ACBNews The Association for Clinical Biochemistry & Laboratory Medicine | Issue 620 | December 2014 In this issue Clinical Cases Book Launched Video Links to Advise on Making a Stand at Focus Establishing an Enteric Lab in Sierra Leone Focus Abstracts Time Again

About ACB News The Editor is responsible for the final content. Views expressed are not necessarily those of the ACB. Editor Dr Jonathan Berg Department of Clinical Biochemistry City Hospital Dudley Road Birmingham B18 7QH Tel: 07792-912163/0121-507-5353 Fax: 0121-507-5290 Email: [email protected] Associate Editors Mrs Sophie Barnes Department of Clinical Biochemistry 12th Floor, Lab Block Charing Cross Hospital Fulham Palace Road London W6 8RF Email: [email protected] Mr Ian Hanning Department of Clinical Biochemistry Hull Royal Infirmary Anlaby Road Hull HU3 2JZ Email: [email protected] Dr Derren Ready Microbial Diseases Eastman Dental Hospital University College London Hospitals (UCLH) 256 Gray’s Inn Road London WC1X 8LD Email: [email protected] Mrs Louise Tilbrook Department of Clinical Biochemistry Broomfield Hospital Chelmsford Essex CM1 5ET Email: [email protected]

ACBNews The monthly magazine for clinical science Issue 620 • December 2014

General News

page 4

Practice FRCPath Style Calculations

page 12

Council Matters

page 14

Current Topics

page 15

Federation News

page 17

Meeting Reports

page 18

Christmas Crossword

page 25

Situations Vacant

page 26

Situations Vacant Advertising Please contact the ACB Office: Tel: 0207-403-8001 Fax: 0207-403-8006 Email: [email protected] Display Advertising & Inserts PRC Associates Ltd 1st Floor Offices 115 Roebuck Road Chessington Surrey KT9 1JZ Tel: 0208-337-3749 Fax: 0208-337-7346 Email: [email protected] ACB Administrative Office Association for Clinical Biochemistry & Laboratory Medicine 130-132 Tooley Street London SE1 2TU Tel: 0207-403-8001 Fax: 0207-403-8006 Email: [email protected] ACB President Professor Eric Kilpatrick Tel: 01482-607-708 Email: [email protected] Twitter: @ACBPresident ACB Home Page http://www.acb.org.uk Printed by Swan Print Ltd, Bedford ISSN 1461 0337 © Association for Clinical Biochemistry & Laboratory Medicine 2014

Front cover: Beverly Harris, William Marshall and Jane French, authors of the Clinical Cases book, along with Paul Newland who oversees Venture Publications

Issue 620 | December 2014 | ACB News

4 | General News

ACB Extras ACB Extras is the latest addition to membership. As an ACB Member, you have access to a fantastic portfolio containing money-saving discounts, designed to support you both personally and professionally. There is no sign-up process, nor any extra charge to access these benefits! Benefits include discounted cinema tickets at many major cinema chains, great savings on a wide range of Apple products, discounted 4G phone tariffs, retail cashback at over 50 major retailers, discounts on package holidays from many of the major tour operators, hotel bookings, car hire, foreign currency, car insurance, home insurance, CV and interview training, IT and professional development training and much more. ■

Clinical Cases Book Launched in Liverpool

Sudoku This Month’s Puzzle

Last Month’s Solution

And last month’s Crossword Solution . . . The launch of the latest ACB Venture Publications book was held during EuroLabFocus in Liverpool. Clinical Cases in Laboratory Medicine is jointly authored by Jane French, Beverley Harris and William Marshall. It contains a total of 80 cases and suggested interpretations. Ideal for those coming up to professional exams and also those wishing to use it as a refresher. Priced at £25 the book can be purchased from the ACB website or can be ordered from your laboratory book supplier. ISBN 978-0-902429-56-7 ■

ACB News | Issue 620 | December 2014

6 | General News

Liverpool Clinical Laboratories

The EuroLabFocus exhibition had some interesting stands including several from clinical laboratories. Of note was the Liverpool Clinical Laboratories stand, run by Jane Mills and a team of laboratory staff. Liverpool Clinical Laboratories (LCL) is a clinically led NHS shared service launched in 2014. LCL’s key aim is the provision of pathology services and the venture is jointly owned by Aintree University Hospital NHS Foundation Trust and Royal Liverpool & Broadgreen University Hospitals NHS Trust. Stand at Cardiff The LCL stand was certainly busy but Jane kindly took time out to help with a short video clip explaining why they had taken the stand and what their key aims at EuroLabFocus were. Shortages of skilled staff are a problem on Merseyside as elsewhere and part of the stand’s aim was to help with the current recruitment issues. Highlighting some of the specialist tests that are offered by LCL was also part of the plan. Based on the success of their EuroLabFocus presence LCL has decided to consider a stand to attend the Focus meeting next June in Cardiff. You can see the YouTube by putting “Liverpool Clinical Laboratories YouTube” in as a Google/YouTube search where you will find it may be the first hit. Alternatively, if reading the electronic version of ACB News then just click on the image above or click here…. ■ ACB News | Issue 620 | December 2014

LTOL is Ten . . . the Video

Next month we look at how Lab Tests Online-UK is helping with patient result initiatives. For now there is a fun video giving a feel for the Liverpool celebrations. If reading the electronic copy of ACB News just click on the image above or if you are reading this on paper then go online to www.labtestsonline.org.uk and find the video link on the website. ■

ACB News Archive Copies The ACB Office would like to get copies of the ACB News from 1999 to 2008 to supplement the archive copy we already have. Please email [email protected] if you have copies you would like to donate to the ACB for their archives. ■

Photos for ACB News We value photos to go with ACB News articles. Occasionally photos taken on a good quality mobile phone may be of sufficient quality to be used. Indeed, we used a photo from an iPhone 4 on the front cover a year or so ago. However, often mobile phone photos are not of acceptable quality. Please consider using a proper camera and sending us the original JPEG. Send the JPEG image separate to the Word document – embedded images are not suitable. ■

General News | 7

Meet the Scientist in Brum In support of National Pathology Week 2014, Scientists from the West Midlands got together for a fun, interactive “Meet the Scientist” event at the Birmingham Thinktank science museum. The event, organised by Dr Sukhbir Kaur (Senior Clinical Scientist at Heart of England NHS Foundation Trust), tackled the topical themes of diabetes and patient access to medical records whilst raising awareness for pathology. Children of all ages were given a lab coat and clipboard and taken on a journey from presentation to diagnosis of three patients. Along the way the children practised taking blood from a fake arm and learnt all about where your blood goes and what happens to it once it has been taken. They then performed various tests to correctly diagnose Type 1 and Type 2 diabetes, were introduced to chromatography and even went away with a bracelet coding their names in DNA.

Positive for Access to Medical Records Whilst the children experimented, parents were given the opportunity to voice their views on the following question “What access would you like to your medical records, if any?”. Only 8 out of 75 survey responses were against the idea of patients having access to their own results. Of these 8 responses, the primary reasoning was a concern for security of privacy and “hackers” or “the government” having access to medical information. One other response that stood

out was “confusing and possibly worrying”, what do you do with information about yourself that you don’t understand? Ninety percent of people were positive and in favour of more access. However, some of these also commented that they would only want access through a secure medium and if terminology could be explained to them. Overall the Thinktank event was extremely successful with everyone involved having something to take away. The children got a hands on laboratory experience and a goodie bag whilst adults were given pause for thought on one of the most talked about issues in pathology today. As for the scientists, we gained two exciting days of public engagement and can reflect on some interesting public opinion. ■

Issue 620 | December 2014 | ACB News

8 | General News

Well Done Guys! Kaiya Chowdhary, St Thomas’ Hospital, London World Quality Day, instigated by the United Nations in 1990, is an annual event promoting awareness of quality. It provides organisations across the globe the opportunity to reinforce their ultimate quality goal of achieving excellence and highlights the important factors required to achieve this, including innovation and sustainability. Noting the similarity with Viapath’s values – innovation, collaboration and expertise, we decided to join in the fun. Our aim was to broadcast the message of the 2014 theme ‘Building a Quality World Together’ across our organisation and making a ‘pledge’ to show our ongoing commitment to quality.

Quality Jigsaw Our challenge consisted of teams from each of our five sites transporting puzzle pieces approximately 100 km from Bedford General Hospital to Guy’s Hospital without the use of any motorised transport. At the end of the challenge these pieces would be fitted together to reveal our Quality Pledge for the year ahead. Viapath’s employees voted from a shortlist of suggested pledges. After an overwhelming response, a single pledge was the outright winner taking more than 50% of the available votes. The challenge route included a 5 km run, two 40 km cycle legs and two 10 km runs to finish. A team captain was chosen for each team who in turn selected their team mates.

Our teams joined forces to collaboratively raise sponsorship of around £1,400 for our chosen charity which was Children in Need.

Running Legs in Golders Green The day began in Bedford with a 5 km run, illustrating that the combination of dedication and training is important to achieve success. These individuals had previously volunteered to complete the ‘NHS couch to 5 km programme’, showing that continual commitment can lead to improvement in fitness over a nine week period. This was followed by the two 40 km cycle legs taking us to Golders Green where the first of the two road running legs began. The second running leg from St Thomas’ Hospital to London Bridge was especially exciting as it saw participants cheered home by a large contingent of their colleagues at the finish line. First through the finish line was Susan Bint. The day ended with the assembling of the five puzzle pieces, which fit side by side, revealing Viapath’s Quality Pledge for the year ahead: ‘We pledge to continually improve our service by listening to our patients, customers and colleagues and taking positive action as a result of each interaction.’ This year’s ‘2014 Viapath World Quality Day Challenge’ Cup was awarded to the team from Guy’s Hospital who accumulated the greatest number of challenge points during the day. ■

ACB News | Issue 620 | December 2014

General News | 9

Focus Fringe: Going the Extra Yard in Cardiff Gina Sanki, Focus Publicity The venues for the social events at Focus Cardiff, 2015 have now been confirmed and I am delighted to announce that thanks to the work of the Social Programme Organisers, Michael Melhuish and Meeting Makers, the following exciting venues are now awaiting us in June 2015!

Cardiff Bay Corporate Evening The Corporate Evening on Monday 8th June 2015 will be held in the stunning Terra Nova, located in Cardiff Bay and only a couple of minutes walk from the conference venue, The Millennium Centre. The Terra Nova offers a sophisticated, relaxed environment to wind-down after work and spend an evening overlooking the quay. You can enjoy a full range of Cardiff’s finest Brains cask ales and smooth beers and also an extensive range of great wines and champagne.

Brewery Quarter Fringe This year’s Focus Fringe will be taking place at “The Yard” which is located within the Brewery Quarter in Cardiff. The Yard is very centrally located making it an ideal venue to hold the Fringe for all Focus attendees. It is a perfect place to start a night in Cardiff for a bite to eat for those who also wouldn’t normally attend the Fringe as it is located on the main”strip” known as St Mary’s Street in Cardiff centre. The Yard has also been awarded a Trip Advisor certificate of

excellence demonstrating its popularity as somewhere to eat and drink in a city where there is plenty to choose from! For the Fringe itself, a private area of The Yard upstairs known as the Jam Jar has been reserved and amps etc will be provided for those wish to jam and plenty of comfy booths surround the performance area for those who wish to enjoy the musical talents of their colleagues. There is also a private bar at the Jam Jar and a fantastic menu to choose from at the Yard (more details/offers will be provided nearer to the event).

National Museum Banquet As always, Focus wouldn’t be complete without the Conference Dinner held on the final evening. The Conference Dinner in Cardiff will be held in the iconic National Museum. It houses the Welsh national collections of archaeology, geology, natural history and art and there will be an opportunity to view the exhibits as drinks will be served in the Art Gallery (don’t forget to look out for the woolly mammoth and her baby!). Ticket prices will be advertised on the ACB Focus website as soon as they become available. Look forward to hearing you all at the Fringe, and in the words of the recent number one single . . . “Its all about the bass, ‘bout the bass, ‘bout the bass, no treble!”. ■

Issue 620 | December 2014 | ACB News

10 | General News

Focus Update The programme for the Cardiff Focus meeting has now been distributed. The sciences include topics that will be of interest to all Pathology departments. Do consider the important opportunities:

Electronic Links to Video Clips Liverpool Labs: Click here for key reasons to get out there and be an exhibitor at Focus:

Poster Submission There will be an emphasis on interaction at the posters. The key date is 16th January when you need to ensure you have made your electronic submission. Guidelines on the poster abstract are given on the Focus web page with tips on what to include in your 300 word abstract to ensure success. To see more visit www.focus-acb.org.uk

City Assays NHS: Tips from an NHS Pathology Department on a successful Focus stand presence:

NIHR: Understand more about the NIHR Diagnostic Evidence Co-operative:

Making a Stand in Cardiff There have been a number of laboratories and non-commercial organisations with interests in Pathology who have exhibited at Focus over the years. This can really be an excellent way of meeting those you want to communicate with. If you are busy developing your laboratory marketing communications plan for 2015 why not consider a stand at Focus in Cardiff as part of your strategy. To understand more about this listen to some of the exhibitors at the EuroLabFocus meeting in Liverpool with tips on how to have a successful stand by clicking on the thumbnails on the electronic version of ACB News in the next column.

ACB News | Issue 620 | December 2014

To find out more about your laboratory having a stand at Focus 2015 in Cardiff please contact: Vicki Grant at: [email protected] ACB News hopes to offer further practical tips on stand success for commercial and non-commercial exhibitors in the New Year. ■

General News | 11

STP Trainees Involved in National Pathology Week Outreach Amy Dunne, St George’s NHS Trust, London To celebrate National Pathology Week 2014, The Royal College of Pathologists held a free event for students aged 14-18. This gave students the opportunity to meet Pathologists and discover the different disciplines within pathology. Four London-based Biochemistry Trainees were involved in an interactive session which gave students the chance to find out about the different pathology specialties, learn what pathologists do and also take part in activities that explore why pathology is important to healthcare. Zoe Barclay (Imperial), Amy Dunne (St George’s), Danni Fan (UCL) and Hannah Fearon (King’s College) hosted two stands at the event to show students some of the tests performed in the laboratory, and to provide information on the STP training scheme.

Pros & Cons of POCT The first stand gave students the opportunity to use point of care glucose meters and discuss their use in the management of

diabetes. The advantages and disadvantages of such point of care testing were discussed, and the STP trainees were able to describe the process of laboratory based testing, from barcoding samples to entering results. The students were also shown kits for pregnancy testing and drugs of abuse screening. At the second stand the students were able to perform a screening test for bowel cancer using FOB cards – with some surprisingly realistic fake samples – and also find out how urinalysis can be useful in patient testing. The students had to guess what might be wrong with patients from the appearance of their urine – including a case of beeturia and frothing proteinuria – and were able to perform various dipstick tests to investigate the pH and content of the urine. This was an excellent opportunity for the trainees to be able to inform students about the STP Training Scheme, and to advertise not just biochemistry but all clinical sciences as a career for eager young scientists. ■

Coming Next Year . . . A special thank you to everyone who has helped on ACB News, from those directly working on each issue, Associate Editors, our publishers, and to everyone in all areas of production. Also a big thanks to everyone who has contributed over the year. We will continue to experiment with electronic links from ACB News editorial and adverts for the electronic copy of ACB News. Remember we Tweet a link as soon as ACB News goes online. Next year we continue to try and report news and views of our pathology environment and welcome contributions from everyone. In January we will be looking at Lab Tests Online-UK and in February we look at how to have a successful presence at a Focus exhibition. ■

Issue 620 | December 2014 | ACB News

12 | Practice FRCPath Style Calculations

Deacon’s Challenge No 163 - Answer Calculate the loading dose of intravenous aminophylline required to achieve a plasma theophylline concentration of 15 mg/L in a 65 kg man, given that the volume of distribution of theophylline is 0.5 L/kg and that aminophylline is 80% w/w theophylline. What infusion rate would be required to maintain this concentration if the half-life is 8 hours? FRCPath, Autumn 2013

Loading dose (LD) = Plasma concentration (Cp0) x Volume of distribution (Vd) Purity (S) x Bioavailability (F)

Cp0 Vd S F

= target plasma concentration = 15 mg/L = volume of distribution = 0.5 L/Kg. Body wt = 65 Kg. Total Vd = 0.5 x 65 = 32.5 L = salt factor or purity = 80 % = 0.8 = bioavailability. Not given so assume value of 1 (probably irrelevant as IV route used) LD

=

=

15 x 32.5 0.8 x 1

609 mg

If the drug is infused to maintain a constant plasma concentration (Cpss) then a steady state exists in which the administration rate is equal to the rate of removal. Rate of administration = Infusion rate x F x S Rate of removal Therefore:

= Clearance x Cpss

Infusion rate x F x S

Infusion rate

=

=

Clearance x Cpss

Clearance x Cpss F x S

Cpss = plasma steady state concentration F

= bioavailability = 1;

= 15 mg/L

S = salt factor or purity = 0.8

The clearance is not given. However we are given the half life (8h) which is related to the elimination rate constant (kd) by the expression: kd

=

0.693 t1/2

ACB News | Issue 620 | December 2014

Therefore kd = 0.693 8

= 0.0866 h-1

Practice FRCPath Style Calculations | 13 Clearance is related to kd by the expression Clearance =

kd x Vd

Therefore, clearance = 0.0866 x 32.5

= 2.81 L/h

Substituting these values to calculate infusion rate: Infusion rate =

2.81 x 15 1 x 0.8

=

53 mg/h

(2 sig figs)

Question 164 A neonate weighing 850 g is admitted to the Neonatal Intensive Care Unit. Following intubation and artificial ventilation, blood gases reveal an arterial blood hydrogen ion concentration of 120 nmol/L and a pCO2 of 6.2 kPa. Estimate the dose of sodium bicarbonate (1.25%) required to reduce the hydrogen ion concentration to 80 nmol/L. You should assume that ventilator settings remain unchanged, and ignore any effects due to changes in plasma volume and peripheral circulation. You should assume also that the total body water in neonates is 80% of body mass, due to an expansion of extracellular fluid volume compared to adults, and is evenly distributed between intra- and extracellular compartments. FRCPath, Autumn 2013

Issue 620 | December 2014 | ACB News

14 | Council Matters

Boundary Issues . . . Paul Newland, Alder Hey Children’s Hospital

Report of Council Meeting held on 13th November 2014 The first topic of the day at the November Council Meeting was regional boundaries. Part of the reasoning for this discussion was to ensure that all Members are able to access regional meetings to keep pace with educational developments and business matters of the Association. Previous discussions with regional chairs suggested that most regions were happy with their geography except for two regions, Southern and Trent, Northern and Yorkshire. Council discussed the wider issues of meeting attendance and concluded that regional boundaries was one issue for limited attendance, but this was multifactorial including release of staff from the department becoming a difficult issue. Broader discussions on the potential use of Innovative IT solutions such as video conferencing and webinars took place. Limited conclusions were derived however it was agreed that the two regions would review their boundaries and if required draw up a proposal for consultation.

Information Sharing Across Regions The discussion moved onto standardising the information received from each region and also who should represent each region at Council. There was a view expressed that the regional chair should be the representative at council and this was agreed. The expectation from this is that there would be a consistency in how information is shared across each of

ACB News | Issue 620 | December 2014

the regions. Additionally, to support information sharing, a template has been prepared for regional reports so they take a consistent format. To support these changes, it was agreed that a generic job description would be prepared for the role of regional chair, together with guidance on this position.

Personalised EQA The second topic of the day focussed on personalised EQA. There has been a document prepared by our President, Eric Kilpatrick, in collaboration with Dr Bernie Croal, RCPath Vice President for Professionalism, which was presented to the College and was well received. Council agreed that this document was far reaching, tackling the need for evidencing personal proficiency. Elements discussed in the document include demonstrating proficiency in knowledge, continuous learning and development, service quality improvement or innovation, effective leadership and team work, demonstrated valued teaching coupled with feedback from colleagues, staff, service users and patients. This document aims to give an outline framework for future development of systems to enable all Clinical Scientists from all disciplines, at all grades to be able to demonstrate personal EQA in their specific role.

Regional Chair to Provide Consistency If you would like to give your view on these topics or have any ideas that would help to progress them, please contact me at: [email protected] ■

Current Topics | 15

Establishing an Enteric Reference Laboratory in Sierra Leone: A Six Week Elective Chloe Eaton, Oxford University NHS Trust Sierra Leone experienced the worst Cholera outbreak for 15 years in 2012. With over 300 fatalities and more than 20,000 people affected, the World Health Organisation (WHO) together with the Ministry of Health and Sanitation (MoHS) established a Cholera Command and Control Centre to manage this national emergency. The Gastrointestinal Bacteria Reference Unit, Colindale (GBRU), in collaboration with other Public Health England (PHE) laboratories developed an enteric bacteria diagnostic and reference laboratory – Central Public Health Reference Laboratory (CPHRL) in Lakka. Since PHE left CPHRL in 2013 Marie Anne Chattaway, (GBRU, Colindale) and her colleagues worked tirelessly to obtain funding to reinforce and sustain activities with a view to accredit the laboratory to ISO15189 standards under ‘Strengthening Laboratory Management Towards Accreditation’ (SLMTA) guidelines. As a result a further Microbiologist request was released in February; interviews were held in March and by April I was on my way to Freetown.

Self-Sufficiency During week one we undertook a two-day workshop led by PHE’s Global Consultant, Mark Salter, discussing the future of Sierra Leone’s public health. It was a great opportunity to meet key stakeholders and discuss the requirements to develop CPHRL capacity. A laboratory visit determined that without samples, generator fuel or running water for hand washing, major issues needed addressing before undertaking some of my main objectives,

such as implementing antimicrobial susceptibility testing. The project was aimed at helping CPHRL become self-sufficient and independent, the available budget was therefore restricted to providing expertise and consumables, not laboratory infrastructure. During the following weeks we began to adapt to the immediate challenges, by sourcing and containing fresh hand-wash water daily from the local village, communicating fuel availability so daily activities (e.g. media preparation or safety cabinet usage) were planned around power provision, and began to re-build relationships with local hospitals and district surveillance officers. This regenerated sample collection and as a result helped maintain and develop

Issue 620 | December 2014 | ACB News

16 | Current Topics

Eric Sefoi, Chloe Eaton and Marie Chattaway discussing with staff at the Ola During Children’s Hospital, Freetown, the prospect of triaging Rotavirus negative samples for enteric bacteriology at CPHRL

staff competency ensuring fulfillment of CPHRL’s key purpose.

Tight Timescales Outcomes were required within a very tight timescale and being posted to Sierra Leone independently, time management between all aspects represented a real challenge. Despite this, weekly action-plans ensured intense training activities, implementation of new techniques, and improvement of quality systems such as audit training and introduction of an EQA scheme provided by the National Institute for Communicable Diseases in South Africa. It was encouraging to see the laboratory making progress despite the initial setbacks. Unfortunately Week 5 manifested another unexpected course of events; Sunday morning I was called to an emergency meeting at the Ministry following reports of 4 fatalities in the Kailahun district. Sadly, this represented the spread of the relentless Ebola outbreak from neighbouring Guinea into Sierra Leone. With diarrhoea and vomiting being the predominant features, Cholera was suspected first and subsequently, highly infectious samples ended up at CPHRL. It was traumatic experiencing the fear instilled amongst the local community and healthcare workers

ACB News | Issue 620 | December 2014

expected to manage this situation without requisite training, and certainly not a situation I had anticipated being involved with. Action was needed and I was aware that posting specialist response teams to manage the outbreak would take time. I was fortunate to have access to UK resources and support by PHE colleagues, Professor Noel Gill and Dr Colin Brown. After an overnight crash-course reading relevant guidance, the following morning we sourced storage containers from local markets and managed to store and successfully dispose of infectious samples safely. Upon returning to everyday comforts, my peers have asked if I would ever return to undertake a similar project. Without any hesitation, my answer is ‘Yes’; the unique experience of being pushed to my limits, thinking spontaneously and meeting amazing people in stunning surrounds developed my personal and professional skills in an unimaginable manner. My experience will stay with me for a lifetime. ■

Konneh Kelfala, laboratory technician in Sierra Leone, being trained to perform antimicrobial susceptibility testing

Federation News | 17

NHS Pensions 8: Choice 2 & More Geoff Lester, Federation Pensions Representative By the end of November all staff in the groups affected by “Choice 2” should have received your Choice 2 letter from your employer. This affects those who opted to stay in the 1995 scheme under Pensions Choice and who are not in the fully protected group, i.e. at some time on or after 1st April 2015 will be automatically transferred into the 2015 CARE scheme. If you think you should have had a letter and have not had one in the first place contact your employer’s Pensions Officer. If you have left NHS employment but still have investment in an NHS pension contact either your most recent employer or the NHS BSA at Fleetwood quoting your National Insurance number. See their website for contact details. Originally we indicated that the deadline for your Choice 2 decision was three months after receiving your letter. For simplicity this has now been revised by NHSBSA to a common date for all of 16th March 2015. This is an absolute deadline. This is 4 months away. However, FCS would urge you to keep this decision at the top of your “to do” list. Do not let it get buried because of that time scale. If you do not respond the default decision is that you stay in the 1995 scheme and that may not be the best decision. Make your decision a distinct action under your control base on thoughtful consideration.

2015 Scheme Regulations The formal consultations on four Statutory Instruments going before parliament over the next few months to bring the 2015 Scheme regulations and the associated transition arrangements into force have now been issued. FCS officers are currently scrutinising these highly technical documents. The consultations close between the end of November and mid-December in order to meet consultation requirements and fit the parliamentary timetable ahead of next May’s general election. One of the new provisions in the 2015 scheme that may be attractive to some

members is “ERRBO” – Early Retirement Reduction Buy Out – where you can enter into a contract to pay additional contributions so that you can retire up to 3 years earlier than your 2015 pension age (your State Pension Age) without your 2015 pension being actuarially reduced.

Salary Sacrifice Salary sacrifice schemes are fairly common across the public sector and are trumpeted as a benefit for staff. The facility lets you give up part of your salary in exchange for non-cash items such as child care or lease cars on favourable terms negotiated by your employer or the company they contract with to provide the facility. There may be tax advantages. The sacrificed salary however reduces your pensionable pay. Both you and your employer pay pensions contributions on a lower gross sum and if that keeps you below a contributions tier threshold then it may be significant. Under the 1995 and 2008 final salary schemes the negative impact on the pensionable pay on which your pension benefit is calculated can be removed by withdrawing from the salary sacrifice arrangement in your final years of working thus maximising your “final” salary. You need to be aware that in the 2015 CARE based scheme you can never “rescue” that negative impact and the reduced pensionable pay will reduce your CARE pension pot for good and your loss will be index linked at CPI+1.5% until you retire. Those considering entering into new salary sacrifice or continuing existing arrangements beyond your transfer date to the 2015 scheme should consider the balance of the immediate pros and long-term cons carefully.

FCS Pensions Jargon Buster Glossary Pensions is a mine-field of its own technical jargon. FCS has posted its own jargon buster on the ACB/FCS members web pages at http://www.acb.org.uk/docs/fcs/pensionsglossary.pdf ■ Issue 620 | December 2014 | ACB News

18 | Meeting Reports

Carbapenemase Threats Samantha Horridge The programme at this year’s European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) and ‘The year in Clinical Microbiology’ session reflected clearly the progress we have made and yet the large challenges we face. Microbiology diagnosis is advancing rapidly with an increase in automated instruments and emphasis on antibiotic stewardship, giving faster results and optimised patient management. As this occurs, the pathogens continue to evolve and change in parallel. Antimicrobial resistance has now been called a ‘serious threat to public health’ by the World Health Organisation and is a global problem that without recognition and quick action using a multidisciplinary approach could bring the end of the ‘antibiotic era’ faster than anticipated. ECCMID’s symposium debate on whether new drugs should be used empirically or saved as a last resort highlighted the impact and worrying realisation of drug resistance. The inappropriate use of antibiotics without global antimicrobial stewardship or new drug development has been the main contributor to this problem. Historical concerns of MRSA and ESBLs have been added to with the rise in multi-drug

resistant gram negative and carbapenemase producing organisms (CPOs) since the 2000s following an increased use of carbapenem.

Microbiology of Carbapenemases Carbapenemases are β-lactamases that hydrolyse all or some of the antibiotics in the carbapenem group, and may also confer resistance to all other β-lactam antibiotics. Although certain gram-negative bacteria are intrinsically resistant to some of the carbapenems or contain the carbapenemase gene with the potential to express resistance; it is the acquired enzymes that are of increasing concern. Acquired carbapenemase genes are typically carried on plasmids which carry determinants of resistance to multiple classes of antibiotics, leaving few options for effective therapy. These plasmids can be transferred between distinct strains and organisms in different genera.

Screening Work from laboratories across Europe and the world was presented at ECCMID demonstrating a variety of detection methods. The difficulty with detection lies in the fact that carbapenemase producing organisms (CPOs) do not always exhibit resistance to the group of antibiotics and not all carbapenem

Ambler class

Main carbapenemases

Organisms of main concern

A (serine-β-lactamases)

KPC SME, IMI

Enterobacteriaceae KPC found most commonly on Klebsiella pneumoniae

B (metallo-β-lactamases) [MBL]

VIM, NDM IMP

VIM found mainly in Pseudomonas aeruginosa, increasingly found in Enterobacteriaceae NDM found predominantly in coliforms, particularly E.coli and Klebsiella

Require zinc ion for activity D (serine-β-lactamases)

OXA-48, OXA-23

ACB News | Issue 620 | December 2014

OXA-48 found in Enterobacteriaceae OXA-23 frequently found in Acinetobacter baumannii

Meeting Reports | 19 resistance isolates are as a result of carbapenemase production. Briefly, an indicator carbapenem is tested against clinically-significant gram-negative organisms either for patients being screened to look for resistance or in isolates where their susceptibility profile indicates the possible presence of carbapenemases. Chromagenic agar is sensitive, but not specific, so confirmatory tests are needed. Molecular tests are increasingly available, but may have cost implications. Confirmatory tests often act to show synergy between an indicator carbapenem and β-lactamase inhibitor. Ethylene-diaminetetraacetic acid (EDTA) or dipicolonic acid can be used in detection of MBL. Confirmatory tests available include Modified Hodge test, but this shows poor sensitivity and specificity. The CarbaNP assay is a promising step but many of the conference posters showed poor sensitivity when used in routine laboratories. Inhibitor based assays is another option but no single assay inhibits all classes. The issue with screening in addition to detection methods already identified is deciding who to screen: Travel cases? All those in high prevalence areas? ‘High-risk’ patients?

Carbapenemase The symposium on carbapenemases addressed key issues in prevention, detection and treatment and demonstrated the worldwide focus on this issue. Yehuda Carmeli highlighted the need for strict infection control procedures and how they can prevent the spread of CPOs following a hospital outbreak in an Israeli hospital. Using local epidemiology to survey who to screen and effective epidemiology investigation to trace time and site of acquisition is key. Subsequent tracing and screening to reliably identify carriers early lets infection control measures be put in place promptly. Cohorting positive patients with a dedicated nurse, rather than isolation rooms, was found to be an effective isolation method. Maria Virginia Villegas’ talk on ‘KPC around the world’ described the global expansion of KPC carrying sequence types ST258 of

K.pneumoniae, with some reports of it being found in Pseudomonas spp. in Latin America. There have been isolated cases in countries such as Spain, France, India and Scotland and the occasional one described in Africa, Australia and New Zealand. Other countries have experienced disseminated infection from their first case resulting in an endemic problem, for example, Greece where KPC is the most prevalent carbapenemase or KPC-3 in Italy. China faces concerns about contaminated water reservoirs serving as a source of infection. Following effective nationwide intervention, including active surveillance and isolating carriers, Israel managed to reduce numbers of new cases following widespread dissemination of KPC. Timothy Walsh described the global spread of NDM with an interesting insight suggesting that NDM may be linked to reduced virulence and potentially found in less virulent strains. He re-emphasised carbapenem resistance being more a public health problem rather than a medical one, with the focus needing to be on infection control and vulnerable patients.

Treatment The increased resistance of these often hospital-associated organisms dramatically reduces treatment options to mainly colistin, tigeycycline and fosfomycin; aminoglycosides in some cases. These are not ideal as a single agent due to toxicity, therapeutic levels and research presented at ECCMID showed increased mortality with monotherapy versus combination therapy. There is some hope for the future with the use of avibactam, a beta-lactamase inhibitor that is active against Ambler class A and D, therefore KPC and OXA-48 and effective when combined with ceftazidime and ceftaroline. Unfortunately no drugs targeting class B are available or on the horizon. This new threat in resistant organisms is of great concern, but ECCMID highlighted that it is a global problem that people are not only aware of but are improving detection methods, treatment options and re-emphasises the vital role effective infection control can play in reducing transmission. ■

Issue 620 | December 2014 | ACB News

20 | Meeting Reports

Placenta in Paris’ Latin Quarter Daniella Nice, Manchester Royal Infirmary I was supported by the ACB to attend the Annual Conference of the International Federation of Placenta Associations (IFPA), held alongside the meeting of the European Placenta Group (EPG). Held within the Latin Quarter of Paris, the picturesque Campus des Cordeliers hosted the conference in September of this year. The conference was attended by over 400 international delegates including myself and a large delegation from the Manchester based Maternal and Fetal Health Research Centre. Sessions were structured to include plenary talks, presentations by New Investigators and parallel sessions of specific interests, along with over 300 poster presentations. Talks spanned the scope of placenta research, including specific areas of research to clinical intervention trials.

Placental Hormones Hormones produced by the mother, fetus and placenta act as environmental signals, regulating fetal growth and development in relation to maternal stress and intrauterine nutrient availability. The placenta also contains receptors that can respond to the hormones in the maternal blood, acting to mediate levels between the fetal and maternal circulations. Studies in both mice and sheep have shown that maternal hormones such as cortisol, insulin and insulin-like growth factors have been shown to alter the morphological and functional characteristics of the placenta, which in turn affects the growth of the fetus. Monitoring these hormones may give insight into the development of the fetus, and further research may dictate treatments given during pregnancy. Currently, no biomarkers have been identified that are sensitive or specific enough to identify placental pathology. During the conference, the ideal characteristics of novel

ACB News | Issue 620 | December 2014

biomarkers were discussed, with emphasis on objective measurements, and discussion of how the biomarkers will be used in conjunction with existing screening techniques such as scanning. The ideal biomarkers will be specific to certain pathologies, and would be able to identify those pregnancies that would require intervention, or rule out healthy pregnancies. The use of genomic technologies, such as the analysis of the placental and maternal transcriptome was also presented. The use of Next Generation Sequencing has allowed a large number of genes related to placental function to be analysed. Studies showed that environmental factors when combined with certain genetic haplotypes conferred the greatest risk of a poor pregnancy outcome. As such, genetic screening alone may not be a useful predictive tool in pregnancy outcome, showing that any biomarkers or genetic changes identified would have to contribute to a holistic management programme of an individual patient.

Cohort Studies With the production of large amounts of data comes the importance of being able to share data in a manageable way, something that is relevant across many scientific disciplines, including laboratory medicine. A number of approaches to the sharing of data were demonstrated, including large databases that converted individual study data into useable and merged formats, and newer studies that have standardised collection protocols and biobanking facilities. In conclusion, this was an exciting conference to attend, with much research still to be undertaken in the field of placental research, where findings and interventions are helping to improve pregnancy outcomes for both mothers and babies. ■

Meeting Reports | 21

Training Days in Liverpool Kia Langford-Smith, Aintree University Hospital Trainees from a variety of healthcare science specialisms arrived at the BT Convention Centre in Liverpool on a rainy Monday morning and were happy to be greeted with tea, coffee and cookies before the first lecture began! The Training Day started with a session about the principles and clinical applications of mass spectrometry in clinical biochemistry. Brian Keevil began by describing the types of instruments available, and how they have been designed to increase sensitivity without increasing the interfering background noise. This was followed by a discussion of accurate mass measurement using time of flight (TOF) detectors, which can increase analytical specificity. The session continued with presentations from Laura Owen, who discussed the importance of selecting a good internal standard, and Joanne Adaway, who described how appropriate sample preparation can reduce ion suppression. Overall, these lectures provided a great practical introduction with fantastic tips for any trainees undertaking assay development

on a mass spectrometer. This was followed by an interesting look at the application of mass spectrometry in microbiology, with Rebecca Gorton’s presentation on identification of micro-organisms from solid agar culture using MALDI-TOF mass spectrometry. In the future, further developments may also allow this method to be used for the detection of mycobacterium and fungi, which are difficult to grow and identify, and to identify micro-organisms direct from clinical specimens.

Norovirus and C. Diff After lunch, the training day resumed with a session focusing on gastrointestinal disorders. Miren Iturriza-Gómara spoke about the detection of norovirus, with a particular focus on the types that are common in healthcare associated infections, and Derren Ready described the diagnosis of Clostridium difficile using a rapid screening test followed by faecal toxin detection. Both speakers discussed the use of RNA analysis to link cases and monitor outbreaks in hospitals. Next, Matthew Helbert

Issue 620 | December 2014 | ACB News

22 | Meeting Reports gave a comprehensive overview of testing strategies for a variety of immune related gastrointestinal diseases, including oral allergy syndrome, pernicious anaemia, Coeliac disease, Crohn’s disease and IgG40-related diseases. In the final session of the day, Susan Martin described the testing performed by histocompatibility and immunogenetics laboratories for both solid organ and haematopoietic stem cell transplantation. It was particularly interesting to hear about the introduction of more modern techniques, such as the use of PCR instead of serological tests for HLA typing, and the use of flow cytometry and bead arrays instead of cell based assays for HLA antibody identification.

Blood Gas Unravelled Following a delicious meal on Monday evening at the atmospheric Alma De Cuba restaurant, Trainees began the second training day with a presentation from William Marshall on “unravelling” blood gas disorders. After a quick re-cap of acid-base homeostasis, the audience were called upon to diagnose of a variety of cases, using the straightforward techniques that had been described. The key tip was to focus on the measurements of hydrogen ion concentration and partial pressure of CO2, to avoid being confused by the additional calculated parameters. This was followed by an extensive overview of disorders involving sodium and water homeostasis from Andrew Day, who highlighted the value of measuring urine osmolality and urine sodium to assist with diagnosis, rather than relying on the assessment of volume status, which can be difficult to do. In the next session, which focused on immunoglobulins, trainees heard from Berne Ferry about the testing strategies for myeloma screening, in particular the use of serum free light chain measurements as a more analytically sensitive and biologically specific test than urine electrophoresis. The detection of intact paraproteins using the “Hevylite” assay was also introduced as an

ACB News | Issue 620 | December 2014

additional test that may be useful in monitoring monoclonal proteins that are difficult to quantify using serum electrophoresis, or to allow earlier detection of relapse. This was followed by an interesting presentation on IgG4-related diseases by Ross Sadler, who described the discovery of these unusual autoimmune diseases and the importance of combining IgG4 measurements with histological findings to confirm diagnosis.

Sequencing in Routine Use A team from the West Midlands Regional Genetics Laboratory described the use of next generation sequencing (NGS) in diagnostics. First the trainees were introduced to the technology and the different sequencing approaches, including sequencing of gene panels, whole exome sequencing, and whole genome sequencing. Developing areas of NGS were discussed, including non-invasive pre-natal screening through sequencing of free foetal DNA found in the maternal circulation, and tumour profiling using NGS to sequence panels of genes that are associated with prognosis and treatment success. The massive data storage and processing capacity required for NGS was astounding, as were the huge number of bioinformatics programs required to properly assemble and interpret the data generated. There are also significant hurdles still to overcome regarding the interpretation of results, determining which variants are important, and the ethical considerations of which results should be reported. This was followed by the final session of the training programme, chaired by Danielle Freedman, in which six Trainees were selected to present interesting clinical cases. Each presentation included interactive questions allowing those in the audience to test their knowledge. This was a fantastic way to end the training programme, and one of the many highlights of an enjoyable and educational two days. ■

Meeting Reports | 23

Transforming Staff and Patient Experience With Stories, Case Histories and Numbers Chris Price, Oxford You might wonder why I attended this meeting jointly organised by The Kings Fund and The Point of Care Foundation. There were several reasons. During the Carter Review a common theme of discussion was the need for pathologists, meaning all staff working in laboratory medicine, to “get out more” – to step out of the silo. This comment was often reiterated at the conclusion of NHS Improvement projects. Again from the Carter Review, the consequences of patients gaining direct access to their results from April 2015 made the topic of this meeting highly relevant. A third reason was a broader consideration of the reasons for the slow, and highly variable, rate of adoption of new tests as illustrated in the NHS Atlas of Variation in Diagnostic Services. To the latter one can add the myriad of clinical audits, benchmarking and publication activities related to what might be broadly described as inappropriate testing, including: 1. tests not requested, 2. unnecessary tests requested, 3. results not received, and 4. results not acted upon – appropriately or at all. I was trying to put all of this into the broader context of the Darzi Review and the foundation of healthcare and the NHS in the future – patient experience, safety and effectiveness. I went to this meeting, therefore, to better understand how one might assess patient and staff interaction with the laboratory medicine services and use this information to transform their experience and enhance the benefits to patients and staff – as well as for providers and commissioners.

make sense of experience and why?”. The scene was set by Professor Trisha Greenhalgh in a talk entitled “Not stories or number, but stories and numbers”. She made the point that evidence of good practice comprises both narrative (story) qualitative evidence from patient and staff experiences and quantitative evidence from, e.g., clinical trials and collection of key performance indicator data, etc. In the hierarchy of evidence qualitative evidence is the lowest quality, in part because of the variability of its accuracy for any given event. However, quantitative data also has limitations, e.g., the degree of relevance to individual clinical (patient) situations as well as the differences between research (trial) and routine environments. Even in this first talk it was possible to see the relevance for laboratory medicine – the test result alone is meaningless. In the second talk Andrea Sutcliffe, Chief Inspector for Social Care at the Care Quality Commission, in her talk “Behind every number is a human story”, described her use of the Mum Test (is it good enough for my mother?) to assess patient experience. This translates to – is it 1. well-led, 2. effective, 3. responsive to patients’ needs, 4. safe, and 5. caring? The core of the approach is “listen, understand and act”. The parallel with laboratory accreditation is obvious – albeit with a broader patient and clinical focus, but also with quality improvement and translational research in laboratory medicine.

Stories and Numbers Please . . .

The second session explored the power of narrative to generate understanding, in which Sara Ryan from the Health Experiences Research Group in Oxford, talked about the importance of identifying those patients

The focus of the meeting was learning about the importance of the inter-relationship between staff and patient experience, and the first session posed the question “How do we

Stories to Make the Point

Issue 620 | December 2014 | ACB News

24 | Meeting Reports whose views may not always be heard (see healthtalk.org for more information), giving some poignant examples. Dr Michael Easton, an academic GP from Imperial Collage, London described training doctors on how to listen. A number of questions crossed my mind at this point. 1. How can the laboratory help GPs faced with patients armed with their results? 2. As more point of care tests become available, how will GPs integrate them into their practice? 3. Can performing a test as part of the consultation increase patient empowerment? Professor Nick Black from the London School of Hygiene and Tropical Medicine introduced a session on the value of numbers and their uses to drive improvements. He emphasised the importance of patient experience, safety and effectiveness (aka Darzi) in the context of the domains of the current NHS Outcomes Framework as the main accountability mechanism between NHS England and the Minister of State for Health. The 2014/5 domains are: ◆ Preventing people from dying

prematurely. ◆ Enhancing quality of life for people with

long term conditions. ◆ Helping people to recover from episodes

of ill health or following injury. ◆ Ensuring that people have a positive

experience of care. ◆ Treating and caring for people in a safe

environment and protecting them from avoidable harm. The potential opportunity for laboratory medicine is obvious. Mike Davidge from NHS Elect described how to use data in campaigns, the methodology being similar to quality improvement methodologies – in this case “decide the aim, chose the measures, define the measures, collect the data, analyse and present the data and then review the measures, with the last three actions being the basis for ongoing cycles. This could be a useful approach to promote change - in technology adoption and benchmarking activities. The final presentation in this session was from Dan Wellings on the Friends and Family Test.

ACB News | Issue 620 | December 2014

This tool is intended to gain insight into patient experiences through the medium of whether patients would recommend the services they have experienced to friends and family. Clearly the core of this is qualitative research, as well as having a quantitative element. It is obvious that this will be important for laboratory medicine as laboratories get closer to patients.

Team Approaches Key The afternoon session began with a choice of workshops covering Schwartz Rounds, experience-based co-design, benefits of listening to patients and the role of patient leaders. Schwartz Rounds are multidisciplinary meetings to review experience; do laboratory medicine professionals attend these meetings? Research into the effectiveness of Schwartz Rounds shows the positive impact that they have on individuals, teams, patient outcomes and organisational culture and implementation of new programmes etc. As patients begin to have direct access to their results, these rounds could become very important to the outward facing laboratory medicine service. The session on experience-based co-design described successful approaches to patient experience projects and emphasised the importance of a team approach to projects, and which could be an important adjunct in the design of outcome studies of new laboratory investigations. The workshops were followed by a number of case studies illustrating points made in the earlier sessions of the day. Was this a useful day? Most definitely and as a “quantitative researcher” it was valuable to gain a better appreciation of the use of “qualitative research”, the common theme being the need to be aware of robust methodology, as well as the importance of critical appraisal and communication skills. As we begin to think more about value-based healthcare and the contribution of laboratory medicine to this philosophy, and the more direct links between the laboratory and individual patients, the learnings from the day were appreciated. ■

Crossword | 25

The Colley Christmas Cracker 2014 We must look back in ACB News some time and see when this Crossword first appeared! Anyway, never mind about the past, this is the future! Once you have completed the crossword pass this page through the photocopier to make a PDF. Then, email it to [email protected] by Monday 29th December. Every correct solution will receive a suitable reward. Next month we are back to our normal crossword along with some useful laboratory tips.

The grid is symmetrical in both dimensions. Clues are arranged in alphabetical order of their solutions.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Vinegary hermit misses end of stories (6) A sweet child has desire to be back in committee on organ failure (5,6,6) Farewell in lead diode (5) Father is not shut up in gas (2) Short short is husky (4) Part of large vessel for fizzy drink (4) Rod sounds grave (6) Do this to butter to explain (7) Bar balances (13) Palindromic omission from four (3) Baited, gross with complication (6) Sort of exit without end bores (5) Curtailed fourteen to give space (2) French fin (2) Company car (6) Element of Union (2) Headless needlewoman and sheep, right in jug (4) Cut out tax (6) Former lover colours, when Midge's gone out of existence (7) Eastern snowman for rude Roman (5) For example, I’m in reverse to donate in Aberdeen (3) This should sell well if it's the last (3,4) This audible desire produces a phalanx (7) I would have roughly been a princess (3) Burned in, a mix of units (5) Technology from back end of twenty (2) Behold Californian metal ? (2) Variable skill is hidden (6) Recline briefly, for about a third of a mile (2)

30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58

Of more importance as a Prime Minister (5) Mother, female, has disease (6) Scorer for monitoring malignancy (6) Female document? (2) Odd grimace, two thirds silent letter (2) Negative drama (2) Sound, when back in sublime Sion's realm (5) Sounds painful when bird is detailed (2) Lever of the foot (5) Generate fifty-eight with cleverness; give me the bird (6) Sanctimonious letter (2) Gangster follow case of the feet (5) Poet gives right hand for European, not eastern, gets starch (7) One of numerous roots (5) This testing done by a jerk? (6) Learn about the kidney (5) Edible root used for duties (4) Does this spin both ways ? (5) Are you metallic ? (2) Kaolines mixed with tablets are unlikely to cure (5,3,5) Immediate blood test blemish (4) Confused masters of consciousness (7) Appreciate container containing Hydrogen (5) Tail-less bird can have tea, at a push (5) Rings confused fracas (4) Corporation belonging to us shows growth (6) Inconvenient loss of guardianship approaching (4) You’ve arrived, sounds like waste. (4) Sort of accustom to pass this (5)

Issue 620 | December 2014 | ACB News

26 | Situations Vacant

To advertise your vacancy contact: ACB Administrative Office, 130-132 Tooley Street, London SE1 2TU Tel: 0207 403 8001 Fax: 0207 403 8006 Email: [email protected] Deadline: 26th of the month prior to the month of publication Training Posts: When applying for such posts you should ensure that appropriate supervision and training support will be available to enable you to proceed towards HCPC registration and the FRCPath examinations. For advice, contact your Regional Tutor. The Editor reserves the right to amend or reject advertisements deemed unacceptable to the Association. Advertising rates are available on request.

ACB News | Issue 620 | December 2014