fatty livershould not be dismissed as a benignphenomenon as it is a serious predictor ofearly death. He mentioned somepharmacological treatments includinglorcaserin and the anticonvulsant topiramate.He also pulled out the statistic that about97% of type 2 diabetes is due to weight.He mentioned the incretin system and thediabetic drugs available such as GLP1 agonists.He recommended the Nature review article onthese hormones from 2006. He told us thatbehaviour modification really works andconcluded by reminding us of the potency ofweight loss: 6% weight loss has similar effectson HDL as fibrates and on LDL as ezetimibe.Bariatric surgery, he told us during thequestions, can reverse diabetes, but patientsdo need long-term follow-up and it is not yetknown the long term benefits.The final part of the day was a celebration

of two retiring chemical pathologyconsultants: Pooler Archbold and theaforementioned, Mike Ryan. �Clodagh Loughrey and Pooler Archbold

What is happening with tendering ofpathology services in the East of England andnow the East and West Midlands is nothingshort of scandalous. This whole process waschampioned as improving services and whilstthat may have been the intention it iscurrently destroying them.The reality is that with Trusts facing so much

uncertainty over the future of their laboratoryservices investment in pathology for many ofus has virtually dried up. This means nobuilding works and a fight for newequipment. BMS Staff are clearly leaving indroves and who can blame them when no onecan guarantee your job for more than 12months or offer any prospect of futuredevelopment because higher grades are beingcut. As a consequence some labs now findthemselves in the position of operating out ofhours services on a knife edge or evenwithdrawing them. Supporting professionalgroups is becoming impossible – nobody hasthe time anymore.

Networking . . . You Must be Joking!

One of the main drivers for these changes,Lord Carter’s reports, highlighted theimportance of quality, specialist services and ofcourse networking to offer joined up services.The reality is that tendering is causing conflictwithin the profession. Trusts are being pittedagainst each other in what many feels like afight for survival. For the sake of ticking a boxon a tender response laboratories are settingup tests any way they can, without consideringoverall costs to the public purse, rather than

supporting specialist centres that investsensibly in time and money to develop thoseservices. Then of course there is the time, thatis the huge amount of time wasted on thisinstead of driving our services forward.In the East and West Midlands, Leicestershire

CCGs have already pulled out of the tenderprocess and other CCGs are reportedlyconsidering their position. Talking tocolleagues in the East of England the tenderprocess is turning into a farce with hardly acontract signed and the Essex labs are pullingright out. The prevailing opinion appears to bewhen the true cost of the proposed newpathology services becomes apparent theCCG’s will run a mile. By then will we be in aposition to rebuild what we have lost?Ultimately it is the patient and taxpayer who

is suffering as our services become weaker asthe process is prolonged. This is turning intoone of the biggest crises to hit our professionand no doubt will go public soon. Surely it isnow time for the RCPath, IBMS and ACB totake action.As I come from a laboratory that is involved

in the tendering process please do not publishmy name as this may impact both on my careerand also to the work of my pathologydepartment in trying to address this situation.Perhaps others can use ACB News to expresstheir appropriate concerns as well … or is itjust me that feels like this!

Concerned Consultant Clinical Scientist[Name and address supplied to the Editor]

Letters | 19


Weakened Pathology Departmentsfrom Tendering Process

20 | An Appreciation


In January’s ACB News, the Associationreported on the death of Neil Formstone,our Lay Representative on Council, which hadoccurred the previous month.Neil was a very private individual. He lived in

Colwyn Bay, North Wales and had been activein the local community before becominginvolved in Welsh Health initiatives. He hadbeen a cancer patient in 1994 and after thatexperience became convinced that lay peoplehad a vital role to play in all aspects ofhealthcare. He became an active member ofpatient support groups in North Wales andsubsequently became a facilitator, trainer andco-researcher for Macmillan. He encouragedlay people and professionals to interact andwork together towards a common goal.His initial foray into pathology was as aSteering Committee member of the WalesExternal Quality Assurance Scheme.

Opinion With Frank Views

It was Ian Watson who first proposed the ideaof a Lay Representative to ACB Council inMarch 2009. At that time Neil was Chair of theRoyal College of Pathologists Lay Committeeand he was invited to present the case forsimilar representation within the Associationto ACB Executive in February 2009. Neilemphasised that such representation neededto be completely independent and would onlythen be able to offer a diversity of opinion.He was clear that such independence wouldlikely impact on the way both Executive andCouncil worked since this would be challengedby the Lay Representative and might involve afrank and direct criticism of the Association’smission.Neil had already worked in a lay advisory

role with many other organisations in additionto the College, and he was emphatic that sucha representative would not be there to offer arubber stamping to legitimise the activity ofthe professional body.

Refreshingly Wide Perspective

Of course his views were enriched andvalidated by his many faceted engagementswith other organisations, which in recent yearsincluded, amongst others, the Academy ofMedical Royal Colleges Patient Liaison Group,the Council of the Royal College ofRadiologists, the Wales Deanery, theHealthcare Scientist Programme, HealthEducation England Professional Board andClinical Pathology Accreditation.The great thing about him was that he had a

broad perspective and wasn’t focused on aparticular disease or patient type. This wasparticularly evident in policy discussions suchas those at Executive Retreat where there ismore scope for wider-ranging discussions.

Hugely Enjoyable to Be With

Those who knew him and worked with him,as I did over the last three years, can only beamazed by his perception and understandingof the issues healthcare faces. He had anamazing vigour and was also a lively andhugely enjoyable individual to spend timewith socially.The esteem he was held in by so many is

evident by the fact that the Wales Cancer Bankis organising a celebration in tribute to him inCardiff on the 5th July at which statementsand presentations from friends and colleagues,including the ACB, will lead to a sharedstatement of the difference that publicinvolvement can make as a legacy of Neil’swork.He will be missed not only by the ACB, but

also by the many other organisations withwhich he was involved. As we search for asuitable successor we can only hope there isat least one other like him with sufficientknowledge and dedication to take on this vitalrole!

Michael Thomas, Past President

Perception and Understandingin Abundance

Crossword | 21


Last month’s solution

ACB News CrosswordSet by RugosaSo, with the honey out of stock and the trip to the apiary from which itcame over, what shall we do as prizes? All is not lost, any winning entriesreceived this month will be added to the list of those who want thenew crop honey which hopefully, and if the weather improves,be harvested at the end of August. Our photo this month showsMike Cartwright, who used to print ACB News, looking in his bee hivesin disgust to see that his ‘workers’ have done very little so far this year!

Across1 Metal from central Panama (6)5 Failed at organisation of

related records (8)9 Reports 1 with charge of

riotous action (6)10 Cystic fibrosis testers’ set

wears out? (8)11 “Ancient Mariner” back in

stock at last (4)12 Endocrine syndrome made

calmer with yoga (10)13 Make secure recovery (6)14 Left out acclaimed eccentric

intellectual (8)16 Ends up in smoke at a plane

disaster (8)

20 Signed out unregisteredduct (6)

23/28 A result of self over-treatmentcould be kinky ill melodramas(4,6,8)

25 Party hands (4)26 A method for 19 could

start out from a basic soymixture (8)

27 Number 53 of redesignednew edition went off (6)

28 See 2329 Strength of many difficult

clues (6)Down2 Operation leader times a

tardy group (7)

3 Stupid 27 lost direction,was confused, had spasm (7)

4 Element manages in Frenchrevolution (9)

5 Difficult passage aboutunknown radius (7)

6 Physical unit of weathermeasurement (5)

7 Exhaust damage fromrepeated stress (7)

8 Traditions prevaricateabout German spirit (7)

15 Two bends in minimalconstruction of metal (9)

17 Activity of US soldierinvolved Italy (7)

18 Embarrassing charge aftera short week (7)

19 A neatly modified componentwe determine (7)

21 Conceals informationupsetting second Englandopener (7)

22 For ever late up admittedEric’s partner (7)

24 Used for roping wild stallions,lint-free (5)

22 | Situations Vacant


Situations Vacant | 23


To advertise yourvacancy contact:ACB Administrative Office130-132 Tooley Street

LondonSE1 2TU

Tel: 0207 403 8001Fax: 0207 403 8006

Email: [email protected]

Deadline: 26th of the month prior tothe month of publication

Training Posts:When applying for such posts youshould ensure that appropriate supervision and

training support will be available to enable you toproceed towards HPC registration and the FRCPath

examinations. For advice, contact your Regional Tutor.The editor reserves the right to amend

or reject advertisements deemed unacceptableto the Association.

Advertising rates are available on request.

Customer Services SpecialistField Based Role – Birmingham, Leeds and Scotland TerritoriesCompetitive salary with final salary pension and attractive flexible benefits

Abbott Laboratories is a leading healthcare company dedicated to improving human healthcare by providing high quality, safe andeffective diagnostic products across a range of automated platforms to suit customer need. We are a Fortune 200 company withapproximately 70,000 employees worldwide. Our science-based offerings in Diagnostics, Medical devices, Nutrition are addressingimportant health needs of people in more than 150 countries. We are looking for Customer Services Specialists to join our fastpaced Diagnostics business. These are exciting roles that bring with it opportunities for career development. As Customer ServicesSpecialist you will provide field based engineering support to Abbott Diagnostics (ADD) customers. You will currently be working asan Engineer or have a laboratory background.

Main Responsibilities as Customer Service Specialist include:• Responding to all field service calls promptly and communicating effectively with customers and the ADD organisation as

necessary.• Completing assigned instrument upgrades and documentation within approved time periods.• Performing all administrative tasks in a timely manner and keeping the manager informed of any issues arising.• Completing all quality-associated tasks within approved time periods.• Actively participating in service meetings.• Maintaining spare parts inventory accurately and minimize unnecessary parts usage.• Completing service reports for each call, and ensuring data that is entered into the contact management system is accurate

and appropriate. Ensure service report is left with customer.• Working together with the customer service and business unit teams to achieve outstanding customer service.

Education and Experience:• Education Requirements: Bachelor’s degree or HNC is desirable in Science, Engineering, Electronics or significant experience

in laboratory environment, filed service or Diagnostics• Engineering/Electronic skills.• Working knowledge of a Laboratory and familiarity with Laboratory safety.• You should be living on one of the Birmingham, Leeds and Scotland Territories

If you are interested, please send your CV to [email protected] 5 August 2013.

We look forward to hearing from you!

issue 603 | july 2013 - association of clinical biochemists

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