The Association for Clinical Biochemistry | Issue 591 | July 2012

In this issue

ManchesterLabs Chop20% from GPPathologyPrices fromAugust 2012

Legionnaires’Disease inScotland

MarshallPlan forACB Finance

OSPETrainingand Advice

InsideVenturePublications

The Association for Clinical Biochemistry | Issue 591 | July 2012

ACBNews

About ACB NewsThe editor is responsible for the finalcontent. Views expressed are notnecessarily those of the ACB.

EditorDr Jonathan BergDepartment of Clinical BiochemistryCity HospitalDudley RoadBirmingham B18 7QHTel: 07973-379050/0121-507-5353Fax: 0121-507-5290Email: [email protected]

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

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

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

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

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

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

ACB Administrative OfficeAssociation for Clinical Biochemistry130-132 Tooley StreetLondon SE1 2TUTel: 0207-403-8001Fax: 0207-403-8006Email: [email protected]

ACB PresidentDr Michael ThomasDepartment of Clinical BiochemistryRoyal Free HospitalPond StreetLondon NW3 2QGEmail: [email protected]

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

Printed by Swan Print Ltd, BedfordISSN 1461 0337© Association for Clinical Biochemistry 2012

ACBNews

General News page 4

Practice FRCPath Style Calculations page 9

Council Matters page 11

Publications page 12

Trainees News page 14

Meeting Reports page 16

Around the World page 19

Obituary page 21

ACB News Crossword page 23

Issue 591 • July 2012

The monthly magazine for clinical science

Issue 591 | July 2012 | ACB News

Front cover: Training day at Focus with practice OSPE questions causingsome stresses and strains

East and West MidlandsGP Pathology TenderingPlans for reconfiguration of GP pathologyacross the East and West Midlands have beenapproved by PCTs. Although a number of areasof the East and West Midlands put up strongarguments to be excluded, ACB Newsunderstands that all PCTs have signed up to theprocess being undertaken by the SHA. A callfor feedback on the proposed specificationunder which tendering will progress was set inmotion in June with a deadline of 11th July2012. The initial proposal for four lots wasreported in the May issue of ACB News and hassince raised many concerns. Feedback on theseproposals has been requested and the finalconfiguration and the number of lots to betendered is expected to be known in earlyAugust.Although in some documents emanating

from the SHA there is still a suggestion thatthe final decision to proceed with an opentender has still to be made the SHAe-newsletter sent on 20th June and availableon their website could not be clearer, stating:“A procurement for services in the region willcommence in the third quarter of 2012 andwill be open to qualified NHS, independentsector and voluntary sector providers in anopen competitive process. Participation will beinvited from all interested and qualifiedorganisations to ensure that we have exploredthe best and most innovative proposals for thisreconfiguration.” �

4 | General News

ACB News | Issue 591 | July 2012

SudokuThis month’s puzzle

Last month’s solution

MHRA MoM Hip . . . New AdviceIssued (MDA/2012/036 Issued25th June 2012)

The MHRA has issued updated informationand advice about the follow-up of patientsimplanted with metal-on-metal (MoM) hipreplacements. The key action which needs tobe in place is updated systems for thefollow-up and investigation of patientsimplanted with MoM hip replacements.This must be completed by 28th August 2012.Following extensive consultation with theMHRA’s clinical orthopaedic experts, theMHRA is issuing this updated advice in themanagement of patients implanted withMoM hip replacements. This advice updatesthe recommendations for patient follow-uppreviously given in MDA/2010/033,MDA/2010/069 and MDA/2012/008.It incorporates updated advice on theduration of follow-up of symptomaticpatients implanted with: MoM hipresurfacing (no stem); and stemmed MoMtotal hip replacements that have a femoralhead diameter <36 mm. To download the fulladvice simply enter the MDA referencenumber in your search engine. �


6 | General News

ACB Trent, Northern & Yorkshire RegionScientific Meeting

Marketing PathologyThursday 18th October 2012The Earl of Doncaster Hotel,Doncaster, DN2 6AD

09:30-10:00 Coffee & Registration

The Pathology Market Place: The New VentureChair: Dr Tim Lang, Consultant Clinical Scientist, University Hospital of North Durham10:00-10:45 The ‘Ideal’ Pathology Service - A GP & Clinical Commissioning Perspective

Dr Nick Summerton, GP, Driffield, East Yorkshire, Author & Advisor(Diagnostics, Screening & General Practice)

10:45-11:30 Introduction to the Science of Marketing & the FutureDr Mariann Hardey, Lecturer in Marketing, Durham Business School

11:30-12:15 Producing Publicity and Using it EffectivelyDr S Lishman, Vice-President of Royal College of Pathologists andLead for National Pathology Year

12:15-13:15 Lunch

Marketing Tools & ExperiencesChair: Mrs Hazel Borthwick, Principal Clinical Scientist, County Durham and Darlington NHSFoundation Trust13:15-14:00 Using www2.0 to Publicise the Laboratory – Tips on Making the Web Work

for YouMr Craig Webster, Consultant Clinical Scientist, Heartlands Hospital,Birmingham

14:00-14:45 Professional Marketing Communications is Vital for PathologyDr Jonathan Berg, Pathology Director, SWBH NHS Trust, Birmingham

14:45-15:30 Experiences of a Lab AmbassadorMr Bill Chaffe, GP Liaison Officer, Dept of Laboratory Medicine, East KentHospitals University NHS Foundation Trust

15:30-15:45 Coffee15:45-16:15 Panel discussion

Registration:ACB Members: £50 Non-ACB Members: £80

Payments can be made online via the Association for Clinical Biochemistry website at www.acb.orgor send cheques payable to Association for Clinical Biochemistry as instructed on the website.

Further information from email: steve.holding.hey.nhs.uk

Microbiology in the NewsDr Zoie Aiken

General News | 7


Imported Case of RabiesA lady died from rabies after being bitten bya dog in South Asia. She was in her 50s andwas reported to have sought medicalattention on three separate occasions beforebeing admitted to hospital in London.She was later transferred to the Hospital forTropical Diseases and died a few days later.As the virus is spread via the salivarysecretions of the infected animal, the risk toher contacts was negligible. The finer detailsof her circumstances have been speculated inthe media, although the exact region she wasvisiting in South Asia, how long she wasvisiting for or whether vaccination wouldhave been appropriate for her remainunclear. The Department of Healthrecommends pre-exposure immunisation forall travellers to rabies-endemic areas for visitsgreater than one month, or for those visitingfor less than a month but with an increasedexposure risk due to the nature of their visit.A post-exposure vaccine is available for highrisk patients, immunoglobulin can also beadministered.

http://www.thesun.co.uk/sol/homepage/news/4343585/Rabies-granny-dies-in-hospital.html

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_133118.pdf

Legionnaires’ Diseasein ScotlandSixty-one cases of Legionnaires’ Disease havebeen identified in Scotland’s biggest outbreakof this disease. Legionnaires’ Disease is a lunginfection, often starting with ‘flu-like’symptoms including lethargy, muscle aches,headache, and fever. It can progress topneumonia and death in serious cases.Infection is more common in the elderlycommunity, and men are three times morelikely to contract the disease than women.Legionnaires’ Disease is commonly caused bythe bacterium Legionella pneumophilia and istransmitted by inhaling airborne dropletscontaining bacteria from sources such asshowers or air conditioning units. Around halfof the cases seen in the UK are imported andthis is believed to be due to local inadequatewater treatment. The source of the Scottishoutbreak is still unknown and underinvestigation; a number of water coolingtowers have been treated as a precautionarymeasure.

http://www.telegraph.co.uk/health/healthnews/9318505/Legionnaires-source-still-unknown-as-number-of-cases-continues-to-rise.html

http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/LegionnairesDisease/GeneralInformation/

More Legionnaires’ Disease, but Compost as the CulpritA man in Scotland died after contractingLegionnaires’ Disease, which was thought tobe caused by handling compost. The infectionwas caused by Legionella longbeachae whichis a less common cause of the disease in theUK. This bacterium is released fromdecomposing compost, especially during hotweather. L. longbeachae is a more commoncause of Legionnaires’ Disease in Australia andwarnings about the risk of infection areprinted on bags of compost. Health Protection

Scotland released a warning for gardeners,promoting good hand hygiene after contactwith compost but no other precautionarymeasures have been advocated. A commonsource has yet to be found (i.e. a particulartype of compost or activity); however the riskto gardeners remains low.http://www.guardian.co.uk/lifeandstyle/2012/jun/03/dr-dillner-legionella-from-gardening?newsfeed=true

http://www.hps.scot.nhs.uk/ewr/article.aspx

Coming NextMonth . . .

PathologyPhlebotomyExcesses Revisited

Launch ofPathologyHarmony TumourMarker Guidelinesfor non-specialists

We reported on the possibility of primary carepathology work being tendered in the GreaterManchester last December. At the end of lastyear the Greater Manchester ClinicalCommissioning Board was presented with aproposal from the five acute hospitals inGreater Manchester who currently provideGP direct access work.These hospitals are now working together to

provide a single comprehensive pathologyservice across the patch. This pathologygrouping includes: Wrightington, Wigan andLeigh, Salford Royal, University Hospital SouthManchester, Stockport and Tameside NHSTrusts.These Trusts proposals included:

� 20% reduction in the price GPs arecharged by August 2012, equating to a£7 million QIPP.

� A further 5% reduction in 2014 – givinga further £1.5 million saving.

� Moving to block contract arrangements� Working with Commissioners and the

Network to deliver measurable qualityimprovements of at least 20%.

� Working with Commissioners to reviewappropriateness of activity and in futureimplement robust and measurablevariable contracts.

Bolton NHS Foundation Trust, CentralManchester University Hospitals NHSFoundation Trust and Pennine Acute HospitalTrust indicated they will meet the terms.Central Manchester and Pennine Acuteare exploring opportunities to workcollaboratively and Bolton is also looking forcollaborative partners. The Christie does notprovide services directly to primary care buthas initiated a process to seek a partner.ACB News understands commissioners have

been reassured by this initiative, which isbeing described by some as a locality-widepathology tariff, and that the threat oftendering has now been lifted. �

Local Tariff Style Changesin Great Manchester

Stuart MannStuart Mann worked at Birmingham Children’sHospital in Clinical Chemistry for over 25 years,ending his career as the Pathology BusinessManager. He died unexpectedly on Sunday27th May having celebrated his 69th birthdayin April. Stuart had retired in March 2005.Stuart was sailing on Gailey Pool in South

Staffordshire and had run the first race butdecided it was too windy to carry on andcollapsed while packing up his boat.ACB News sends its thoughts to Stuart’s

family and all former work colleagues whoare saddened by this news. �


8 | General News

Replicate analyses are often employed in an attempt to overcome poor assay imprecision.

a) What is the imprecision (expressed as a percentage of the imprecision for a singlemeasurement) for a mean calculated from duplicate measurements?

b) Calculate the minimum number of replicate measurements required to produce a meanvalue with an imprecision of one half of the value which would be obtained for singlemeasurements.

a) Each individual measurement (value of x) has a standard deviation (s value) equal to thewithin-run analytical s of the assay.

If the assay is performed in duplicate then two results (x1 and x2) are obtained, each withtheir own standard deviations (s1 and s2).

The mean of the two duplicate measurements = (x1 + x2)

2

When two values are added their combined s is the square root of the sum of the squaresof the individual s values (see Question 125). Furthermore when a value is divided by aconstant then the s value must also be divided by the same constant. Therefore the s valuefor the mean (sm) calculated from two values is given by:

sm = √ (s12 + s22)

2

However, s1 = s2 which is the within-run analytical imprecision of the assay (s). Thereforethe above expression can be simplified:

sm = √(s2 + s2) = √2s2 = √2 x s = s = s

2 2 2 √2 1.414

To obtain sm as a percentage of s simply substitute s = 100:

sm = 100 = 71% (2 sig figs)1.414

Therefore performing the assay in duplicate has only reduced the imprecision to 71% ofthat obtained with single measurements.

b) An expression can be derived in a similar way to cover the generalised case where nreplicate measurements are made with values x1, x2........ xn which have standarddeviations s1, s2...... sn:

Mean (m) = (x1 + x2 + .......xn)

n

Deacon’s ChallengeNo 134 - Answer


Practice FRCPath Style Calculations | 9

sm = √ (s12 + s22 + .....sn2) = √ ns2 = √n x s = s

n n n √n

sm is also referred to as the standard error of the mean (SEm) and its formula is wellworth committing to memory:

SEm = s

√n

To find a value for n which reduces the imprecision by a half, substitute s = 1and SEm = 0.5 then solve for n:

0.5 = 1

√n

√n = 1 = 2

0.5

n = 22 = 4

Therefore to reduce the imprecision obtained for single measurements by a half at leastfour replicate analyses are required.

Question 135A teenage male presents to A&E after a session of “binge drinking” with a plasma sodiumconcentration of 125 mmol/L and a body weight of 72 Kg. As no other cause can be foundfor his hyponatremia a diagnosis of “beer potomania” is made. Stating any assumptionsyou make, estimate the fluid excess in litres.


10 | Practice FRCPath Style Calculations

Dr William Marshall, newDirector of Finance for theACB, sets out his stall

You may be tempted to skip this item, butplease don’t. If our Association is to continueto function effectively in relation to its workin the fields of education, publications,engagement with Departments of Health andthe like, it must continue to be successful as abusiness. In the simplest terms, it must havesufficient income to cover its budgetedoutgoings and a sufficient reserve to bufferthe inevitable short term imbalances.

Good Foundations on Which to Work

Thanks to the skills of previous treasurers andall those involved in running financiallysuccessful national and international meetings,our Association owns a long lease on premisesin London that are adequate for its presentneeds and likely to remain so for some years tocome. It also has adequate financial reserves.However, whereas in the past, our annualmeetings were virtually guaranteed to resultin an excess of income over expenditure, this isno longer the case. There are several reasons:trusts may be less willing to release staff toattend (and to support their attendance) atsuch events; the number of companies thathave historically provided generous supporthas decreased as a result of mergers andacquisitions and there is increasing pressure ontheir budgets. At the same time, low interestrates make it impossible to invest money toprovide real income (that is, greater than therate of inflation) without risk.

Reducing Meeting Costs

As many readers will be aware, we are takingthe first step to reducing expenditure on ourannual meeting (without, we hope,

compromising on quality) by moving to auniversity setting (York) for Focus 2013, ratherthan continuing to use commercial conferencecentres.

Excellent Office Support

On the other hand, there are many positivefactors. Our Association has a stablemembership that provides a major source ofincome through subscriptions. Annals ofClinical Biochemistry is becoming anincreasingly highly regarded journal andmakes a profit for us. We have an enthusiastic,highly-skilled and dedicated staff in ourheadquarters building, and a considerablenumber of members. I would estimate at least15% are actively involved in running theorganisation. This includes members ofregional and national committees, tutors,officers and elected members of Council, andthrough contributing to the organisation ofmeetings, our various publications and oureducational and trade union activities.

Get and Give Value

Over the next few months, I intend to make adetailed analysis of our Association’s finances,which will be a major topic for discussion atthe Executive’s autumn retreat.Priorities include making our investments

work harder for us and ensuring that fees,whether for membership or educationalactivities, continue to provide value formoney; and that we get, and give, value formoney in relation to activities where we worktogether with other organisations. Butwhile I have plenty of ideas of my own,I would be grateful for any suggestions thatyou, our members, may have that maycontribute to our continuing to run asuccessful business on which we can base anorganisation that delivers what you want, andof which you are as proud as I am to be amember. �


Council Matters | 11

Value in and Value Out . . .William Marshall

Inside Venture PublicationsMarta Lapsley

12 | Publications


Have you ever wondered how theACB produces the Venture Publicationsseries of books, the latest of which isPrimary Care and Laboratory Medicine?

Book production is a surprisingly complexprocess, the actual printing and distributioncontributing only a very minor part in theporcess. Venture Publications (VP) was formedalmost 25 years ago to provide educationalmaterial for members of the ACB and to givetraining and experience in editing andpublishing. During that time, 19 books havebeen produced, along with several educationalCDs. The key to successful book production isadvance planning, ensuring there is aprogramme of activity for the next 3-4 years.The entire process is managed by members ofthe ACB, with final printing being contractedto an outside company. The challenge for thefuture will be to adapt to the changing worldof publishing, especially embracing newpublication formats and to attract new,younger members to ensure continuity.

Choosing Authors

The VP Committee meets four times a year atthe ACB offices and has regular catch upsessions in between meetings via email.Several members, especially those from ourCeltic branches, use the conference callfacilities to avoid the long travelling times.We usually manage to discuss the progress ofall the books in production as well as considernew books, alternative media and futureprojects within the allocated 2 hour slot.New books and second or subsequent

editions of previous books are suggestedeither from within the committee or byanother member of the ACB. Potential authorsare discussed at the next VP meeting. If thesuggestion sounds reasonable, one of uscontacts the potential lead author to discussthe proposed content and scope of the book.We ask the author(s) to provide a two pagesynopsis with chapter headings and brief

outline of each chapter. The synopsis isdiscussed and amended as necessary by theVP Committee, in agreement with the authors.Once the synopsis has been agreed, the

ACB office sends out an author contractdetailing the responsibilities of both authorsand editors, as well as expected timescales.The VP Committee appoints two editors, oneof whom will be the main contact for theauthors. Authors are asked to send individualchapters to editors as soon as they are ready,rather than waiting until the whole book iscomplete. That allows editors to advise onrelevant content, length and style at an earlystage.

New Publishing and Marketing Methods

The advent of e-mail and electronic documenttransfer has greatly increased the speed ofcommunication between authors and editors,but necessitates meticulous attention toversion control of chapters. Once editors andauthors have agreed the final content of thechapter (usually by the second or thirditeration), the text and figures are sent to oneof the technical editors on the committee,who designs the layout. Proof-reading isusually done by the editors, although authorssometimes express an interest in seeing thepublication at this stage too. The actualprinting part of the process takes a matter ofdays, with distribution of the books tomembers (organised by the ACB Office) takinga further couple of weeks. We aim to completethe whole process from commissioning toprinting within 3 years.We are always keen to welcome new

contributors, whether as editors on thecommittee or as authors of new or secondedition books. Some of the topics we havediscussed but have not yet managed tocommission include:

� Calcium and bone metabolism

� Cancer biochemistry, including not onlytumour markers but also general

ACB Training CourseUniversity of Warwick5th-7th November 2012This new style course is focussed on those preparing to take the FRCPath.In particular, the course centres on those topics that are not in the textbooks.

Topics to be covered include:

� Critical Illness� Interpretation of CSF analysis� Interpretation and application of Dynamic Function Tests� Neonatal Screening� Antenatal Screening� R&D within the NHS� Scientific Writing Skills� Study Design� Health and Safety� IT within laboratories� Clinical Cases

The course fees are: ACB Member £460 (Non-Member £610)and places will be allocated on a first-come, first-served basis.

For further details and to register please go to: www.acb.org.uk/training/trainingabt.asp

biochemistry, molecular aspects andanti-cancer drug biochemistry

� Update of Clinical Investigations andLaboratory Statistics (1st ed) to includecurrent research governancerequirements

� Women’s health and fetal medicine

� Separation techniques and theirapplications in clinical laboratories

� Practical clinical biochemistry

We would also welcome contributions andsuggestions from our microbiology andimmunology colleagues, especially in areasthat are of common interest.With the advent of new technologies and

formats, especially electronic books, we arelooking for people, perhaps from the morejunior end of the membership, who would beinterested in developing the technical skillsneeded to publish some of these titles inelectronic format.

If you would be interested in writing orediting books on any of these topics or inproviding the technical support needed forelectronic publishing, please contact one of usdirectly or via the ACB Office. Current detailsof the committee can be found on the ACBwebsite and in the handbook.

Why Not Join Us?

Do you have a flair for words that could beshared with other ACB members? Have youever dreamt of seeing your name in print?Are you interested in writing or editing books?Do you have the aptitude to develop technicalskills needed for publishing electronic books?We are looking for authors, editors andtechnical editors for the VP series of books(see main article). If you would like anyfurther information or would like tovolunteer please contact Marta Lapsley,Chair of the VP Committee,Email: [email protected] or via theACB Office. �

Publications | 13



14 | Trainees News

The ACB Focus 2012Training Day gave practicalhelp to those who are toface the new style FRCPathPart 2 Examination

At this year’s Focus Training Day, the emphasiswas on the new style FRCPath Part 2 exam thatwas launched in 2011. Dr Andrew Hutchesson,Chair of the Panel of FRCPath ChemistryExaminers, opened up the morning sessionwith an introduction on how the exam isstructured.After passing the theory tested in the

written Part 1, the aim of Part 2 is to testapplication of knowledge in clinical andpractical scenarios to ensure individualscan practise safely and independently.As Dr Hutchesson aptly stated, “ClinicalScientists work as consultants to Consultants”.

New Style FRCPath Part 2Module 1 Paper 1 (3 hour OSPE)

14 Questions4 Calculations1 Communication Scenario

Paper 2 (3 hour Practical)Experimental DesignData InterpretationPractical Work

Module 2 Paper 3(3 hours Written Paper)6 Clinical Cases2 Critical Appraisal ofJournal ArticlesOral2 Examinations (20 minutes):Management and AnalyticalLaboratory and Patient Safetyand Clinical Cases

Ready, Steady . . . OSPE!Dr Susan Vickery, East Kent Hospitals University NHS Foundation Trust


Trainees News | 15

Mock OSPE

It was then all go as everyone took part in asimulated mock Objective Structured PracticalExamination (OSPE) comprising of 10individual stations. With only 9 minutes perstation the race was on to complete all thequestions within the time. It became clear thatthis was not always possible and was all partof the exercise. Trainees were exposed totechniques or clinical scenarios never beforeencountered, as will happen in the realexamination. But, a logical approach often ledto the correct answer. For most, this gave avery real life experience of what to expect onthe day.

Critical Appraisal Skills

The afternoon session tackled how to correctlyassess journal articles found in Paper 3 of theexamination. Trainees were shown appraisaltools such as PICO (Population, Intervention,Comparator, Outcome), CASP (CriticalAppraisal Skills Programme) and STARD(STAndards for the Reporting of Diagnosticaccuracy studies).

Understanding the Statistics

Andy Vail, a statistician from ManchesterUniversity, presented a clear approach tounderstanding basic statistics that are likely toappear in a published paper. We were steeredthrough sensitivity, specificity, negativepredictive value (NPV), positive predictivevalue (PPV), hazard ratios and meta-analyses.Common statistical pitfalls were explainedwith a word of caution that not all publishedpapers have correctly analysed their data.

The Three Minute Abstract

The afternoon session closed with an exercise,led by Sally Benton, on writing abstracts; a skillthat is likely to be examined in Paper 3. Usinga published paper, with the abstract removed,trainees were given 3 minutes to write eachsection; introduction, methods, results anddiscussion. The exercise highlighted the needto pull the important take home messages

from the paper in a concise format and indoing so demonstrate an understanding ofcontent to the examiner.The training day was invaluable for those

individuals preparing to sit the examination.Answers to the mock OSPE questions and allpresentations from the day can be found onthe trainee page of the ACB website.Thanks go to Hazel Borthwick, Sally Benton,

provided the mock questions and arrangingsuch a successful day. Delivering a mockexam for 120 Trainees was no doubt a test initself! �

16 | Meeting Reports


On the 12th April, as part of the ACB Spotlightseries of meetings, we gathered for theinaugural meeting of the LC-MS specialinterest group. The meeting was launched byNeil Leaver with an introduction to the aimsand objectives of this SIG.The first presentation was provided by

Professor Neil Dalton from St Thomas’, Londonand gave both the inexperienced and MS-wisea thorough introduction of the technologyemployed in MS. An introduction to the birthof the use of MS in clinical labs was providedincluding the use a of sewing machine in a labfor paper chromatography and with a clearlesson on why MS was better with achromatographic stage first. Ionisationtechniques and types of mass detectors werecovered. He then discussed factors thataffected sensitivity and specificity and gave aninsight into the problems with isobariccompounds. The presentation concluded witha taste of the capacity for doing multipleanalysis on single samples and the use of MSfor protein analysis.

Not Plug and PlaySandra Rainbow from Northwick Park Hospitalfollowed, providing an overview of what toconsider when choosing a machine for yourlab. The clear message taken from thispresentation was one of doing thepreparation and being realistic on what canbe obtained and achieved. Having a clearknowledge of your goal, an understandingof the, at times, rather mind-bogglingterminology used, and being realistic abouthow long the process will take, stressing thatthese instruments aren’t simply “plug andplay”.The coffee break was followed by Brian

Keevil from Manchester discussing method

evaluation. Lessons learnt included theunderstanding that the same column typefrom different manufacturers will behavedifferently, that transfer of a method betweenthe same machine models will require finetuning and that fragmentation patterns maybe different on different systems; therebyindicating that transfer of methods frompublications is far from straightforward.Consideration should be given to “other”components of a sample and the necessity,where possible, to closely match matricesbetween sample and calibrator. Checks for ionsuppression were also highlighted, not only inthe development phase but as a periodic checkonce a method is up and running. Columnchoice was considered along with potentialinterference from metabolites. The use of bothquantifier and qualifier ions was emphasisedas this provides a constant check for assayinterference and gives greater confidence inthe result. While most of us doing methodevaluation are very familiar with ensuringinformation is gathered with regard to samplestability, in the case of MS analysis where anextract is prepared, we were made aware ofthe advantages of knowing the stability of thisextract in case re-injection is required, savingtime on re-extraction.

Don’t Try and Measure Too Much!Despite the constant assault of advertising ofthe number of analyses that can be performedon a single sample in one run, we werewarned of the dangers of trying to measuretoo much. The dwell time and hence numberof analytical points measured per peak isreduced, having a substantial impact onaccuracy of quantitiation. Key points were tochoose the column carefully, assess the sampleclean up requirement, use a good internal

LC/MS-MS Special InterestGroup Meeting Up andRunningClare Jeffray, Clinical Biochemist, Freeman Hospital, Newcastle upon Tyne

Meeting Reports | 17


standard and have robust calibration.Finally we were all advised to pray for morecommercial field calibration sets.The first part of the afternoon was

dedicated to two current hot topics in LC-MS,immunosuppressants from Neil Leaver (RoyalBrompton & Harefield Trust) and vitamin Dfrom Craig Webster (Birmingham Heartlands).Neil began with a recap ofimmunosuppressant analysis up to the abilitytoday to analyse four immunosuppressantssimultaneously on a single sample. Thelimitations of adding mycophenylate to thisquad was discussed. He highlighted thechanges in requesting patterns and thecontinuing need to improve standardisationbetween laboratories. An indication was givenof the possibilities available with the use ofToF and Orbitrap systems to measuremetabolite profiles that may aid in detectingtoxicity. It was also highlighted that due to thecocktail of drugs this patient group were likelyto be on, the possibility of ion suppression inan individual sample was greatly increased.

Vitamin D analysis was then considered witha discussion of the limitations of immunoassayand the need to consider what we are actuallymeasuring. Craig gave us an insight into howtheir assay was performed with an outline ofthe workflow, liquid-liquid extraction,application (and limitations!) of robotics andchromatographic and analytical conditions.Interfacing was also discussed to provide areduction in the risk with relation toworksheet preparation and result transfer.A final break was followed by a look into

the future with the application of salivary testsby Brian Keevil, from Manchester, blood spotanalysis by Robyn Shea, SWBH Hospitals,Birmingham and how to future-proof thetechnology by Michael Wright fromAddenbrooke’s in Cambridge.

Up and Coming IdeasOur introduction to the arena of salivary testswas into the measurement of steroids, mainlydriven by the advantages to patients andclinicians to be able to take samples at just

about any time of day without a stay inhospital and without venepuncture. Thelimitations of different types of salivarycollection devices were discussed with Brianindicating that they have chosen to use theunstimulated passive drool technique with afreeze-thaw cycle to break down the mucins.The focus was on cortisol and the bestrepresentation of free cortisol. Cortisol andcortisone were considered and followingsubstantial data analysis they determined thatsalivary cortisone is the best equivalentmeasure of serum free cortisol. Theinvestigation of salivary testosterone wasdriven by the lack of specificity ofimmunoassay at low concentrations. Thisapplication appeared to have proven moredifficult as a high sensitivity method wasrequired for measuring low level, usuallyfemale, testosterone.Robyn followed with a discussion of the

history and future of the use of MS in driedblood spot analysis. The advantages of usingblood spots was made clear as was the scopeof their application, a matrix increasingly usedin the pharma industry, especially in children.She introduced the delegates to a pilotvitamin D in blood spot trial at City Hospitaland also to the fact that there are also otherblood spot tests already available commerciallyto the public such as HbA1c. The futurepossibilities of using blood spots were furtherhighlighted by the introduction of thetechnology whereby analysis could beperformed directly from the blood spot usingLC-MS/MS without need for pre-extraction.Could blood spot analysis be our analyticalfuture?Michael Wright concluded the meeting with

a demonstration of what can happen whenyou let an analytical chemist loose on ahumble LC-TMS in a hospital laboratory.We were introduced to the world ofmultiplexing. In light of the constant NHS

drive for efficiency savings the question posedwas topical: “what’s the point of running alate evening batch at 2 min/sample when thesystem then sits unused for 10 hoursthroughout the rest of the night? A very goodpoint, especially when access to theseinstruments during the standard working dayfor method development nears to impossible.Apparently it‘s all about plumbing (and frommy perspective being fairly brave!). With somequite scary pictures of the set-up atAddenbrookes we were taken through theability to put multiple column types, mobilephases and chromatographic conditionsthrough one piece of kit all by use of selectionvalves and column switchers. The exampleprovided was being able to run a batch eachof testosterones, cortisols and vitamin Dsbetween 4pm and 9am leaving the day todevelop other tests on the machine. This isvery appealing, especially with theintroduction of split MS sources so ESI andAPCI methods can be run on the same MS.He highlighted the need to remember thatthere is extensive tubing in the system so thisshould have a small internal diameter toreduce diffusion. Incompatible mobile phasesrequire longer equilibration so the assay ordershould be considered carefully. The benefits interms of cost and efficiency were easy to see.Overall the meeting was an excellent

introduction to the scope of the topic. The keymessages I took home from this meeting werethat though this technology is progressing inclinical laboratories, it is still a relatively newfield of application for the companiesinvolved. This is completely differentinstrumentation to the workhorses that wehave become so accustomed to in thelaboratory. The need for good, dedicated staffin this area, and hopefully our laboratorycolleagues will take up the challenge ofsomething that requires a little moreapplication! �


18 | Meeting Reports

Francesca describes hertime teaching clinicalbiochemistry in Zambia

The Tropical Health and Education Trust (THET)was established in 1988 and is now aninternational development organisation thatworks to improve the health of people inAfrica and Asia. Health services in developingcountries face a multitude of challengesincluding a lack of qualified health workers,inadequate facilities and a critical lack ofmedication. THET organises volunteerprogrammes that rely on UK healthprofessionals to develop the skills of healthworkers in some of the poorest countries inthe world.During the month I was in Zambia I taught

on the Physiology and Pharmacology modulecovering basic principles of endocrinology. Thestructure of the course allowed time forlectures and tutorials each week.

Zambian Contrasts

Zambia, like many African countries, has had aturbulent political past, but is a country full offriendly and welcoming people and isoverflowing with culture and tradition. Themarkets are full of brightly coloured fabrics,fresh fruit and vegetables and all the shopfronts are painted fun colours to attract yourattention. The tourist industry is growing atquite a pace, but most of the country remainsquite unspoilt and undeveloped at themoment. The main tourist destination inZambia is the town of Livingstone and thebreathtaking Victoria Falls at theZambia-Zimbabwe border, described by thelocals as ‘Mosi-oa-Tunya’, the smoke thatthunders. The falls stretch for nearly 2 km witha depth of over 100 m and during the wet

season over a million litres of water fall overthe edge each second – an experience that isextremely well qualified as one of the SevenWonders of the World. Zambia has a fantasticselection of wildlife, and whilst safari parks arebecoming more popular with both locals andtourists, it is possible to find yourselves theonly people in the park on a game drive whichis a truly special experience.Zambia has a growing economy and the

copper industry in the Northern Province hashistorically been the source of much of thecountry’s wealth. However, the life expectancyis just 43 for females and 42 for males, 1 in 5children die before the age of 5 and 1 in 4people are HIV positive.

Teaching at UNZA

THET has been working in Zambia as theappointed management agent for a projectthat aims to strengthen health and medicaltraining. The newest branch of this project isinvolvement in a BSc degree in nutrition at theUniversity of Zambia (UNZA) in Lusaka.Zambia has a high malnutrition rate that is

associated with both high child and infantmortality rates. Chronic malnutrition is presentin 45% of children and this has an extremeeffect on the productivity of the country andthe general health of the population. At theother extreme, Zambia is also experiencing thehealth problems associated with a change inlifestyle such as hypertension and diabetes.The nutritional issues are exacerbated by theother health challenges including HIV/AIDSand tuberculosis.Currently the BSc Nutrition is being taught

from the Faculty of Agricultural Science atUNZA and is in the first year of it running.There is no nutrition faculty as such, but thehead of department, Dr Nyirenda, has a keeninterest in this subject area. The course isbeing taught by a series of lecturers from the

A Zambian TeachingExperienceFrancesca Mills, Trainee Clinical Biochemist, Derriford Hospital, Plymouth


Around the World | 19

20 | Around the World

medical school in Lusaka and Dr Nyirendaherself. THET has recruited volunteers fromthe UK to help teach modules on this coursewhere there is a lack of local knowledge.

Education is the Key

It is an incredibly humbling experience to workin a country where flowing water is notguaranteed every day, electricity is unreliableand access to textbooks or the internet isextremely limited. Although there are starkdifferences between university facilities in theUK and those in Zambia, I have never met agroup of people who are more keen to learn.Of the 23 students in the BSc Nutrition class,the majority of them had been working in theprofession for many years and had given uptheir job to study for the BSc over 5 years.There are no scholarships for these studentsand many of them have young families tosupport. However, education is extremelyimportant, and achieving the BSc will result insignificant career progression for theseindividuals.Initially it was a challenge to know at what

level to pitch my teaching and what previousknowledge to assume. It was important to methat the students asked me any questions andthat they felt comfortable enough to speak to

me after class if they needed to. It’s only a fewyears ago that it was me sat in lectures beingtaught endocrinology and I certainly hadplenty of questions! The students were quietto begin with; I was later told that it isconsidered rude to ask a question of a teacherbecause it implies that they have not taughtwell enough! For the tutorial sessions Iprepared a series of clinical cases withquestions for each of the topics I had coveredand asked the students to work through thescenarios in groups. This type of learning wasreally well received and the class seemed toenjoy it although they did say that it was thefirst time they had done anything like that. Iquickly became very aware of the differencesbetween education in the UK where theemphasis has moved greatly onto interactivelearning, and in Zambia where dictation is stilla relatively common way of teaching.This has been an unforgettable month for

me and I have gained some extremely valuableteaching skills and made some wonderfulfriends and international colleagues. I amlooking forward to returning to Zambia in thefuture to continue to support THET and UNZA.If you are interested in finding out more or

volunteering with THET, please visitwww.thet.org or email [email protected] �


Integrity, Professionalismand Enthusiasm in Everything

Obituary | 21


Sue Martin, who made a major contribution toClinical Biochemistry and the work of theAssociation, acknowledged by the award ofEmeritus membership, died on 27th Marchafter a typically determined two year battleagainst cancer.Born and raised in Reading, Sue excelled

academically and won a scholarship toNewnham College, Cambridge, where she readNatural Sciences. After graduation she workedas research assistant in Leeds before decidingthat Clinical Biochemistry was the career forher. She was appointed to a post in VincentMarks’ Department at St Luke’s HospitalGuildford, undertook the University of SurreyMSc and graduated in 1978 with a Distinction.Sue quickly became a valued member of theSt Luke’s staff and an active participant in thesocial scene of the hospital, includingbackstage and on-stage participation inhospital pantomimes and later more seriousmusical productions, an interest she retainedthroughout her life.

Visionary Clinical DirectorSue developed a special interest in proteinsand in 1987, moved to Queen Mary’s Hospitalin Roehampton, where there was a SpecialistProtein Unit. She soon became ConsultantClinical Biochemist and in 1997, following ahospital merger, moved to Kingston Hospital.She remained at the hospital for theremainder of her career, serving as both Headof Department and Pathology Clinical Director,while retaining her specialist interests.Sue excelled in the role of Clinical Director

because she had vision, saw the necessity ofreview and reform and had the patience toexplain changes, with constantencouragement to staff across the pathologydisciplines. She was unsparing of her time inensuring good practice, not only in her ownservice provision, but in the training ofnumerous Clinical Scientists in Biochemistry,who worked in the Kingston Hospital

laboratory under her supervision. Not only didthe trainees benefit from Sue’s knowledge andexperience but also her professionalism andintegrity. Her contribution to training wentbeyond her own laboratory and many willremember the practical sessions on proteinsthat she organised and ran for the GuildfordMSc course.In the early 1980s, Sue first took up office

with the ACB, becoming junior representativeon the Southern Region Committee. In 1998,she first held a national role as AssistantSecretary of the Regulating Committee (nowFCS), but it was in the field of publications thatshe found her niche. It was her soundknowledge and expertise in proteins that gaveSue her first encounter with ACB Publications.Her contribution as a referee for the Annals ofClinical Biochemistry would evolve into arelationship with publications which wouldlast her professional career.


22 | Obituary

Never one to seek the limelight, Sue helpedbehind the scenes with the Focus Supplementof the Annals before it became theProceedings of the ACB National Meeting in1989. Sue became Associate Editor in 1990, theyear of the Brighton Focus meeting. Thismeeting drew talent from across the southeastand Sue contributed to both the programmecommittee under her old boss, Arthur Walker,and to the tight deadlines demanded by theProceedings. In 1991 Sue employed her quietcompetence as Secretary to the PublicationsCommittee, a commitment she made until1998 when she took the demanding role ofEditor of the Proceedings. Sue quicklydeveloped a loyal team who assessed andprepared submissions for this publication overthe next 11 years.

ACB Publications’ CommitteeSue’s effectiveness as Editor of the Proceedingswas quickly recognised by the NationalMeetings Committee and in 2002 she beganserving as a member, an activity whichcontinued until her retirement. Sue wasaccumulating major roles within theAssociation whilst also being PathologyDirector of her Kingston Hospital laboratorybut her very evident competence, hercommitment, her gentle nature and genuineenjoyment and enthusiasm of her chosenprofession remained with her until she retiredin 2009. Sue was by then Deputy Director ofPublications and Communications havingserved 4 years as Chair of the ACB PublicationCommittee and somehow she had squeezed ina considerable contribution to the RoyalCollege’s major successes at the Chelsea FlowerShow.

Sue was a true achiever in all aspects of herlife. She was a keen cyclist and with her‘green’ principles, whenever possible, shecycled a substantial part of her daily journey towork from SW Surrey to Kingston uponThames. In 2002 she cycled from Land’s End toJohn O’Groats with one of her nephews, andin 2007 cycled the ‘opposite diagonal’, fromDover to Cape Wrath. She also loved walkingchallenges, taking part in the Welsh ThreeThousands Challenge.

To Know Her Was an EnrichingExperienceSue was a dear friend to many of us but it wasthe natural world that was Sue’s real home.Her garden, chickens and bees were her firstpassion, one she shared with her husbandRichard. Her life was cut short when she wasdeserving of time for total immersion in thebeauty of the Welsh hills and her vegetableand flower garden. Even so, in her owninimitable style, she wouldn’t allow her illnessto limit what she had set out to achieve inthose last two years. The profession wasenriched by her intellect and integrity and itsmembers by her gentle manner and genuinefriendship. She will be much missed andremembered with respect and affection by hermany friends, both those in the profession andthose from all parts of her life.Her family was very important to Sue.

She was adored by her nephews and nieces,taking an active part in their lives. Ourcondolences go to Richard, her sisters and herwider family. �

JS, SH, JL & JS

Crossword | 23


ACB News CrosswordSet by RugosaThe response to the June ACB News crossword was remarkable and manylucky departments now have the new edition of Marshall, Bangert &Lapsley’s, Clinical Chemistry. This month we are delighted to offerlaboratories that send in a correct solution free packs of the PathologyHarmony Tumour Marker Requesting Guideline Bookmark. This newinitiative will be fully reported in the August edition of ACB News.To receive your packs just scan your crossword solution and email it tothe Editor and also state how many bookmarks you would like – theycome in packs of fifty.

Last month’s solution

Across1 Use one staining hormone (11)7 Tally sounds incomplete (3)9 Ill-chosen replacement paint (5)10 Student develops best cure for

nodules (9)11 Specialty that treats you longer (9)12 Lacking aims, manifesto rewritten

time and again (5)13 Incomplete dollar pay-out to doctor

for medical examination (7)15 Correct poor diet (4)18 Dependant returning in

withdrawal (4)20 Contraction of a muscle adapting

to less energy ultimately (7)23 Professional in an outfit (5)

24 Cut EPROMs ordered forprocessors (9)

26 Perhaps turn pig heart into food (9)27 Try out tyrosine derivative as a

stain (5)28 Academic flower (3)29 Released extremist can cause

harm (4,7)

Down1 Distressed old nag in bad pain -

test for acidosis (5,3)2 Former student argued at

assembly (8)3 Better alfresco party? (5)4 Measure of lack of energy –

strange hankering to imbibefortified wine arising (7)

5 Terribly upset by being describedas secondary or subordinate (7)

6 Accost in mid-afternoon aboutdrugs (9)

7 Substance dissolved in absolutealcohol (6)

8 Very small things make no mess (6)14 Patent dispute: former title of

claimant (9)16 Censor if upset about description

of science used in evidence (8)17 Frequency of emotional upset

affecting saleswoman(neither maiden nor wife) (8)

19 Tractable doctor lied aboutbad cut (7)

20 Tutorial for advanced studentsremains uncertain (7)

21 Staffed questionably and thensome after those left (6)

22 Right away Spanish new raisedproduction increases 1 down (6)

25 Unpredicted lack of credit affectedturn over (5)

Cathie Shearing launches theTumour Marker RequestingGuideline bookmark at theACB Audit Meeting inBirmingham on 20th June

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The Association for Clinical Biochemistry | Issue 591 | July 2012

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