Agenda

Registration

8am – 9am BST, 13 June 2023 ‐ 1 hour

Registration

Welcome from ACB

9am – 9.20am BST, 13 June 2023 ‐ 20 mins

Plenary

The International Award Lecture - Lessons in chemistry

9.20am – 9.50am BST, 13 June 2023 ‐ 30 mins

Plenary

The use and evidence for biomarkers of inflammation in CV and other diseases.

Session chair: Bernie Croal

Coffee break

9.50am – 10.15am BST, 13 June 2023 ‐ 25 mins

Break

The Leeds experience

10.15am – 11.45am BST, 13 June 2023 ‐ 1 hour 30 mins

Trent, Northern & Yorkshire

Session Chair: Jennifer Spencer

10.15am Stephen Gibbons, Essential blood testing in the patient abusing androgenic anabolic steroids

10.45am Carys Lippiatt, Lead toxicity in children

11.15am Robert Barski,  The metabolic effects of nitrous oxide abuse - “no laughing matter!”

Essential blood testing in the patient abusing androgenic anabolic steroids - Stephen Gibbons

Are we facing a steroid-emic? Can we save NHS money through better patient management? Complications associated with anabolic steroid abuse are becoming increasingly common with presentation of patients to both primary and secondary care. With no defined patient pathway we risk inappropriate referrals, inappropriate investigations and inappropriate patient management. Leeds have developed and approved a pathway detailing the essential blood tests that should be undertaken in these patients and when referral should be considered. 

Lead toxicity in children - Carys Lippiatt

A few years ago a 2 year old boy died of encephalopathy caused by lead poisoning at Leeds Teaching Hospitals NHS Trust. This was a tragic case and whilst I worked with the Consultant Paediatrician who cared for him to investigate this preventable death, it became apparent that a likely contributory factor was the lack of awareness amongst clinicians that lead poisoning was still possible in the UK today. At MedLab23 I will describe how we have raised awareness of lead poisoning, particularly in children with pica and what we have learnt in Leeds about identifying and managing lead toxicity in children following the death of this little boy. 

The metabolic effects of nitrous oxide abuse - “no laughing matter!” - Robert Barski

The recreational use of nitrous oxide (“laughing gas”) has increased significantly in recent times with up to 3.9% of 16-24 year-olds now reported to use it.  Nitrous oxide inactivates vitamin B12 and chronic abuse has adverse effects on metabolic pathways with enzymes requiring B12 as a cofactor.  The widespread use has led to an increasing number of patients presenting with and requiring treatment for nitrous oxide toxicity.  In the Leeds laboratory we have observed a rapidly increasing number of such patients and a need for functional assays to demonstrate B12 inactivation.  In this talk I will discuss the effects of nitrous oxide abuse on metabolic pathways and the pros and cons of using serum B12, plasma total homocysteine and plasma methylmalonic acid for identifying B12 inactivation.     

Neuroendocrine tumours

10.15am – 11.45am BST, 13 June 2023 ‐ 1 hour 30 mins

Northern Ireland

Session Chair: Kirsty Spence

10.15am Joy Ardill, A lifetime experience in peptides and neuroendocrine tumours

10.45am Una Graham, Carcinoid syndrome

11.15am Claire McHenry, MEN1

Northern Ireland has several decades of experience in diagnosis and management of patients with Neuroendocrine Tumours (NETs). These tumours, once thought rare, arise from cells of the neuroendocrine system and include gastrinoma, insulinoma, glucagonoma and carcinoid syndrome. Some patients will present with florid symptoms whereas others may be found incidentally. Advances in recent years have seen a step change in diagnosis and management of these patients and in 2019 Belfast became a European Centre of Excellence in NETs, acknowledging the high standard of care afforded to NET patients in the province. 

Professor Joy Ardill, our first speaker, has over 50 years’ experience in the field of NETs. She has played a key role in the service since its inception, researching into and developing some of the early radioimmunoassays used to measure gut hormones in Belfast. Joy has dedicated her life to the field and is going to speak on ‘A lifetime experience in Peptides and Neuroendocrine Tumours’.

Our next topic, presented by Dr Una Graham (Consultant Endocrinologist, Deputy Chair of NI NET MDM) will focus on Carcinoid Syndrome. This condition typically only becomes clinically evident post-hepatic metastasis. Dr Graham will discuss carcinoid types, symptoms, diagnosis and management, and will conclude with a case presentation. 

Our final speaker is Dr Claire McHenry. Claire is a Consultant Endocrinologist and the newest member of our NET MDM. Her clinical interests include multiple endocrine neoplasia type 1 (MEN1), an inherited disorder, presenting with tumours in endocrine glands (eg pituitary, pancreas, adrenals) and the duodenum.  Dr McHenry will discuss MEN1 presentation, diagnosis, monitoring and management, and close the session with a MEN1 case presentation. 

Lunch & poster rounds - Royal Armouries Hall

11.45am – 1.45pm BST, 13 June 2023 ‐ 2 hours

Break

Industry sponsored workshops

12pm – 1pm BST, 13 June 2023 ‐ 1 hour

Industry sponsored workshops

12.00 - 12.30 Bury Theatre - Abbott with Helen Ashby and Pervaz Mohammed - Using Active B12 assay as a frontline test for investigating B12 deficiency

The current standard of investigation for B12 deficiency is Total B-12 testing, however measuring Total B-12 levels has numerous limitations including poorly defined deficiency and sufficiency cut-offs, and a large grey-zone. Active B12 has a better diagnostic accuracy than Total B12 and can replace it as a screening test.

Achieving improved standards of patient care through making improvements to diagnostic testing protocols is a function of every clinical laboratory service. Taking the steps to implement changes in well-established protocols takes effort and focus, and needs to persuade large groups of clinical colleagues to learn about and adopt a different way of doing things.

In this presentation, laboratory clinicians from Black Country Pathology Service, an NHS pathology network, will share their experience of assessing Alinity Active B-12 assay and successfully transitioning of GPs across their region from Total B12 to Active B12 requesting.

12.00 - 12.30 Wellington Suite - The Binding Site with Luke Martinson - Free Light Chain analysis for the detection of intrathecal immunoglobulin synthesis                                                                                                                                       

Intrathecal immunoglobulin synthesis indicates an ongoing immune/inflammatory response in the CNS and is often a feature of neuro-inflammatory conditions including multiple sclerosis (MS) and other neuro-inflammatory conditions. Detection of intrathecal immunoglobulin synthesis can therefore aid in the diagnosis of neuro-inflammatory disease when assessed in conjunction with other clinical and laboratory findings. The current standard of care for detecting intrathecal immunoglobulin is Oligo Clonal Banding (OCB), which is an electrophoretic method that uses paired serum and CSF samples to detect the synthesis of IgG in the CNS. While OCB is considered the gold standard, it has limitations which can prove challenging for some laboratories, including subjective interpretation, long TAT, high cost and the requirement for expert staff.

Given the limitations referred to above, there is a need for a rapid, quantitative and automated test that is of sufficient sensitivity and specificity for the inclusion in the diagnostic work-up for neuro-inflammatory conditions. Here, we present data showing that measurement of kappa Free Light Chains in CSF and serum samples using the automated Freelite Mx assay can be used as a screening test and guide when to perform OCB, thus improving laboratory workflow and efficiency while maintaining diagnostic performance

12.00 - 12.30 Churchill Suite- Biohit Healthcare with Pranvera Hiseni - Capturing gut microbiota (im)balance with GA-map® Dysbiosis Test

The composition of the microbes in the human gut has an undeniable impact on human health and well-being. The gut microbiota, composed of thousands of microbial species, influences biological processes by producing and modifying molecules of various types and levels of complexity. Different microbial species specialize in performing different functional tasks, so the more diverse the microbial community, the more stable it is. Diet, lifestyle, exposure to antibiotics, and genetics, all influence the gut microbiota, making it dynamic and unique from one individual to another. 

It is well established that people suffering from certain diseases have significantly different microbial compositions compared to healthy populations: for example, there is generally a lower species diversity, marked by an overgrowth of some species while others become depleted. This state of imbalance is known as dysbiosis. Regardless of whether dysbiosis is a cause or a consequence of these diseases, clinical monitoring of the microbial composition is of primary value. This is especially true after learning that various diseases, such as Parkinson's disease, show signs of dysbiosis before clinical symptoms appear.

As knowledge in this area is rapidly increasing, there is a strong demand for tools that can systematically detect dysbiosis in a clinical setting. The GA-map® Dysbiosis Test - a well-established and standardised dysbiosis test, has been shown to meet this need. Join our workshop to learn more about how GA-map® technology has opened up the world of microbiota assessments in routine clinical settings.

12.30 - 1.00 Bury Theatre - BD with Robert Navesy, BD Head of Marketing and Integrated Diagnostics Solutions

Come and join the BD team to hear about their latest White Paper on the future of Diagnostics services and how there are opportunities to work in partnership with Integrated Care Boards to drive change.

12.30 - 1.00 Wellington Suite - Chromsystems with James Russell - Chromsystems Solutions for Clinical Mass Spectrometry

Chromsystems offers more than 400 parameters for clinical HPLC and LC-MS/MS users, encompassing complete kits, Internal Standards, quality controls and calibrators. LC-MS/MS is considered the gold standard for therapeutic drug monitoring with high accuracy, specificity and a high speed of analysis. Therefore, the interest in automation in clinical laboratories is high, with the effort to reduce tedious manual preparations. MassSTAR in conjunction with Chromsystems assays offers an automated CE-IVD workflow for more than 100 drugs, immunosuppressants, and vitamin D.

12.30 - 1.00 Churchill Suite - Siemens with Jennifer Spencer - The Enhanced Liver Fibrosis (ELF) Test

Dr Spencer will discuss what is an ELF score and the context of its use in the laboratory to support the Liver Unit at St. James Hospital Leeds. The presentation will cover the role of ELF in patient liver pathways advocated by The British Society of Gastroenterology (BSG), The British Association for the study of Liver Disease (BASL) and internationally by EASL and AASLD.

The Impact Award Lecture: Development of a national home finger-prick blood laboratory testing service for clinicians of Paediatric Highly Specialist Services for complex conditions

1.45pm – 2.15pm BST, 13 June 2023 ‐ 30 mins

Plenary

Session chair:  Bernie Croal

Specialist interest updates in heavy metals, drugs of abuse and bile acid malabsorption

2.15pm – 3.45pm BST, 13 June 2023 ‐ 1 hour 30 mins

West Midlands

Session Chair: Alexandra Yates

2.15pm Nicola Barlow, Diagnosis and monitoring of heavy metal poisoning: interactive case illustrations

2.45pm Alex Lawson, From the laboratory to the headlines, the emergence of nitazene opioids in the UK

3.15pm Lauren Starbrook, Diagnostic difficulties in bile acid diarrhoea

This session hosted by the West Midlands will provide an update in three specialist areas of interest and progress within the region. Heavy metals is often an area of uncertainty for Clinical Scientists and Dr Nicola Barlow will use a series of interactive case presentations to convey the latest evidence-based information with respect to identifying, diagnosing and monitoring lead, mercury and arsenic poisoning. Dr Alex Lawson will then present on developments in detection of novel opioids, including 2-benzyl benzimidazole (nitazene), which has been detected with increasing frequency in the UK over the past two to three years. He will cover the potential for harm, analytical strategies to detect these drugs and discuss several pertinent cases. In the final session, Lauren Starbrook will provide an overview of the presentation, prevalence and treatment of bile acid diarrhoea and consider the difficulties in diagnosing this condition. She will then present new work on diagnostic tests, encompassing faecal bile acids and serum 7-α-hydroxy-4-cholesten-3-one.

Diagnosis and monitoring of heavy metal poisoning: interactive case illustrations - Nicola Barlow

In the past, heavy metal measurement and interpretation was performed only in specialist trace element laboratories. However, with the formation of pathology networks and increased availability of instrumentation, heavy metal analysis is increasingly taking place in non-specialist laboratories, requiring general clinical scientists to have a better understanding of the field. This presentation will cover pertinent aspects of when heavy metal testing is appropriate, sample collection requirements and interpretation of results for the most commonly encountered heavy metals, lead mercury and arsenic, through a series of interactive case illustrations.

From the laboratory to the headlines, the emergence of nitazene opioids in the UK - Alex Lawson

In the US, the death rate from drug overdoses more than tripled between 1999 and 2017, this was driven by increase use of opioids. This opioid epidemic had three phases: the first was dominated by prescription opioids such as oxycodone, the second by heroin, and the third by cheaper but more potent synthetic opioids such as fentanyl. Despite a few outbreaks of synthetic opioids (such as fentanyl analogues) causing death is particular geographic areas, the UK has not faced the same epidemic as the US. However, over the past 2-3 years the UK has seen an increase in the detection of 2-benzyl benzimidazole (‘nitazene’) type opioids. These are found mixed with heroin or purchased online, typically sold as oxycodone. This talk will give a brief overview of novel opioids, discuss the potential for harm, the analytical strategies to detect these drugs and discuss a number of pertient cases. 

Diagnostic difficulties in bile acid diarrhoea - Lauren Starbrook

 

Bile Acid Diarrhoea (BAD) is a prevalent condition that is significantly under-diagnosed. This is due to lack of available diagnostic methods. The gold standard for diagnosis is the 75-SeHCAT scan which is time consuming, expensive, and exposes patients to a dose of radiation. This presentation will discuss other alternative ways of diagnosing BAD that may be brought into routine clinical practice, to improve diagnosis and patient outcomes.

Diagnosis and treatment of diabetes in Scotland: The past, present and future

2.15pm – 3.45pm BST, 13 June 2023 ‐ 1 hour 30 mins

Scotland

Session Chair: Melissa McNaughton

2.15pm Karen Smith, Past, present and future of specialist endocrine testing

2.35pm Mark Strachan, C-peptide measurement in diabetes

3.00pm Kirsty Duncan, Islet cell transplant

3.20pm Ian Hunter, Diabetes in adolescence

ACB Scotland would like to invite you to our session at UKMedLab which will explore current and future advances in the diagnosis and treatment of diabetes as well as taking a broader look at where we have come from in the landscape of specialist endocrine testing. We have chosen this topic to showcase the talent we have in Scotland in this ever relevant area of clinical biochemistry and also to highlight particular success stories. We hope you find the session interesting and stimulating, we as organisers are certainly happy with how our session has come together. See you there!

The ACB Scotland Committee

Past, present and future of specialist endocrine testing - Karen Smith

I will talk about the developments in methodology for measuring hormones across the 30 years of my career in clinical biochemistry

C-peptide measurement in diabetes - Mark Strachan

C-peptide is a measure of endogenous insulin secretion and has a well-established role in determining the aetiology of spontaneous hypoglycaemia. In recent years, there has been considerable interest in the utility of serum or urine C-peptide in helping to determine more accurately the correct aetiology of diabetes. In this presentation, I shall demonstrate the impact that serum C-peptide testing had on diabetes diagnosis in one UK centre. In addition, I shall consider the prognostic significance of retained, detectable C-peptide in people with Type 1 diabetes, with regards to vascular and metabolic complications. Finally, I shall consider whether C-peptide has a role in people with Type 2 diabetes with respect to choosing the most appropriate anti-diabetic therapy.

Islet cell transplant - Kirsty Duncan

Islet cell transplant is a treatment for people with type 1 diabetes mellitus who have severe impaired awareness of hypoglycaemia despite intensive insulin management. This can often be life threatening. Islet cell transplant is a way of restoring hypoglycaemic awareness in this group of patients with prevention of further significant hypoglycaemia. This can include insulin independence in some patients.

Diabetes in adolescence - Ian Hunter

 

 

Coffee break

3.45pm – 4pm BST, 13 June 2023 ‐ 15 mins

Break

The pre and post analytical phases

4pm – 5.30pm BST, 13 June 2023 ‐ 1 hour 30 mins

South West and Wessex

Session Chair: George Allen

4.00pm Tim McDonald, A newborn screening programme for neonatal diabetes

4.30pm Kat Mordue, Use of clinical decision support in patient test pathways

5.00pm Kristen Lilly, Demand management of ANA and specific IgEs

The majority of errors in laboratory medicine originate in the pre and post analytical phases of testing. Yet arguably these are the phases where the laboratory has the least influence or control. Join our session which will focus on innovations in the South West & Wessex to ensure that the right test is done at the right time, in the right location for the patient and that the right action is taken in response to the result. 

A newborn screening programme for neonatal diabetes - Tim McDonald

Professor Tim McDonald will present his experience of introducing a Newborn Screening Program for Neonatal Diabetes in the UK.  Tim will present his experience of the hurdles and challenges of generating the evidence required to satisfy the National Screening Committee that a test meets the standards to be considered for implementation into newborn screening in the UK.

Use of clinical decision support in patient test pathways - Kat Mordue

University Hospitals Plymouth has piloted the use of Clinical Decision Support (CDS) software (AlinIQ, Abbott) to interrogate patient cases against a rules-based algorithm, built using evidence-based clinically defined thresholds for determining the cause of anaemia. The pilot CDS project has focused on the diagnosis of anaemia due to iron deficiency, vitamin B12 and folate deficiency, and anaemia secondary to chronic kidney disease. This presentation will share our experience designing the CDS anaemia pathway and how the CDS software can support our primary care colleagues in requesting the right tests at the right time.

Demand management of ANA and specific IgEs - Kristen Lilly

Laboratory tests are essential to support diagnosis but can also be requested in the wrong clinical context which may prove difficult to interpret. We aim to present an algorithmic approach to demand management which provides additional clinical advice at the point of request (via order communication IT) to reduce inappropriate testing from primary care, provide clinical advice and prevent incidental findings.

The Medal Award Finalists Presentation

4pm – 5.40pm BST, 13 June 2023 ‐ 1 hour 40 mins

UKMedLab23

Shortlisted abstracts submitted from members in active training will be presented orally and will be considered by the judging panel within this session.

Nick Flynn - A computer vision approach to the assessment of dried blood spot size and quality in newborn screening

Louise O'Donnell - Determining the viability of capillary blood analysis for renal transplant patients across hospitals in NHS Greater Glasgow and Clyde

Jonathan Atkins - Development and validation of a novel serum 7a-hydroxy-4-cholestn-3-one (C4) LC-MS/MS method for diagnosis of bile acid diarrhoea.

Trish Woodley - Poo-tentially better? Faecal calprotectin and elastase stability in different sample collection devices and a trial of at home patient-led extraction

Eun Ji Kim - Differential regulation of circulating FGF21 by vitamin K1 and K2

Session chair:  Katharine Hayden

Registration

8am – 9am BST, 14 June 2023 ‐ 1 hour

Registration

Point of Care Testing: Wriggly worms out of the can

9am – 10.30am BST, 14 June 2023 ‐ 1 hour 30 mins

UKMedLab23

Session Chair: Katy Heaney

9.00am  Fiona Riddoch and Bethan Phillips, Neonatal jaundice assessment: Banana skins and snake pits

9.30am  Lisa Vipond and Anthea Patterson, Hs-cTnI implementation: The POCT obstacle course

10.00am  Jonathan Kay, POCT IT: Nailing down the great unknown

Point of care testing (POCT) is an expanding, yet challenging discipline of pathology that requires both in-depth analytical knowledge of the tests we use, and practical, operational understanding of how the tests can provide maximum patient benefit. This session brings some tricky topics to the table for a real-life discussion on the challenges faced in the service, delivered by experts in the field. A review of POCT jaundice assessment; a well-established POCT used for many years. Dr Fiona Riddoch sets the scene of interplay between laboratory and POCT methods, and Miss Bethan Phillips gives a scientific appraisal of transcutaneous jaundice assessment. New clinical services embracing community care of patients increases the requirement for POCT to be truly effective, and highlights the need for IT integration; we question whether our POCT systems are ready for this challenge. Long-awaited POCT HS-Troponin methods have emerged onto market; but now comes the challenge of implementing not just as a replacement for laboratory methods but into new ways of working to optimise their use and, bring clinical and operational benefit to the current NHS Emergency Department crisis.

Neonatal jaundice assessment: Banana skins and snake pits - Fiona Riddoch and Bethan Phillips

Multiple methods are available for the assessment of neonatal jaundice, not least visual checking of skin or sclera as a first line screen. However, jaundice can be easy to miss, particularly in babies with pigmented skin, so many midwife and neonatal services use transcutaneous jaundice meters to screen for and estimate the extent of jaundice. This testing can be easily performed within both acute and community settings to assess the need for a blood sample to be collected for bilirubin measurement, the results of which can be used to make treatment decisions.

Laboratory serum tests are often wet chemistry with spectrophotometric detection and may be traceable to the Doumas method and NIST 916, or 916b. This requires phlebotomy and 1-2mLs of blood, but this can often be utilised to perform a range of other tests. Point of care (POCT) plasma methods require a glass capillary from a skin prick (usually heel prick) and separation of serum/plasma using a centrifuge before dual wavelength spectrophotometric measurement of bilirubin pigment. POCT measurement of bilirubin can also be achieved on blood gas analysers. Lab and POCT tests require the baby to be present in the neonatal unit.

These methods all have their pros and cons but do offer flexibility around testing methodology, sampling and location. However, there are frequently discrepancies between the methods which can cause clinical confusion, over-testing and possible over- or under-treatment by phototherapy or exchange transfusion, when using non-method-specific NICE cut-offs (NICE CG98).

Like laboratory tests, device verification and acceptance criteria should be defined for the implementation of point of care tests. We will discuss in detail the analytical performance of the JM-105 (Draeger) transcutaneous jaundice meters observed within our network. Furthermore, we will consider potential approaches to derive a reflective acceptance criterion which may be used, alongside safety netting within clinical protocols, to allow these devices to be safely implemented and maximise benefit to patient care.

POCT IT: Nailing down the great unknown - Jonathan Kay

Hs-cTnI implementation: The POCT obstacle course - Lisa Vipond

Cornwall has one acute hospital with one Emergency Dept (ED), plus a network of community hospitals with Clinical Decision Centres (CDCs), Urgent treatment centres (UTC) and Minor injuries Units (MIUs).   

The slide down and bump at the bottom: “Ambulance response times in Cornwall among worst in UK, 2022”  Newspaper headlines like this make depressing reading and reflect the extreme difficulty in maintaining a safe service in such challenging times. Innovative ways of working, using new technology and clinical pathways were urgently needed.

The wall to be scaled: A POCT device that met the analytical criteria specified by NICE, for the diagnosis of Myocardial Infarction (MI), became commercially available in 2021. The POCT team at RCHT initiated the technical verification of the Atellica VTLi, working closely with the clinical teams to collect patient comparison samples and with UKNEQAS on the EQA evaluation.

Building Bridges:  The stakeholders including lab representatives, ED Clinicians and acute GPs formed a multidisciplinary team to look at the use of the POCT device in UTC.  A low risk cardiac chest pain pathway was developed that used clinical scoring and the hs-cTnI POCT result to triage patients; all of whom would formally have been transferred from the community to ED by ambulance.

The finishing line:  Audits are on-going, however early data shows the use of the chest pain pathway has resulted in at least a 50% reduction in transfers of patients to AE from community settings, with no clinical harm having been observed. This initiative has significantly reduced the burden on the ambulance service and on ED, but most significantly, patients who would otherwise have had to endure a prolonged wait in ED can be sent home, safely.

A selection of topics from the Republic of Ireland

9am – 10.30am BST, 14 June 2023 ‐ 1 hour 30 mins

Republic of Ireland

Session Chair: Brendan Byrne

9.00am Peadar McGing, Biochemical testing of atypical fluids – a personal perspective

9.30am M J Duffy, Circulating tumor DNA (ctDNA): The next major blood-based cancer biomarker?

10.00am Graham Lee, It's a big big problem... happening again and again

The Association of Clinical Biochemists in Ireland has previously published two sets of guidelines, The Biochemistry of Biological Fluids and Guidelines for the Use of Tumour Markers. This session will provide an update on how atypical fluids can be utilised in diagnosis and patient management. It will also provide an insight in to the potential for circulating tumour DNA to be added to the existing panel of tumour markers. Finally, we will focus on Prolactin and whether it’s always necessary to screen for Macroprolactin.

Biochemical testing of atypical fluids – a personal perspective - Peadar McGing

First there was urine, for a few thousand years. Then blood testing was added to the repertoire. For Pathology labs today these body fluids are what are tested for the vast majority of patients. But, as in life, there are always exceptions. Along the way laboratory scientists and clinicians have learned that occasionally testing of other body fluids may be of benefit. In Ireland we have an old saying ‘An rud is annamh is iontach’ which translates as ‘the thing that is rare is wonderful’. This lecture will endeavour to show how atypical fluid clinical biochemistry may be wonderful, but it needs more careful review and oversight than it got throughout the 20^th century.

For laboratory purposes ‘atypical fluids’ are any body fluids we test other than blood/plasma or urine. In practice these are almost all transcellular fluids and are of particular interest where disease causes an increase in volume (e.g. pleural effusion or ascites). In such cases removal of fluid is therapeutic and analysis is aimed at helping or confirming diagnosis. Unlike blood, where usually a repeat test is still valid if there is a problem with the initial sample, there is often only one shot at diagnostic testing of an atypical fluid. For CSF the body will still contain sufficient fluid but the lumbar puncture procedure is itself very invasive. Therefore there is an onus on pre-analytical aspects of sampling and all tests that the clinician should require are ordered and analysed. Typical problem areas are when both blood and fluid are required simultaneously, and also when special preservatives are required for some of the tests, e.g. you cannot add in pH testing some hours later.

Test procedures such as Light’s Criteria for distinguishing between exudate and transudate origin of pleural fluids has long been accepted as of clinical value. However it is only recently that we in labs have begun to address the issue of such testing being off-label. Testing of atypical fluids needs at least some in-house verification. EQA of these fluids was non-existent until recently but is now being addressed, at least in part.

This presentation will give a brief overview of atypical fluid biochemistry and how it fits into clinical diagnosis. Some examples will be given of both common and more unusual testing of fluids. The presentation will also give a personal view of how to simply address verification and some warnings on avoiding assumptions regarding our assays.

Circulating tumor DNA (ctDNA): The next major blood-based cancer biomarker? - M J Duffy

Protein-based biomarkers are widely used in monitoring patients with diagnosed cancer. These biomarkers however, lack specificity for cancer and have poor sensitivity in detecting new cancers, early recurrences and monitoring therapy effectiveness. Emerging data suggests that the use of circulating tumor DNA (ctDNA) has several advantages over standard biomarkers including greater specificity, higher sensitivity, a broader range of applications and a shorter half-life.

One of the most exciting possibilities with ctDNA is as a screening test for multiple types of cancer using a single sample of blood. Currently, this possibility is being evaluated in a large randomized prospective trial in the UK using the Galleri test. For patients with an established diagnosis of cancer, ctDNA appears to be superior to radiology and standard biomarkers in detecting early recurrent/metastatic disease. Thus, in patients with surgically resected colorectal cancer, ctDNA was shown to be more sensitive than CEA in detecting residual disease and early recurrence. Similarly, in breast cancer, ctDNA was shown to be more sensitive than CA 15-3 in detecting early recurrences. One of the first established clinical uses of ctDNA is in selecting the most appropriate therapy for patients with specific types of cancer, (e.g., mutation testing of EGFR for predicting response to EGFR inhibitors in patients with non-small cell lung cancer). Compared to the traditional tissue analysis approach for the measurement of therapy predictive biomarkers, use of ctDNA is relatively non-invasive, faster, cheaper and importantly provides a more comprehensive overview of mutations present in a tunor than a single biopsy of tissue.

In contrast to proteins however, ctDNA biomarkers are more expensive to measure, less widely available and have longer turn-around times for reporting. Furthermore, ctDNA assays are less well standardized. Despite these limitations, it is likely that ctDNA measurements, will become more widely available where they will complement existing biomarkers and imaging in detecting and managing patients with cancer. Hopefully, these combined approaches will lead to a better outcome.

It's a big big problem... happening again and again

Hyperprolactinaemia has a broad differential ranging from physiological, pharmacological and pathological causes, which may contribute in isolation or in combination to the biochemical and clinical picture.  Patients may present with classical symptoms including galactorrhoea, amenorrhea, infertility and vision disturbances or may be asymptomatic. Treatment for hyperprolactinaemia consequently varies from no treatment to pharmacological and surgical intervention.  Obtaining the correct differential diagnosis and management is therefore key.  Prolactin is not a tumour specific marker nor does its level consistently correlate with tumour size however its role in helping to identify patients with prolactinoma has been long standing and beneficial.  Unfortunately, the ability to specifically measure prolactin (bioactive/monomeric) is affected by cross-reactivity with macroprolactin for which treatment is not recommended. This “big big” issue remains to the present day and is one which faces laboratories time and time again.  In the immediate sense, we advocate a need for change to current protocols involving macroprolactin testing! 

Coffee break

10.30am – 11am BST, 14 June 2023 ‐ 30 mins

Break

The Southern region response to challenges in laboratory medicine

11am – 12.30pm BST, 14 June 2023 ‐ 1 hour 30 mins

Southern

Session Chair: Alex Read

11.00am Penny Cliff, Performance evaluation of the Viasure PCR assay for the diagnosis of mpox: A multicentre study

11.30am Joanne Morris, Measurement of free light chain - technical challenges and clinical utility

12.00am Isabelle Piec, Measuring FGF23 in patients treated with Burosumab

The Southern Region is home to a plethora of specialist labs that are often at the frontier of responding to disruptive changes. These include rapid responses to outbreaks of infectious disease like Mpox or vast overhauls in conventional practice in response to clinical guidelines. This session provides a illuminative glimpse into our response to these challenge across laboratory medicine.

Performance evaluation of the Viasure PCR assay for the diagnosis of mpox: A multicentre study - Penny Cliff

Following the first laboratory confirmed case of mpox in England in early May 2022, it soon became apparent that there was a rapidly evolving outbreak within the GBMSM community, with the majority of cases detected in London. Virology Laboratories from three major teaching hospitals in London worked together to verify a newly available commercial realtime PCR kit (Viasure MPXV PCR) for use within their departments. 217 paired samples were collected, one of each pair tested by the Rare and Imported Pathogens Laboratory and the other on the Viasure PCR. Viasure results were concordant with RIPL for 91.2% of samples, and the assay demonstrated good accuracy (88.6 – 94.7%), diagnostic sensitivity (89.7 – 100%), PPV (87.2 – 96.3%), and NPV (87.9 – 100%). The collaborative approach allowed rapid and robust verification of the assay, providing the laboratories with a timelier alternative to sending samples to the reference laboratory.

Measurement of free light chain - technical challenges and clinical utility - Joanne Morris

The analysis of free light chains in clinical laboratories to support the diagnosis and treatment monitoring of Myeloma has evolved over 6 decades. From urine analysis for Bence Jones Protein using gel electrophoresis in the 1950s to the launch of the first commercial assay for serum free light chain measurement in 2001. This talk will describe the biochemistry of free light chains, the benefits and challenges of the different methodologies available in laboratories today. I will also describe the complexity of clinical interpretation of results, highlighting relevant national guidance, recently developed diagnostic tools for clinicians and testing advice for laboratories.

Measuring FGF23 in patients treated with Burosumab - Isabelle Piec

X-linked hypophosphatemia (XLH) is a hereditary, progressive, and lifelong condition that affects both children and adults with an incidence of 1/20,000. The disease is characterised by elevated circulating fibroblast growth factor 23 (FGF23). High FGF23 induces hypophosphatemia, reduced 1,25 Dihydroxyvitamin D concentration and defective bone mineralisation (osteomalacia/rickets). Treatment with burosumab, a fully human IgG1 monoclonal antibody that binds intact FGF23 (iFGF23) decreases rickets severity, prevents enthesiopathy, improves growth, increases serum phosphate and 1,25(OH)₂D as well as the ratio of tubular maximum reabsorption rate of phosphate to glomerular filtration rate (TmP/GFR). However, symptoms in some patients are not fully resolved suggesting some free iFGF23 may remain circulating and acting in these patients while concomitantly paediatricians are keen to measure FGF23 to avoid overtreatment with associated potential calcification risk.

Measuring FGF23 in patients treated with burosumab is problematic as we and others have observed interference (false positive) of the therapeutic antibody in multiple assays (Immutopics c-terminal FGF23 [cFGF23], MedFrontiers and Immutopics iFGF23) while being seemingly low/normal in the DiaSorin iFGF23 (false negative).

We immunoprecipitated burosumab using magnetic A/G beads from samples obtained from treated patients. Cleanliness of the supernatant was checked by western blot and FGF23 was then measured in the supernatant using Immutopics cFGF23. This ELISA measures both intact and cFGF23. We also analysed for the presence of cFGF23 alone by western blot using anti-cFGF23 (186-206) antibody (Quidel). We were only able to detect intact FGF23 by these methods suggesting that either there is no free cFGF23 present or the technique is not sensitive enough to detect the circulating concentration of cFGF23 fragment in patients treated with burosumab.

The presence of sufficient circulating intact FGF23 and absence of cFGF23 in patients treated with burosumab could explain the persistence of some symptoms of XLH. In future we may be able to correlate outcome with circulating concentrations of free iFGF23. The changes in efficacy of burosumab in older children and adolescents may partly reflect a requirement for an increased dose of burosumab to fully capture iFGF23.

Myths, legends and WLIMS

11am – 12.30pm BST, 14 June 2023 ‐ 1 hour 30 mins

Wales

Session Chair: Anthony Jackson-Crawford

11.00am Danja Schulenburg-Brand, A whistle stop tour of the porphyria's and Cardiff Porphyria Centre

11.30am Catherine Bailey and Rachel Still, Blood science standardisation - why bother?

12.00am Joanne Rogers, WEDINOS (Welsh Emerging Drugs and Identification of Novel Substances)

A whistle stop tour of the porphyria's and Cardiff Porphyria Centre - Danja Schulenburg-Brand

The Cardiff Porphyria Centre manages patients with porphyria in Wales, Scotland and parts of England. The fully integrated service consists of both a cutaneous and acute porphyria clinical service as well as a specialist porphyrin laboratory. In addition to discussing the role and operation of the service, we will briefly discuss the porphyrias, a group of mainly inherited conditions of haem biosynthesis, focusing on current diagnostic and management approaches.

Blood science standardisation - why bother? - Catherine Bailey and Rachel Still

All-Wales Blood Sciences standardisation started in 2010, alongside implementation of an All-Wales Pathology Laboratory Information System (WLIMS). This presentation will cover developments in standardisation in Wales, covering successes (e.g. implementation of All-Wales reference ranges and report comments for PSA), failures (e.g. documentation) and challenges (e.g. standardised telephone limits across Wales). We will also discuss preparations being undertaken for implementation of a replacement WLIMS and how the benefit of hindsight is influencing this process.

WEDINOS (Welsh Emerging Drugs and Identification of Novel Substances) - Joanne Rogers

An overview of a Welsh Public Health Harm Reduction project which provides a robust mechanism for the collection and testing of unknown/unidentified or new psychoactive substances and combinations of substances from the Welsh Analytical Toxicology Laboratory providing this analysis.

Lunch & poster rounds - Royal Armouries Hall

12.30pm – 2.30pm BST, 14 June 2023 ‐ 2 hours

Break

Industry sponsored workshops

1pm – 1.30pm BST, 14 June 2023 ‐ 30 mins

Industry sponsored workshops

1.00 - 1.15pm Bury Theatre, The New Alegria 2 from Sebia with Janice O'Shea – Lifting Autoimmunity and Infectious Diseases to the next level of automation

The Alegria 2 is a new fully automated analyser for autoimmunity and infectious diseases.

The session will include:

• A look at the acquisition of Orgentec by Sebia and where the Alegria 2 sits within the UK market.
• The challenges that face autoimmunity and diagnostic testing.
• A look at the Alegria 2 – including the main features.
• Understanding SMC technology
• A brief look at the user friendly software
• Assay profiles
• Q and A

1.15 - 1.30pm Bury Theatre, X-Lab with Angus Whitham - Eliminating paper requests from the lab - an Order Comms System for 'hard-to-reach' requesters

Despite strides in recent years to digitise lab-to-lab referral and reporting workflows, it’s thought that over 35 million test requests per year are still referred and reported on paper to labs across the UK and Ireland. Lab referrals from screening programmes, tertiary care, community care, private organisations, and other ‘hard-to-reach’ referrers are left behind by mainstream Order Comms Systems (OCS) on the market, leaving labs to manually process and report up to 10% of their incoming work on paper.

X-Lab, the company behind Labgnostic, have developed a new OCS called LabReach which is currently being piloted at University Hospitals of Leicester NHS Foundation Trust and Liverpool University Hospitals NHS Foundation Trust. LabReach’s vision is to remove paper from the lab for good and has been designed to improve turnaround times, reduce costs, and increase patient safety. LabReach is set to open up digital access to labs, and permanently shift how lab referrals happen across the UK.

Join us to learn more about LabReach and how it’s improving our pilot labs and the lives of the people who work within them. 

1.00 - 1.30pm Wellington Suite, QuidelOrtho with Eoin Madigan - The power of POCT in improving patient pathways 

POC testing offers a much faster solution to rule out – or rule in – diseases near to the patient, reducing turnaround times from hours to minutes. This provides quicker assessment of patients, allowing hospitals to streamline patient management, optimising the use of resources for those most in need, and allowing low risk patients to go home to rest. Many POC diagnostic tests rely on established technologies, applying them in a user-friendly format to bring testing closer to the bedside and decrease turnaround time.

1.00 - 1.30pm Churchill Room, Randox with Barry Maguire - Realising IQC Software Potential

A brief look at how laboratories are benefiting from the use of IQC software for advanced statistical analysis. Focusing on features that provide automation to timely tasks such as validation of new IQC lots and IQC review reports. An easy to use, multi-disciplinary software, that can be customised to any laboratory large or small.

ACB Annual General Meeting

1.30pm – 2.15pm BST, 14 June 2023 ‐ 45 mins

ACB Annual General Meeting

President's address

2.30pm – 3pm BST, 14 June 2023 ‐ 30 mins

Plenary

The Foundation Award Lecture: Metamorphosis - from retrospective confirmation to management tool, the evolution of cardiovascular biomarkers.

3pm – 3.30pm BST, 14 June 2023 ‐ 30 mins

Plenary

Metamorphosis - from retrospective confirmation to management tool, the evolution of cardiovascular biomarkers.

Cardiovascular biomarkers, then known as cardiac enzymes, were first incorporated into the diagnosis of myocardial infarction in 1979. Conventional teaching was that cardiac enzymes, creatine kinase (CK), aspartate transaminase (AST) and lactate dehydrogenase (LDH) were measured serially over three days. At this time management of myocardial infarction (MI) was symptomatic and non-interventional. Retrospective confirmation was all that was required and the electrocardiogram (ECG) was the predominant diagnostic technology. Improved measurement methodology, especially for CK and measurement of its cardiac (MB) isoenzyme (CK-MB) were the only changes. Measurement of natriuretic peptides was a research undertaking. The first technology shift was the concept of immunoassay for cardiac biomarkers with assays developed for myoglobin and CK-MB. Interest in more rapid diagnosis came from the Emergency Department, especially in the United States, and with the advent of thrombolytic therapy. A more proactive approach to management of MI both confirmation and exclusion resulted in the development of rapid serial enzyme measurement and the calculation of delta change. The paradigm shift came with the development of immunoassay for the cardiac specific proteins cardiac troponin T (cTnT) and cardiac troponin I (cTnI) followed by those for B type natriuretic peptides. Measurement of cTnT and cTnI group diagnostically superior to conventional cardiac enzymes as they identified one third of patients said to have unstable angina who had missed, and most importantly, treatable myocardial infarction. The combination of a cardiac specific biomarker tied to a treatment strategy was irresistible. Myocardial infarction was redefined with cardiac troponin integral to diagnosis and treatment strategies. Evolution of measurement technology has produced high sensitivity assays and latterly point of care testing capable of matching the analytical sensitivity of laboratory assays. Incorporation of testing strategies within clinical decision support (artificial intelligence) systems represents the next step on the biomarker journey.

Session chair:  Katharine Hayden

Coffee break

3.30pm – 3.45pm BST, 14 June 2023 ‐ 15 mins

Break

Interactive clinical case presentations

3.45pm – 5.15pm BST, 14 June 2023 ‐ 1 hour 30 mins

UKMedLab23

This is an extremely  popular interactive session that will test your diagnostic prowess: 

• Short presentation of unusual cases selected from submitted abstracts 
• Interactive throughout with audience participation required 
• Audience vote for the best presentation at the end of the session 

List of Presenters and Titles

1. Angela Boal  -  Glasgow 

          "It’s a H-A-R-D-U-P life"

      2 .   Rhys Goodhead -   Stoke on Trent

          "Bad to the bone ?"

      3 .    Azza Osman -   Cardiff

           "The abnormal abnormality"

     4.  Julie Tarling    -  Bedford

          "A labyrinthine journey- 12 years to spot patient diagnosis…"

      5. Jessica Johnson  -    Sheffield

          "Variety is the spice of life"

      6. Lorenz Becker  -    North Midland and Cheshire

          "The why of water"

      7. Corey Pritchard   -  Bristol

        "Be aware !"

 

Innovation and specialist biochemistry in the North West

3.45pm – 5.15pm BST, 14 June 2023 ‐ 1 hour 30 mins

North West

Session Chair: Niamh Horton

3.45pm Carrie Chadwick and Khaja Syed, The Liverpool Neuroscience Biobank and The Walton Centre: Our journey so far

4.15pm Phillip Monaghan, The VALTIVE1 trial: Validation of plasma Tie2 as the first tumour vascular response biomarker for VE

4.30pm Sally Thirkettle, Validation of high-sensitive thyroglobulin and autoantibodies assays

4.45pm Beverly Hird, Fetal thyroid function

The North West session will focus upon recent innovation projects and specialist areas of Biochemistry from across the region.  

The session will start with the specialist neurobiochemistry and neuroimmunology laboratory at The Walton Centre in Liverpool. The Neuroscience biobank manager Khaja Syed and Consultant Clinical Scientist and Laboratory Director Carrie Chadwick will discuss their experiences of developing a neuroscience biobank, how the process has been undertaken and the role of the biobank since its inception, including a focus upon external review and the accreditation process. 

This will follow with talks from Consultant Clinical Scientist and Clinical Director of Pathology Dr Phillip Monaghan and Principal Clinical Scientist Dr Sally Thirkettle from The Christie Pathology partnership. The Christie Hospital is the largest single site cancer centre in Europe and the first UK centre to be accredited as a comprehensive cancer centre. Their talks will focus upon their specialist laboratory experience of cancer biomarker validation. Firstly, discussing the laboratory aspects of the VALTIVE1 trial, and the second talk will include discussion on the considerations for implementation of new biomarker assays for thyroid cancer monitoring.  

Closing the session will be Director of Newborn Screening and Consultant Clinical Biochemist Beverly Hird from the Royal Manchester Children's Hospital, part of the Manchester University NHS Foundation Trust. The laboratory covers the newborn screening across Greater Manchester, Lancashire and South Cumbria and analyses approximately 60,000 samples per year. In addition to newborn blood spot screening, the department also provides a specialist endocrinology service. Beverly Hird will be giving an overview of fetal thyroid function and the talk will include discussion of a rare case of fetal gotire.  

The Liverpool Neuroscience Biobank and The Walton Centre: Our journey so far - Carrie Chadwick and Khaja Syed

The Neuroscience Laboratories are part of The Walton Centre NHS Foundation Trust, a unique specialist neurology and neurosurgical Hospital providing care for a population of 3.5 million across the North West of England and North Wales.   Neurobiochemistry, Neuroimmunology and Neuropathology services are provided by a team of twenty-one highly skilled staff. 

We work as a cross discipline team to aid in the diagnosis of tumours and neurological conditions.   We have established a neuroscience biobank –The Liverpool Neuroscience Biobank at The Walton Centre (LNBW), which supports translational research with local health partners.  This presentation will describe our journey in establishing and developing the LNBW, including embedding biobanking processes into the patient pathway, building relationships with local health partners to enable translational research and being a pilot site for UKAS ISO20387 Biobanking Accreditation Program.

The VALTIVE1 trial: Validation of plasma Tie2 as the first tumour vascular response biomarker for VE - Phillip Monaghan

Universally, ovarian cancer is the seventh most frequently diagnosed cancer in women with a global 5-year survival rate of 30-40%.  Currently, ovarian cancer patients are treated using bevacizumab, an anti-angiogenic therapy that targets tumour vasculature.  Bevacizumab binds to circulating VEGF, inhibiting angiogenesis through the VEGFR signalling pathway which results in down regulation of biomarker - Tunica internal endothelial cell kinase 2 (Tie2); a tyrosine protein kinase receptor that plays a crucial role in angiogenesis. 

There is a global need to develop biomarkers for VEGF inhibitors (VEGFi) to optimise their cost-effectiveness while minimising toxicity.  Plasma Tie2 has been identified as a potential biomarker which can be monitored to optimise efficacy of treatment. Measuring circulating Tie2 concentrations in plasma can help ascertain patients in whom bevacizumab is an effective treatment and help predict progression free survival.  In cases where bevacizumab proves to be ineffective, treatment can be stopped to prevent toxicity and expense.  

In patients with ovarian (OC), colorectal and biliary tract cancer, treated with cytotoxic agents and bevacizumab or cediranib, it has previously been shown that a 25% reduction in plasma Tie2 over 9 weeks of VEGFi defines a vascular response to VEGFi, which is associated with a HR for PD of 0.55.

Our aim for the VALTIVE trial portfolio is to complete the Cancer Research UK (CRUK) biomarker roadmap to support widespread deployment of plasma Tie2 for clinical decision making on VEGFi therapy.

Validation of high-sensitive thyroglobulin and autoantibodies assays - Sally Thirkettle

Thyroglobulin is produced by the follicular cells of the thyroid gland and is present in the serum of healthy individuals but can be elevated in a number of disorders including follicular thyroid carcinoma, and therefore has an important role in the monitoring of these patients following thyroidectomy. Commonly, measured thyroglobulin levels are below the limit of quantitation of the thyroglobulin assay, necessitating the use of thyrogen pre-measurement to stimulate any residual thyroid tissue. However, the development of new, high-sensitive assays, may remove this requirement. This presentation will review verification data of such assays and discuss the considerations required for implementation.

Fetal thyroid function - Beverly Hird

In the fetus, thyroid hormones are essential for normal neurological development and growth, regardless of the source. Thyroid hormone production by the fetal thyroid begins at about 10 weeks gestation and concentrations of thyroxine and triiodothyronine gradually increase during the second and third trimesters. Adequate maternal supply of thyroxine is required during early gestation for all developing fetuses but remains crucial in the second and third trimesters for those with thyroid hormone biosynthetic defects or thyroid gland dysgenesis. Treatment of maternal thyroid disorders should be optimised, and severe iodine deficiency avoided, for the best outcomes. I will discuss a case of fetal goitre, considering the differential diagnosis, risks to the fetus and the input of laboratory medicine.

Closing ceremony & awards

5.15pm – 5.30pm BST, 14 June 2023 ‐ 15 mins

Plenary