ACBNews

The Association for Clinical Biochemistry & Laboratory Medicine | Issue 605 | September 2013

In this issue

Commercial
Pathology
Provision in
Germany
Explained

Strategic
Project Team
Apologise for
Failed Midland
Tender Process

Bird’s Eye
View of
Tooley Street

Welcome Back
to Liverpool
in 2014
About ACB News
The Editor is responsible for the final
content. Views expressed are not
necessarily those of the ACB.
Editor
Dr Jonathan Berg
ACBNews
The monthly magazine for clinical science
Department of Clinical Biochemistry
City Hospital
Dudley Road Issue 605 • September 2013
Birmingham B18 7QH
Tel: 07973-379050/0121-507-5353
Fax: 0121-507-5290
Email: jon@bergfamily.co.uk
General News page 4
Associate Editors
Mrs Sophie Barnes
Department of Clinical Biochemistry
12th Floor, Lab Block Practice FRCPath Style Calculations page 10
Charing Cross Hospital
Fulham Palace Road
London W6 8RF
Email: sophie.barnes@imperial.nhs.uk
Current Topics page 12
Mr Ian Hanning
Department of Clinical Biochemistry
Hull Royal Infirmary EuroLab Focus 2014 page 14
Anlaby Road
Hull HU3 2JZ
Email: ian.hanning@hey.nhs.uk Meeting Reports page 18
Dr Derren Ready
Microbial Diseases
Eastman Dental Hospital
University College London Hospitals (UCLH)
ACB News Crossword page 21
256 Gray’s Inn Road
London WC1X 8LD
Email: derren.ready@phe.gov.uk Situations Vacant page 22
Mrs Louise Tilbrook
Department of Clinical Biochemistry
Broomfield Hospital
Chelmsford
Essex CM1 5ET
Email: louise.tilbrook@meht.nhs.uk
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Laboratory Medicine
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Issue 605 | September 2013 | ACB News

4 | General News

MHRA Alerts Sudoku

GlucoMen LX Sensor blood glucose test
strips used with the GlucoMen LX and This month’s puzzle
GlucoMen LX PLUS
Affected lots have been contaminated during
manufacture, and may give an overestimation
of blood glucose levels, potentially resulting in
inappropriate insulin administration.
The manufacturer distributed the affected
lots in the UK via wholesale outlets during
October and November 2012. The product
may, however, still remain with users or
pharmacies. There is currently no evidence
that UK patients have been affected.
Identify and quarantine affected strips which
are Lot 3212214249, expiry date 31-08-2014
and lot 3212219249, expiry date 31-08-2014.
Identify patients using these meters and advise
them that they should return and not use Last
strips from the affected lots. Ensure that users month’s
who return strips from the affected lots can
continue to monitor their blood glucose.
solution
Contact Menarini to arrange the return of
any strips from the affected lots.
Further information from Tony Jones,
A.Menarini Diagnostics. Tel: 0118 944 4100,
Email: tony.jones@menarinidiag.co.uk I

ACB News | Issue 605 | September 2013

6 | General News

Pathology Ski Trip . . . Open to All

Clem, the SWBH ski guide, with some of his flock

A number of people commented on the
teambuilding article a few months ago and in
particular the laboratory ski trip. SWBH
Pathology are booked to go to the Austrian
Alps again this year. There are sixteen of us
going at present and we have our own ski
guide/trainer for those who are not rampant
black runners!
If there are laboratories that would like to
tag along then you are very welcome.
You need to be able to ski to a blue/red run
standard to be able to ski with our guide.
You could book yourself into lessons if you
were less competent. We are all pretty keen
skiers, but of course we do let our hair down
in the evenings but not so late as to impair our
ski turns the next morning!
There are still places available in our hotel or
others close by. We are going to Hinterglemm,
which is a small village close to Salzburg.
We are booked the week beginning 26th
January, flying out of Birmingham, though
you could fly from another regional or London
airport with our tour operator. Hinterglemm-
Saallbach resort is well known for good value,
excellent skiing and fun après ski. If you are
interested in coming along and benefiting
from a group of friendly and like-minded
laboratory staff please contact:
raj@cityassays.org.uk for further details. I

HCPC Registration
Members with HCPC Registration should have recently received a
registration renewal reminder. If anyone has not yet responded
they should do so immediately. If anyone has not received the reminder,
they should contact the Health and Care Professions Council;
Email: registration@hcpc-uk.org or Tel: 0845 300 4472.

ACB News | Issue 605 | September 2013

 General News | 7

Strategic Projects Team ACB Wales

Apologise as North West Region
Midlands (Lot 2) Pathology Autumn
Tender Abandoned
The tender placed in January 2013 for Community Pathology
Scientific
Services for CCGs covering Birmingham to Stoke was formally
abandoned on 15th August. Reasons given for this included
Meeting
changes in strategy and priorities of Commissioners, which
had been influenced by:
The Biochemistry
N Reduced clinical and financial benefits.
of Neurological
N Changes in PCT and CCG strategic aims. and Muscle
N Increased clinical, financial and operational risk of moving Disease
to new models of service delivery.
N Reduction in the importance of transforming pathology
Thursday 24th
compared to other CCG priorities. October, 2013
The Strategic Projects Team also alluded to those Birchwood House,
Commissioners who wished the tender to still proceed
University Hall, Cardiff
considering whether or not to initiate alternative
procurements. The Projects Team also apologised for any Further details from:
inconvenience caused by the abandonment of the tender Fiona Stratford at Email:
process. I fiona.stratford@wales.nhs.uk

Issue 605 | September 2013 | ACB News

8 | General News

MHRA Alert (2013/058)

OrthoBioVue Multi-reagent Blood Grouping
Cassettes
A small number of multi-reagent cassettes in
affected lots have been found with labels
containing product information on the wrong
side of the cassette.
The use of affected multi-reagent cassettes
may lead to false negative or false positive
results, causing a potential misclassification
of the patient or donor blood groups or
Rh/K phenotypes or incorrect antibody
detection results. This may be of particular
clinical concern where there is no confirmation
of the group, for example in testing of
newborns or where reverse grouping is not in
place.
Ortho Clinical Diagnostics have sent out a
Field Safety Notice having identified the cause
of the manufacturing issue and users should
take the following actions:
N Do not use and quarantine products from
affected lots received prior to 5 July 2013.
Contact the manufacturer urgently for
replacement product.
N Products from affected lots received prior
to 5 July 2013 should be used only where
no alternative stock is available and must
be inspected prior to use.
N Discard products from affected lots
received prior to 5 July 2013 once
replacement stock is available for use.
N Consider the need to review patient
results from the affected lots.
Contacts for Ortho Clinical Diagnostics:
Laurent Oliviero, Marta Carnielli and
Nick Gould. Tel: +33 1 5500 3250,
Email: regaff@ocdgb.jnj.com I

ACB News | Issue 605 | September 2013


MHRA Alert (MDA/2013/061)
Vacutainer Multiple Sample Luer Adaptor
for Blood Sample Collection
BD has received reports where the retractable
sleeve, which covers the non-patient cannula
before and after a blood collection tube is
filled, has either failed to recover on removal
of the sample tube, leaked, or fallen off.
Reports have also been received of leakage at
the Luer tip connection.
This gives increased risk to users of exposure
to blood, and a risk of underfilling of blood
collection tubes, which could lead to
unexpected results in some laboratory tests.
Actions to take:
N Identify affected lots and ensure that all
relevant staff are aware of the
General News | 9
recommended actions in the
manufacturer’s Field Safety Notice
including continuing the use of
universal/standard precautions and
ensuring that filled blood collection
tubes meet the required fill volume as
indicated on the specific tube prior to
processing.
N Contact BD for replacements of products
from affected lots if a local risk assessment
indicates.
Company contact: Lorna Darrock, Becton,
Dickinson and Company, Tel: 01865 781 545,
Email: lorna_darrock@europe.bd.com I
Issue 605 | September 2013 | ACB News
10 | Practice FRCPath Style Calculations

Deacon’s Challenge
No 148 - Answer
It is becoming increasingly common practice to replace pH with hydrogen ion concentration
when reporting acid-base data. Analysis of cord blood in a neonate gave a hydrogen ion
concentration of 66 nmol/L, with a pCO2 of 7.4 kPa and an actual bicarbonate of 20 mmol/L.
After taking steps to improve ventilation and circulation the end-expiration pCO2 is 5.1 kPa and
the actual bicarbonate of 16 nmol/L. Calculate the new hydrogen ion concentration in nmol/L,
stating any assumptions made.
FRCPath, Autumn 2012

Method 1
Insert the new values for pCO2 and bicarbonate into the Henderson-Haselbalch, solve for pH
then convert this to hydrogen ion concentration. This approach requires knowledge of pKa (6.1)
and the Bunsen coefficient of CO2 (0.225).

pH = pKa + log10 [HCO3–]

αpCO2

pH = 6.1 + log10 16
0.225 x 5.1
= 6.1 + log10 13.94
= 6.1 + 1.14
= 7.24
pH = - log10 [H+] which rearranges to [H+] = antilog10 (-pH)
Therefore [H+] = antilog10 (-7.24) = 5.8 x 10-8 mol/L (to 2 sig figs)
Converting to nmol/L, [H+] = 5.8 x 10-8 x 109 = 58 nmol/L

Method 2
Using the constant of 180 which is the hydrogen ion concentration (in nmol/L), multiplied by the
bicarbonate concentration (in mmol/L) and divided by the pCO2 (in kPa):

180 = [H+] [HCO3–]

pCO2

which can be rearranged and evaluated:

[H+] = 180 pCO2 = 180 x 5.1 = 57 nmol/L (to 2 sig figs)
[HCO3 ]
– 16
This is the simplest method but requires knowledge of the 180 factor.

ACB News | Issue 605 | September 2013

 Practice FRCPath Style Calculations | 11

Method 3
It is possible to use the relationship between the hydrogen ion concentration, pCO2 and
bicarbonate concentration without utilizing any numerical constants:
K = [H+] x [HCO3–]
pCO2
where K is a constant with components from the equilibrium constants for carbonic acid
formation and dissociation, water concentration and the Bunsen solubility coefficient for CO2.
Therefore the parameters both before and after treatment are related:

Initial [H+] x Initial [HCO3–] = Final [H+] x Final [HCO3–]

Initial pCO2 Final pCO2

It does not matter if the units for the individual components differ as long as they are the same
on both sides of the equation.
Rearrangement gives the following expression for the final hydrogen ion concentration:
Final [H+] = Initial [H+] x Initial [HCO3–] x Final pCO2
Initial pCO2 x Final [HCO3–]
Substitute: Initial [H+] = 66 nmol/L
Initial pCO2 = 7.4 kPa
Final pCO2 = 5.1 kPa
Initial [HCO3 ]– = 20 mmol/L
Final [HCO3–] = 16 mmol/L
Final [H ]
+ = 66 x 20 x 5.1 = 57 nmol/L (to 2 sig figs)
7.4 x 16

Question 149
You are provided with the details of the alkaline phosphatase method used in your
laboratory. Calculate the serum alkaline phosphatase activity in a sample for which the
absorbance change was 0.073 absorbance units over 270 seconds.
Method details:
Serum alkaline phosphatase activity is measured by monitoring the rate of hydrolysis of
p-nitrophenyl phosphate to p-nitrophenol. p-nitrophenol has a molar absorption coefficient
of 18,700 L.mol-1.cm-1. By convention, 1 U alkaline phosphatase is defined as the amount of
enzyme that results in the formation of p-nitrophenol at a rate of 16.67 nmol per second
under standard conditions. Your laboratory analyzer uses 5 µL serum diluted with 250 µL
reagent in a 0.5 cm light path cuvette. Absorbance is monitored over a period of 270
seconds during which a linear increase in absorbance is expected.
FRCPath, Autumn 2012

Issue 605 | September 2013 | ACB News

12 | Current Topics
Modernising Pathology
Commercial Lessons from
Europe
Hugh Risebrow, Managing Director, synlab UK
Following recent articles
about tendering in East of
England and East and West
Midlands here is a view
from one of the private
companies trying to offer
their pathology services to
the NHS
Developed economies around the world are
currently facing similar challenges to contain
healthcare spending in the face of a steadily
increasing demand. Pathology can be a soft
target for budget cuts in all health economies
and in the UK, many pathology departments
have lacked significant investment for many
years. At the same time there is a shortage of
scientific and medical staff working in
pathology across Europe, with some NHS labs
already struggling to attract new staff and fill
out of hours rotas. Long, drawn-out
consultation and re-organisation processes do
little to attract more into the profession.
The Audit Commission first called for
pathology reform in 1993, followed by two
reports by Lord Carter of Coles in the past
seven years. Carter conservatively suggested
potential savings of over £500 million per
annum from the creation of a hub and spoke
model. However, in spite of many inter-
hospital reviews of pathology services very few
NHS labs have been merged and most NHS
hospitals have duplicated pathology services.
So, what are the lessons from other health
economies which would help the NHS tackle
current financial, staffing and quality
challenges? All health systems have their own
ACB News | Issue 605 | September 2013
nuances and differences and there is no
universal ‘silver bullet’. However, Germany
now has the lowest pathology costs in Western
Europe and has relied largely on market forces
to deliver a reconfiguration, the outcome of
which looks very similar to the hub and spoke
model which Lord Carter recommended for
NHS England.
Germanic Experiences
Fifteen years ago, Germany had around 800
independent labs. Most hospitals, then 70%
public and 30% charity owned, also ran their
own laboratories. There was, and still is, a
tariff for direct access, including most
outpatient pathology.
Starting with a big bang 35% reduction in
1999, the German system has progressively cut
the tariff to where it is equivalent to circa 40%
of NHS reference costs for similar tests. Further
cuts in pathology tariff have happened and a
further 16% will be implemented by 2014. GPs
and community based specialists, have always
been free to choose which lab to send samples
to which means that laboratories compete on
service, quality and interpretive advice but,
because of the tariff, not on cost.
The pathology landscape in Germany is now
very different. With the exception of teaching
hospitals which have reference laboratories,
most DGHs only have an essential laboratory,
providing those analyses where results
are needed in less than 2 hours and
cross-matching for transfusion. Biomedical
Scientists are, as is the norm on the continent
and also in the British armed services, cross
trained in all disciplines.
Many of these essential laboratories are
managed by specialist pathology companies as
German hospital Directors would not see
pathology as core business and prefer to use

the space for revenue generating beds.
Five major pathology groups, of which
synlab is the second largest, now provide
around 60 per cent of the addressable
pathology market.
So what have the successful groups done to
thrive in an environment of severe tariff cuts?
N Optimise laboratory configuration:
An appropriate split between essential
service laboratories on hospital sites, large
hubs and specialist laboratories. Hubs
typically process 10-20,000 blood tubes per
day and 1500-2500 microbiology samples.
N Essential service laboratories, even in 500
bed DGHs offering maternity and trauma,
may only have 10 WTEs, with 4 at peak
times and 1 multi-disciplinary BMS at night.
Some smaller hospitals now close their
laboratories at night and courier
emergency samples such as paediatric CSF
to the hub laboratory if close enough.
N Specialised testing is done at scale: synlab
has two centres doing cervical cytology
with the largest doing 1400 slides per day.
The largest molecular facility undertakes
over 1200 PCR tests per day.
N Procurement: Through standardising
platforms by sub-specialty and moving to a
price per reported result, which covers
equipment, maintenance, consumables and
reagents, large groups can purchase at
prices much lower than NHS organisations.
N Robust IT: This type of integrated hub and
spoke system only works if supported by
robust IT. synlab’s main data centre
supports all of its laboratories in Germany
and increasingly those in the 20 other
countries where the company operates.
A centralised data management approach
Current Topics | 13
reduces IT costs and increases system
reliability and up-time.
N Lean process & continuous improvement:
Samples are bar coded once at the point of
blood collection and this bar code is used
throughout the process. The use of order
communications by GPs is much lower
(<20%) than in the UK but slick OMR/OCR
scanning systems combined with high levels
of automation in pre analytics ensure this
does not cause delay. ISO 15189 is in place
in most large labs.
N Appropriate use of automation:
Automation is used in areas where there is
a clear payback and or quality
improvement. Most UK visitors to German
hub labs are surprised to see stand-alone
high volume analysers rather than tracks
but are generally impressed by the
effectiveness of pre-analytic automation.
N Training of customers: Through the synlab
academy we invest heavily in training
customers, for example in phlebotomy and
centrifugation using equipment which we
provide and maintain.
N Logistics: Dynamic route planning and the
careful scheduling of inter-laboratory
transfers are central to delivering a cost
efficient but high quality service.
The German pathology system demonstrates
that ‘Carter type reconfiguration’ can
generate savings and improve quality,
albeit that the German starting point and
route to reconfiguration were very different.
However, the use of a national tariff to drive
service reconfiguration has proved to be an
effective strategy rather than cumbersome,
costly and fragile large scale tender
processes. I
Issue 605 | September 2013 | ACB News
14 | EuroLab Focus 2014

Welcome Back to Liverpool . . .

EuroLab Focus 2014 will Key Organisers for
be held in Liverpool, EuroLab Focus 2014
7th–10th October 2014 Mr Gilbert Wieringa
Chair, EuroLab Focus 2014
Welcome back to Liverpool, the site for Focus Dr Ian Watson
2012, welcome to the third joint Conference of President, EFLM
the Union of European Medical Specialists Dr Lena Norlund
(UEMS) and the European Federation of President, Section of Biopathology, UEMS
Clinical Chemistry & Laboratory Medicine
(EFLM) to be hosted by the ACB, and
The Conference brings together Europe’s
incorporating Focus 2014. Founded in 1958,
Specialists in Laboratory Medicine in a
UEMS is the representative organisation for
scientific programme that focusses on
1.6 million medical specialists in 34 countries
laboratory medicine’s practice and
across Europe. Established in 2008, EFLM
contribution to health and healthcare across
incorporates EC4 and is the European branch
Europe. Where do we overlap in what we do?
of IFCC. Both organisations’ objectives are to
Where do we differ? What can we learn from
promote better science, higher quality
each other? More details of a programme that
education and training, and improving patient
reflects our roles at the clinical interface and
outcomes through the highest standards of
stimulates us to consider how we can enhance
laboratory medicine practice. For our newly
our contribution will follow in successive
named Association for Clinical Biochemistry
articles for ACB News.
and Laboratory Medicine this is an opportunity
For industry, the conference is the key
to set a precedent by attracting colleagues
platform for engaging delegates across
from within UK and across Europe to a
Europe. Participation packages include
multi-disciplinary laboratory medicine
opportunities for wider involvement and
platform.
promotion; Liverpool’s BT Convention Centre
allows easy access to exhibitors wishing to
launch their latest advances in technology.
The Exhibition Centre will form an integral
part of the scientific programme.
Liverpool
Following Lisbon (2010) and Dubrovnik (2012),
Liverpool is proud to be the host city for this
Congress series; appointed a UNESCO World
Heritage Site status in 2004 as well as The
European Capital of Culture in 2008, Liverpool
is a thriving, bustling conurbation at the heart
of North West England. We are delighted that
Liverpool’s BT Convention Centre will act as
host venue. Opened in 2008, it is a stunning
waterside location close to the Grade 1 listed
Albert Docks (home to Tate Liverpool and The
Beatles Story), Liverpool One shopping centre
and the famous ferry across the Mersey.
The Walker Art Gallery is home to a stunning

ACB News | Issue 605 | September 2013


collection of paintings and sculpture from the
13th century to the present day. Other
museums around the city include the World
Museum, Merseyside Maritime Museum,
International Slavery Museum and the
Museum of Liverpool. The Royal Philharmonic
Orchestra is the UK’s oldest surviving
professional symphony orchestra dating from
1840 and gives over 60 concerts each season in
its home town under the leadership of Chief
Conductor Vasily Petrenko. From time out at
a waterfront café to wining and dining in the
cultural quarter, the choice is endless.
With 5,000 luxury and budget hotels within
walking distance of the centre, a good night’s
sleep is never far away.
The Science Programme
The emerging programme is designed to
appeal to individual laboratory medicine
disciplines as well as a strong cross-disciplinary
theme focussing on the patient’s interaction
with laboratory medicine. Topics include
patient empowerment, childhood diabetes,
presenting data for patients, a debate on
‘over-the-counter’ point of care testing, and
tackling the alcohol epidemic. The ACB’s
Education Committee will be organising two
EuroLab Focus 2014 | 15
Training Days over 6th and 7th October with a
multi-disciplinary theme. Updates on the full
scientific programme will follow in further
ACB News articles.
Social Programme
The social programme will promote many
attractions in and round the BT Convention
Centre including:
The Albert Docks; Situated in the largest
group of Grade I listed buildings in the UK,
the Albert Dock is the most is the most
popular free tourist attraction in the
Northwest and is home to venues like Tate
Liverpool, The Beatles Story, The Slavery
Museum and The Maritime Museum.
(www.albertdock.com).
Liverpool’s cathedrals: Both the Catholic
and the Anglican cathedral are buildings of
outstanding beauty open to visitors during
the day and sometimes in the evening for
specials events and concerts (www.liverpool-
metrocathedral.org.uk and
www.liverpoolcathedral.org.uk).
The Walker Art Gallery: Home to a
stunning collection of paintings and sculpture
from the 13th century to the present day
(www.liverpoolmuseums.org.uk/walker).
Issue 605 | September 2013 | ACB News
16 | EuroLab Focus 2014

The Cavern Club: Made famous by

The Beatles this is the cradle of British pop
music. Impressively, 55 years after its
foundation, it survives and thrives as a
contemporary music venue
(www.cavernclub.org).
Magical Mystery Tour: For the best Beatles
tour of Liverpool step aboard the colourful
Magical Mystery Tour bus for a fun and
fascinating 2 hour tour of Beatles Liverpool.
(www.visitliverpool.com/buy-tickets).
The Williamson Tunnels: The Williamson
Tunnels Heritage Centre is the only tourist
attraction in Liverpool dedicated to 19th
Century philanthropist Joseph Williamson.
Visitors to the Williamson Tunnels Heritage
Centre can take a guided tour through a
section of the network of tunnels and view
exhibits and displays which depict the life and
times of one of Liverpool’s most eccentric
characters. Available to visit on Thursday 9th
of October between the hours of 10:00-17:00,
the last tour is at 16:00. Wednesday 8th October
(www.williamsontunnels.co.uk). Reception in the Exhibition Hall: For delegates
and diagnostics industry representatives alike,
Tuesday 7th October a chance to relax after the day’s events before
Welcome Reception at the Museum of venturing out to see the sights in and around
Liverpool: The Museum of Liverpool reflects the conference centre and hotels. As well as
the city's global significance through its opportunities to access some of the venues
unique geography, history and culture. mentioned above. Or spend an evening in one
Visitors can explore how the port, its people, of the many restaurants in and round the
their creative and sporting history have shaped Albert Docks and Liverpool One.
the city (www.liverpoolmuseums.org.uk). Late night: Focus Fringe at the Pan Am
Blue Bar situated in the Albert Dock:
An annual event for Focus conferences pulling
together ageing lab rockers and budding
singers in a succession of blues and rock bands
that never quite made it to the top of the
charts but knew how to have a good time.
Book early, it’s usually a sell-out!
(www.panambarliverpool.co.uk).

Thursday 9th October

Conference Dinner – St George’s Hall:
Situated within walking distance of the
conference centre and hotels, St George’s Hall
is widely regarded as one of the finest
neo-classical buildings in the world. The Hall
opened to the public in 1854 and is a World
Heritage venue. Enjoy an evening amongst

ACB News | Issue 605 | September 2013


friends and colleagues accompanied by a
string quartet, followed by the opportunity to
dance along to one of Liverpool’s DJs
(www.stgeorgesliverpool.co.uk).
Accessibility
N Two international airports (Manchester
International Airport, 60 km and Liverpool
John Lennon Airport, 10 km) providing
access from across Europe.
N London to Liverpool rail service 18 times
per day, journey time 2 hours 18 minutes.
N Rail connections from all major UK cities
with Liverpool Lime Street a 15 minute
walk from the venue.
N Black cab taxis and frequent bus services to
and from the venue.
EuroLab Focus 2014 | 17
N Local motorway networks.
N Extensive car parking facilities surrounding
the venue.
N Ferry passenger services from Belfast,
Dublin, Isle of Man.
N All venues Disability Discrimination Act
compliant.
Save the Dates!
Keep an eye on the website
(www.eurolabfocus2014.org) and on Twitter
(@eurolabfocus) for the latest updates on the
programme, registration information, bursary
awards and news breaks as they happen.
We look forward to meeting old and new
friends in Liverpool in 2014. I
Issue 605 | September 2013 | ACB News
18 | Meeting Reports

Obesity and GI Disorders

Elizabeth Palmer, Cwm Taf and Rachel Brixey, Cardiff
This year the Spring ACB Wales Meeting was
held in Llanelli at the beginning of May.
Professor Roy Sherwood from King’s College
Hospital, London started the meeting with the
interesting topic of faecal markers of
gastrointestinal tract inflammation. Professor
Sherwood described how the number of
patients being referred to the
Gastroenterology Outpatients is increasing
each year, with irritable bowel syndrome (IBS)
accounting for 50% cases. The audience was
reminded that the symptoms of IBS are very
similar to inflammatory bowel disease (IBD)
but the treatment is very different, therefore
correct diagnosis is important. Colonoscopy is
the gold standard procedure for identifying
IBD but is invasive, expensive and of limited from Bangor who was awarded an OBE this
availability. Roy presented evidence from year for his services to the NHS in Wales.
several studies demonstrating significantly Dr Russell Caravan, Consultant
higher faecal calprotectin concentrations in Gastroenterologist at Bronglais General
patients with organic bowel disease compared Hospital, Aberystwyth, gave the second talk of
with IBS and how faecal calprotectin strongly the meeting on the current challenges in
correlated with histology in symptomatic diagnosis and treatment of Crohn’s disease.
patients with IBD. The positive predictive value The audience was reminded that Crohn’s
of faecal calprotectin was shown to further disease is not common, with a prevalence of
increase when used in combination with the 30-50 per 100,000. There are two peaks in the
Rome III criteria, used in the assessment of diagnosis of Crohn’s, the teens and twenties,
symptoms for IBS. Currently routine practice at and the 50-70s. However, many patients do
King’s College Hospital is for all patients to not go to their GP with symptoms of Crohn’s
have faecal calprotectin measurement and or IBS and therefore do not get referred.
Rome III criteria assessment prior to referral to The current score system that is in place to
a Gastroenterologist. A normal faecal help determine the severity of Crohn’s is based
calprotectin result at this stage allows the
more rapid exclusion of IBD, therefore limiting
lengthy, expensive and unnecessary
investigations in this group of patients, while
conversely providing a more rapid
investigation time for patients with high
faecal calprotectin.
Crohn’s Disease
An Award’s Ceremony followed for the
recognition of colleagues that are retiring this
year: Gethin Roberts who has recently been
working on both the harmonisation in Wales
and the new LIMS project; and Keith Griffiths

ACB News | Issue 605 | September 2013


on the patient’s symptoms. However, this can
be problematic since patients often have
psychological problems. Dr Caravan presented
how it can be possible to use laboratory
measurements such as faecal calprotectin to
help guide treatment strategies, and imaging
techniques to aid diagnosis but these depend
on the expertise of the Radiologist.
Metabolic Complications of
Bariatric Surgery
Mr Jonathan Barry, Consultant Laparoscopic
Bariatric Surgeon from Morriston Hospital,
Swansea, gave the final presentation of the
morning on metabolic complications of
bariatric surgery. Jonathan began by
describing the obesity problem in Wales,
which currently contains 7 out of the 10
regions with the highest rates of obesity in the
UK. It was highlighted that the current
threshold in Wales for bariatric surgery is set
at BMI of 50 and patients must also have
severe and uncontrolled high blood pressure,
sleep apnoea or diabetes. Jonathan suggested
that bariatric surgery in Wales should be
aggressively targeting younger, not as obese
patients with early onset diabetes. Such an
approach would mean that procedures would
pay for themselves within 21/2 years. The
audience was given an overview of the
different types of bariatric surgery available
that can either be restrictive, malabsorptive or
combined. The type of procedure performed
needs to be tailored to the patient and the
patient’s history carefully considered to
maximise the long term success. Finally,
Jonathan finished with a case highlighting the
importance for long term follow-up following
bariatric surgery.
Four Types of Fatty Liver
Following the lunchbreak, Dr Andrew
Yeoman, Consultant Gastroenterologist and
Hepatologist from the Royal Gwent, spoke
about Fatty Liver Disease following the lunch
break. He reminded the audience that there
are four main types of fatty liver disease (FLD):
non-alcoholic (NAFLD), alcoholic (AFLD), drug
related and nutritional. The talk was focused
on NAFLD, which is characterised by hepatic
Meeting Reports | 19
steatosis. Dr Yeomen presented data from a
European study, which showed that 25% of
people with a normal BMI had NAFLD, while
67% of overweight and 94% of obese people
had NAFLD. Extrapolating this to the Welsh
population suggests that 1.4 million people in
Wales will have NAFLD! NAFLD is normally
diagnosed following an incidental finding
from routine LFTs with an isolated rise in ALT
and an ALT:AST ratio of 2:1. It can also be
diagnosed by the detection of fatty liver
observed by USS or a CT scan. It is important to
differentiate between NAFLD and
non-alcoholic steatohepatitis (NASH) and it is
possible to assess the fibrotic score by
Fibroscan, a non-invasive method which
measures the liver fibrosis by transient
elastography. This is an expensive technique
due to the start up cost, but should cut costs
eventually since it will reduce the biopsy need
by 40-60%. The pharmacological treatment
options remain limited due to lack of biopsy
data, but weight loss and exercise remain the
key interventions for steatosis and NASH.
Dr Ross Sadler, Clinical Immunologist for
Oxford University NHS Trust, gave a very
interesting presentation on serological testing
for coeliac disease and IgG4 related disease.
Dr Sadler started by giving a thorough review
of the different serological markers that have
been used in testing for coeliac disease,
highlighting that the most routinely used tests
(anti-tissue transglutaminase and
anti-endomysial antibodies) investigate
autoantibodies of IgA isotype. Dr Sadler
stressed the importance for serum IgA
measurements to identify patients with
selective IgA deficiency who would then need
further IgG specific anti-tissue
transglutaminase and anti-endomysial
antibody testing. The gold standard method
for diagnosing coeliac disease in adults is still
histological examination of a gastric biopsy.
To avoid gastric biopsy in children, the criteria
for diagnosis is a positive anti-EMA and HLA
DQ8/DQ2, and anti-TTG >10x ULRR. However,
this is controversial due to the variability of
testing methods available. The second part of
Dr Sadler’s talk focused on IgG4 related
disease.
Issue 605 | September 2013 | ACB News
20 | Meeting Reports
Audit of Cortisol Use
The final talk of the meeting was by Dr Nadia
El-Farhan, Chemical Pathologist at the Royal
Gwent, presenting the All Wales Cortisol
Audit. A questionnaire for a review of the
screening for Cushing’s syndrome against the
AWCBAG standards was sent out to 13
laboratories, of which 11 were returned.
The audience was shown that there were a
few discrepancies between the different
laboratories and therefore several areas for
improvement.
The reference ranges quoted vary a lot in
terms of the time of day, not all laboratories
have a protocol for low dose DST, and not all
laboratories adhere to the current standards
and perform extraction for the urine free
ACB News | Issue 605 | September 2013
cortisol assay. A second audit was also
performed on the short synacthen test, again
against the AWCBAG standards. There were
quite a few areas highlighted for
improvement following a review of the
questionnaire results. Not all laboratories use
the same test to screen patients for adrenal
insufficiency; half used random cortisol whilst
the other half used 9am cortisol.
Recommended sampling times also varied
between laboratories from 1 sample at 30
minutes, 2 samples at 0 and 30 minutes to 3
samples at 0, 30 and 40 or 60 minutes.
For the interpretive comments, some
laboratories commented on all synacthen tests
whereas others only commented on tests not
requested by an Endocrinologist. I
 Crossword | 21

ACB News Crossword

Set by Rugosa
No honey prizes this month but instead another great ACB News holiday
tip! If you are looking for a late season holiday why not visit Vue de Duras,
where you can do B&B or rent a brilliant 4-person Gite at great rates for
ACB readers. Just 30 minutes from Berjarac Airport and run by the
amazing Hugh and Fiona. Some late season or winter holiday availability,
or why not get in early and book for next summer! Find out more at:
www.vuededuras.com

3 Trainers order rest to contain

persistent dull pain (8)
4 Monitoring investigation makes
men fractious (12)
6 Group headed away from 11
disturbance (6)
7 Tie off vessel on leaving
urogenital operation (8)
8 Eager to leave unorthodox
vegetarianism to get essential
nutrients (8)
11 A chelated dye can be made
from this colourless liquid (12)
15 Hard case disrupted party
game (8)
16 Face fine distributing stimulant
drug (8)
17 Spreading locally, however
possibly via veins (8)
20 Fast rough sport takes
energy (6)
21 Self-seeker carelessly confuses
categories (6)
22 Repair semi or similar
structure (6)

Last month’s solution

Across
1 Differentiate satisfactorily,
arrange ignoring social
element (8)
5 Russian scientist father, opposed
to love, banished sweetheart (6)
9 Part of the CNS thus contains
alarm, suppressing initial
response (8)
10 Reported delay of some
gravity (6)
12 Non-cardiac part of circulation?
Pity my matchless confusion! (9,6)
13 Arranges beforehand gifts
without number (7)
14 Metal press (4)
18 Excitement in the operating
theatre (4)
19 Inculcate representative in New
Latin (7)
23 Data for diagnosis: parameters
follow written
recommendation (9,6)
24 Most dull and uninteresting
about editors’ lost love (6)
25 Emotional outpouring, no time
limits, cry freely (8)
26 Pound store order for
alcohol (6)
27 Sensory organ complex tape
recorder readout (8)
Down
1 Agree seating (6)
2 Areas of interest from factual
short piece of writing? (6)

Issue 605 | September 2013 | ACB News

22 | Situations Vacant

ACB News | Issue 605 | September 2013

 Situations Vacant | 23

To advertise your vacancy contact:

ACB Administrative Office,
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London SE1 2TU
Tel: 0207 403 8001 Fax: 0207 403 8006
Email: acbnewsadverts@acb.org.uk
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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.

Issue 605 | September 2013 | ACB News