Ne...•Jonathan has edited ACB News now for quite a while – as always he pointed out that their comes a time when editors need to retire. Sue, Chair of ACB Publications Committee,

ACBNewACBNewThe Association for Clinical Biochemistry • Issue 524 • 20th December 2006

ssCarter Second

Stage Details

and Board

Announced

Obituary for

Gemmell Morga n

MRCPath Part 1 -

What You Should

Have Written!

Association of

Heads of

Departments

Agree Some

Reference

Ranges Guys . . .

Carter Second

Stage Details

and Board

Announced

Obituary for

Gemmell Morgan

MRCPath Part 1 -

What You Should

Have Written!

Association of

Heads of

Departments

Agree Some

Reference

Ranges Guys . . .

December 2006 • ACB News Issue 524 • 3

About ACB News

The monthly magazine

for Clinical Science

The Editor is responsible for the finalcontent. Views expressed are not necessarily those of the ACB. EditorDr Jonathan BergDepartment of Clinical BiochemistryCity HospitalDudley RoadBirmingham B18 7QHTel: 07973-379050/0121-507-5353Fax: 0121-765-4224Email: [email protected]

Associate EditorsMiss Sophie BarnesDepartment of Chemical PathologySt Thomas’ HospitalLondon SE1 7EHEmail: [email protected]

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

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

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

Display Advertising & InsertsPRC AssociatesThe Annexe, Fitznells ManorChessington RoadEwell VillageSurrey KT17 1TFTel: 0208-786-7376 Fax: 0208-786-7262Email: [email protected]

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

ACB ChairmanDr Ian WatsonDepartment of Clinical BiochemistryUniversity Hospital Aintree, Longmoor LaneLiverpool L9 7ALTel: 0151-529-3575 Fax: 0151-529-3310Email: [email protected]

ACB Home Pagehttp://www.ACB.org.ukPrinted by Piggott Black Bear, CambridgeISSN 1461 0337© Association for Clinical Biochemistry 2006

ACBNewsNumber 524 • December 2006

General News 4

Trainees Committee 8

Disposable Laboratory Tips 9

MRCPath Short Questions 10

MRCPath 12

Meeting Reports 16

Getting to Know 20

Colley’s Christmas Crossword 22

Obituary 24

Letters 27

Situations Vacant 28

Front cover: Members and friends of the ACB News team meet in Essex at the Editorial Board

The Association for ClinicalBiochemistry National MeetingManchester International Convention Centre23rd – 26th April 2007

ocusbeyond the laboratoryƒ

4 • ACB News Issue 524 • December 2006

General News General News General News General News General News

The Project Board of the Carter Second Stage met forthe first time at the beginning of November. The Boardnow includes Martin Marshall, Deputy Chief MedicalOfficer and Mark Britnell, Chief Executive of NHS SouthCentral SHA, representing the NHS.

Each SHA has one pilot site except NHS Londonwhich has two. Lord Carter is intending to visit eachsite and indeed has already made a start on this. LordCarter’s informal visit to the Royal Devon and Exeter inNovember met with a favourable response from staffwho found that he was very well informed about keypathology issues.

The Carter Second Stage aims to obtain robustfinancial activity data. Comparisons will be made withinternational benchmarking data where it is availableand this will lead on to economic modelling which willhelp to define ways that pathology services can becommissioned and organised in the future. ACB Newsbelieves that the Department of Health are currentlyworking on a specification for Pathology services thatcould be used by commissioners in the future. Thetarget for completion of the Carter Second Stage isSeptember 2007 and there still seems to be a generalview that pathology tariff is likely to be implementedfrom April 2008.ACB News has recently been interested to find out morefor readers on the specific timescales for the CarterSecond Stage and also the full make-up of the Board.The proposed timescales and extent of the work is now

becoming much clearer and could come out somethinglike this:December

The distribution of the template to pilot sites is hopedto take place.January-February

The pilot sites will do what is “appropriate” in theirlocality to produce the data for the template. A pilot sitewhich is within an established network would beexpected to provide datasets for their network whichwould include a number of Trusts within their SHA.Contrastingly, a pilot site that currently sits in splendidisolation may find this more difficult and may even justreturn data on its own activity. The Project Boardappears pragmatic and realistic enough to live with such variation, and is clearly not going to be over-prescriptive on the extent of the data collected.End of February – Easter

The template data will be returned to the Project Boardwho are well aware this is a short time scale. After someanalysis a dialogue will continue with pilot sites.Easter – September

Professional help with economic modelling will beused and a specification for professional providers tohelp with this is currently being drawn up. Once thedata have been analysed then it is hoped that cost andactivity drivers that come out of the findings can beconsidered in more detail. ■

Member Role/Affiliation

Lord Carter of Coles Review Team Chairman Robert Alexander Commercial Directorate, DHMalcolm Argent Lay memberIan Barnes National Clinical Lead for Pathology, DHMark Britnell Chief Executive, South Central SHAJon Crockett Chief Executive, Wolverhampton City PCTIan Dodge System Reform Team, DH Martyn Forrest Regional Director, National Programme for IT, DHProfessor Sue Hill Chief Scientific Officer, DHMartin Marshall Deputy CMO, DHProfessor Adrian Newland President, Royal College of Pathologists Sam Oestreicher UnisonProfessor Chris Price Review Team memberMarcus Robinson Review Team member Dan Smith AmicusEdmund Waterhouse Review Manager

Carter Review Second Stage

Carter Review Second Stage Project Board



ACB Members who have achieved CSci Miss H Aitkenhead

Dr A E ArmstonProf A A-B BadawyMiss S C BarnesDr M S Billingham

Dr F G BoaMr W H Bradbury

Mr A BriddonDr D M Cassidy

Dr C A CollingwoodMrs S Cory

Mrs L M CranfieldDr B L Croal

Dr P M CroftonMrs J A DayDr J F DoranDr S P Elliott

Miss R E GallacherDr I M Godber

Dr T A GrayDr C E Gray

Dr D J HalsallDr M R Hancock

Dr I P HargreavesDr D C Henderson

Dr I B Holbrook

Prof Atholl JohnstonDr GJ Kemp

Dr M L KnappMs P Y P Kwong

Mr R J LockDr D J MacDonald

Dr A MarshMs J C Mazurkiewicz

Miss E McCleanDr A A McConnell

Mrs M G McDonnellMr P NewlandMr A M Reid

Dr G RumsbyMrs J Scott

Ms C H ShearingDr J Sheldon

Mr B SheridanMiss K SmithDr S P Spoors

Dr D W S StephenMs T K Teal

Mr M J WatersonDr I D WatsonDr J D White

Dr R L Wilmot

Once every few years the ACB News editorial team meetwith the publisher, printer and others to discuss allareas of the publication. In November the team met atthe Cricketers Arms at Rickling Green. Key objectives atthe meeting included:

• Continue to provide up to date information ontopical issues.

• Look at the changing situation with SituationsVacant by continuing the auditing of the responseto advertised posts. Louise will be taking thisforward on her return from maternity leave and wewill be publishing the results in ACB News.

• Focus Handbook – there has been a lot ofdiscussion about the Focus Handbook behind thescenes. This is produced under the auspices of theACB News editorial team with Ian being the editorresponsible for the publication. The FocusHandbook has traditionally been mailed to thewhole readership, whether or not they areattending the Focus meeting. This will continuenext year but we are interested to evaluate just howuseful this is to people.

• Jonathan has edited ACB News now for quite awhile – as always he pointed out that their comes atime when editors need to retire. Sue, Chair of ACBPublications Committee, said that she appreciatedthat but she “Did not think that time had come justyet”. Nice try Jonathan!

• Sophie was not at the meeting but she has done agreat job in organising the Deacon’s challenge overthe years. Allan Deacon has now retired from theNHS and we will in due course need to considerhow to take this column forward as Allan will bebowing out sometime in 2007. Again feedbackfrom readers would be very useful.

• Joe came along to discuss public relations and hisrole in the ACB. One tangible outcome is thatLouise and Joe will be working to create a regularprofile in ACB News of the work that he isundertaking for the ACB.

• Peter and Sue from PRC Associates gave detailedinformation on the finances and other aspects ofACB News. It is in a healthy state with many of ourCorporate Members still very positive about theprofile they get in the magazine.

• Nikki and Mike from the printing side just seemedto be enjoying the whole event.

So everyone gets a mention except the readers and contributors of ACB News. So, to you all, a very happyChristmas and New Year. Do please consider contributing next year. ■

Editors’ Meeting (left to right from top): Nic Law, Peter Carpenter, Joe O’Meara, Mike Cartwright, Ian Hanning, Jonathan Berg, Louise TilbrookNikki Beeson, Sue Martin and Sue Ojakowa

ACB News Team Meeting



The Greater Manchester Pathology Network, whichaims to deliver improved efficiency and better patientservices, was launched in November. The Networkbrings together ten Primary Care Trusts and ten hospitalTrusts in a collective that will focus on developing integrated, patient-centred pathology services.

The Chair of the Greater Manchester PathologyNetwork is Dr Mike Burrows, Chief Executive of SalfordPCT, who commented that “Establishing a local networkwill enable us to take a holistic view of services acrossthe area and focus on patient care pathways, rather thanorganisations”.

The Greater Manchester Pathology Network has sixadvisory groups that will look at how pathology

services across the area can be redesigned and streamlined, embracing competitiveness and new technology, to improve both their quality and statuswithin the NHS. ■

Although their term of office have not yet formallyexpired Alan Penny and Teresa Teal gave notice to theFCS AGM in Brighton on 15th May 2006 that theywould stand down during the following year. Geoff Lester is also standing down as FCS Secretary.

Nominations for the three FCS National Officers:FCS Chairman, FCS Secretary and FCS AssistantSecretary are therefore invited from the FCS membership. Nominations supported by at least twomembers and including an undertaking from thenominee to fulfil the duties of the post should be sent

to the ACB Office before 31st December 2006.Nominations are not transferable between the vacantposts. In the event of there being more than one nomination for any post an election will be held andthe nominee with most votes, on a simple first-past-the-post system, will be elected.

The FCS National Committee itself puts forward thefollowing nominations:

FCS Chairman: Geoff LesterFCS Secretary: Roberta GoodallFCS Assistant Secretary: Martin Lee ■

Election of FCS Officers

Seasonal Sudoku!Last Month’s Solution

Greater Manchester Pathology Network

Trainees Committee Trainees Committee Trainees Committee


ACB National

Training CourseHulme Hall, Manchester

25th-30th March 2007

• GI, Liver & Pancreas • Flame Photometry

• Nutrition • Atomic Absorption

• Vitamins • Finance

• Trace Elements • Spot Tests

• Plasma Proteins • Calculations

• Spectrophotometry • Practical & Interactive

• Sessions

Social events have been organised for each evening and include a drinks reception in the Whitworth Art Gallery followed by a curry,

a visit to the Trafford Centre with a choice of Laserquest or bowling, with dodgems, and a Course Dinner and disco

at The White Hart Inn

Registration Fees:Residents £595 (ACB Members),

includes full board in en suite accommodation and social programme.Non-Residents £495 (ACB Members)

A £100 levy will be applied to applications from individuals who are notmembers of the Association for Clinical Biochemistry.

For further information contact:ACB Office, 130-132 Tooley Street, London SE1 2TU

Closing date for receipt of full payment: 23rd February 2007

Tips Disposable Laboratory Tips Disposable Laboratory Tips


MRCPath Short Questions MRCPath Short Questions MRCPath Short


Deacon’s ChallengeNo. 69 AnswerA disease has a prevalence of 10 per cent in the population being tested. A diagnostic test was appliedto a random sample of 200 individuals from this population and yielded 15 true positive and 15 falsepositive results. Calculate a) the pre-test odds of disease being present in a an individual being tested,b) the likelihood ratio positive of the test, and c) the post-test odds of disease for a patient with apositive result.

a) The prevalence of disease is 10 per cent, which expressed as a proportion is 0.1.In the absence of any other information the pre-test odds can be calculated fromthe prevalence as follows:

Pre-test odds = prevalence = 0.1 = 0.1 = 0.11 (2 sig figs)(1 – prevalence) (1 – 0.1) 0.9

Therefore the pre-test odds of disease are 0.11 to 1 ( or 1 to 9) for disease or 9 to 1against disease.

b) The likelihood ratio positive (LR+) is defined as the ratio between the probability offinding a positive test in the presence of disease, and the probability of obtaining a positiveresult in the absence of disease:

LR+ = probability of a +ve test with disease probability of a +ve test without disease

The probability of finding a positive result in the presence of disease is simply thesensitivity of the test. The probability of finding a negative result in the absence ofdisease is the specificity of the test, so that the probability of a positive test in theabsence of disease becomes (1 – specificity). Calculation of LR+ then becomes:

LR+ = sensitivity (1 – specificity)

Questions MRCPath Short Questions MRCPath Short Questions


If 10% of individuals have the disease then the sum of true positives and falsenegatives (TP + FN) is simply the total number with disease i.e. 10% of 200 =20. We know that TP (true positives) = 15 so that the sensitivity of the test can becalculated:

Sensitivity = TP = 15 = 0.75(TP + FN) 20

90% of individuals must be disease-free and so the total number of true negativesand false positives (TN + FP) is 90% of 200 which is 180. Since we know thatthere are 15 false positives (FP) then TN can be obtained by subtraction:

TN = (TN + FP) - FP = 180 – 15 = 165

Which can then be used to calculate specificity:

Specificity = TN = 165 = 0.917 (3 sig figs)(TN + FP) 180

LR+ is then calculated from the sensitivity and specificity:

LR+ = 0.75 = 0.75 = 9.0 (2 sig figs)(1 – 0.917) 0.083

c) The post-test odds is simply the pre-test odds multiplied by the likelihood ratiopositive:

Post-test odds = pre-test odds x likelihood ratio positive

= 0.11 x 9.0

= 0.99 (2 sig figs)Therefore the positive test result has increased the odds of the patient having thedisease from 1:9 to an approximately an even chance (i.e. 1:1).

Question 70The transmittance of a solution of NADH at 340 nm is 45%. What is the absorbance at 340 nm of a 1 in 5 dilution of this solution?

MRCPath MRCPath MRCPath MRCPath MRCPath MRCPath MRCPath


Although some good answers were produced throughout bothpapers, a constant problem was illegibility of handwriting andpoor layout. Candidates must practise producing handwritten

answers under exam conditions that are easily readable by theireducational supervisors. They should also ensure that they structuretheir answers properly, with productive use of paragraphs andsubheadings. Continuous poorly legible writing with no breaks makesit difficult to see whether the candidate is thinking logically orwhether their knowledge is adequate. Drawings and diagrams aresometimes helpful but must not be drawn so badly as to underminethe answer.

Paper 1Question 1Outline the factors that should be taken into account when decidingwhether and how a new diagnostic test should be introduced intothe laboratory repertoire in response to clinical demand.All candidates attempted this question. The majority tackled it well andaddressed the major areas. Candidates fell down on their lack ofconsideration of EQA and of audit and the need to consider 24 hourworking rather than a 9 to 5 service.

Question 2 Critically discuss the advantages and disadvantages of automationand robotics in pre-analytical specimen processing.This question was less well tackled than Question 1. Many candidateswho provided incomplete answers failed to consider Health and Safety.Although this applies throughout the laboratory an explicit overview ofthe Health and Safety issues around automation was needed. Evaluationof the costs of equipment against costs of staff was another importantpart of this question not considered in sufficient detail by manycandidates.

Question 3Outline the principles of electrophoresis and review the advantagesand disadvantages of conventional electrophoresis and capillary zoneelectrophoresis giving examples of their use.The most significant deficiency in answers to this question was the lackof detail about the detectors used with capillary zone electrophoresis.Surprisingly, although explicitly mentioned in the question, manycandidates chose to ignore reviewing the advantages and disadvantagesof the two techniques. It was not possible to gain a good mark for thisquestion without doing so.

MRCPath Part 1 Written Examination Spring 2006



Question 4Describe the clinical biochemistry of sex hormone binding globulinand its use in clinical practice.This question was poorly tackled and some mediocre marks were achieved.There was clearly a lack in factual knowledge and it appeared that many ofthe candidates did not know sufficient detail to be able to answer thequestion either logically or comprehensively.

Question 5Describe the biochemical consequences of short bowel syndrome.One of the major deficiencies in answers to this question was a failure toconsider problems that might occur as a result of electrolyte loss due toshort bowel syndrome. Many candidates did not appear to be aware thatthe most common cause of short bowel syndrome is Crohn’s Disease.Others became fixated on parenteral and enteral nutrition and did notdiscuss fully the biochemical consequences of short bowel, particularlywater and electrolyte problems.

Paper 2Question 1aDiscuss the differential diagnosis and management of a 50 year-oldwoman who presents with serum calcium concentration of 3.8 mmol/L. Most candidates attempted this question, the majority doing well. Somemade the mistake of concentrating on hyperparathyroidism while others,surprisingly, completely omitted this common cause of hypercalcaemia.Similar variability in answers also applied to malignancy associatedhypercalcaemia, and in some cases myeloma was omitted as a cause ofhypercalcaemia. Sarcoidosis was ignored by the majority of candidates.Rare causes, such as beryllium poisoning, were occasionally given undueprominence. Differential diagnoses were not always well supported byreference to relevant clinical findings and investigations. Management ofthe condition was generally well described, with most candidatesrecognising the need for fluids and use of bisphosphonates. The risk ofcardiac dysfunction with such a high calcium tended to be ignored.

Question 1bDescribe the principles underlying the use of enzymes as reagents,discussing factors that are important in the optimisation of enzymaticassays with reference to specific examples. Only a small number of candidates attempted this question but those thatdid clearly knew the subject well. Providing that candidates were aware ofthe factors that affect enzyme function and optimisation and covered thesepoints adequately, accumulation of marks was relatively straightforward.Answers should include reference to optimisation of substrateconcentration, the impact of pH, the relevance of ionic strength,temperature and the need for co-factors. A discussion of measurement ofsubstrate or product and the use of reverse or linked reactions wasrequired. Good examples include monitoring of NADH or linkage toperoxide reactions in liquid chemistries, ELISA, EMIT and CEDIA.



Question 2 Discuss the endocrine causes of hyponatraemia, including theirpathophysiology and management. Many candidates failed to recognise the word endocrine in the questionand discussed causes such as diuretics, sick cell syndrome andinappropriate hypotonic fluid intake. This emphasises the need to read thequestion carefully! It was expected that all or most of the endocrine causeswould be discussed, including SIADH, CAH, hypothyroidism, cerebral saltwasting and reset osmostat syndrome. Most candidates did not give acomprehensive list and hardly any mentioned cerebral salt wasting andreset osmostat syndrome. Many did not describe the pathophysiology forall the causes they mentioned. A good answer to this straightforwardquestion also required a systematic approach to investigation in relation topathophysiology, but most candidates just mentioned one or two tests forsome of the causes and failed to give a comprehensive account of theinvestigation of even SIADH. There were also some major inaccuraciesregarding the management of common disorders like SIADH and Addison’sdisease. Good answers to this question made appropriate use of figures andalgorithms.

Question 3Critically discuss the laboratory estimation of glomerular filtrationrate.This question required a brief review and critical discussion of all theavailable methods for laboratory estimation of GFR. A critical discussion ofcreatinine and estimated GFR (eGFR) was expected together withalternatives including cystatin C and urea (which was overlooked by manycandidates). Inulin clearance and isotopic methods may not be laboratorymethods for GFR but should be mentioned as the gold standard. Somecandidates did not review plasma creatinine as a marker of GFR. EstimatedGFR was mentioned by most candidates. However, many did not discuss itcritically and failed to mention that caution should be exercised ininterpreting eGFRs between 60 and 90 ml/min in the absence of clinicaland laboratory evidence of renal disease, failed to grasp the concept ofcorrection for body surface area and did not refer to its inappropriatenessin acute renal failure.

Question 4Define the Metabolic Syndrome and describe its pathophysiology.Discuss the role of the laboratory in the investigation of patients whopresent with features of this syndrome.Very few candidates were able to offer an adequate or accurate definition ofthe metabolic syndrome (MS). There was generally a poor understandingof the pathophysiology of MS and, worryingly, some confusion aboutassociations with Familial Hypercholesterolaemia and Familial CombinedHyperlipidaemia . Some candidates discussed diagnostic use of tests likeinsulin, C-peptide, hs-CRP, fibrinogen and PAI-1 for clinical diagnosis ofMS even though these tests are hardly ever required in clinical practice.Other candidates did not discuss the role of the laboratory at all eventhough this was explicitly part of the question.



Question 5Critically discuss the relative merits of determination of genotypeversus phenotype in the investigation and treatment of disease,illustrating your answer with examples. Given that this continues to be a topical issue, answers showed adisappointingly low level of understanding. Definitions of genotype andphenotype were unclear in many cases, and some answers focussed toonarrowly on diagnostic investigation alone, to the exclusion of impact ofon treatment. Strong candidates were able to discuss the lack of diagnosticsensitivity or specificity sometimes associated with phenotyping and thechallenges of genotyping when there are multiple mutations with similarphenotypic expression, with appropriate examples. Case finding followingdetection and genotyping of an index case should be distinguished fromgeneral diagnosis. Gene frequency, risk of spontaneous mutation and therelevance of penetrance and dominance should also be considered.Candidates who answered this question well were also able to discussrelevance to treatment, such as Her2/neu in breast cancer, and otheraspects of pharmacogenomics. ■

Meeting Reports Meeting Reports Meeting Reports Meeting Reports

The meeting was opened by a warm welcome from the Chair ofthe West Midlands Association for Clinical Biochemistry,Rousseau Gama, who entertained the audience with a card trick

before inviting Anne Green to introduce the meeting. Anne presentedan overview of developments in paediatric biochemistry from 1949 tothe present, highlighting the need for specialist networks to share and co-ordinate activities, and to support laboratories and clinicians inDistrict General Hospitals (DGHs).

Investigating Hypoglycaemia in

ChildrenThe morning session was chaired by Kate Hall, Principal Biochemist atBirmingham Children’s Hospital (BCH). Kate introduced the firstspeaker, Mary Anne Preece, Consultant Biochemist at BCH, who gave atalk on the investigation of hypoglycaemia in children. Mary Anneexplained the difficulties of defining hypoglycaemia although a venous

Paediatric Biochemistry

Has Grown UpReported by Sukhjinder Moore, Birmingham

One of thehighlights of the

meetings calendarfor 2006 in the

West Midlands wasthe Association

for ClinicalBiochemistry’s JuneScientific Meeting


plasma glucose <2.5 mmol/L is widely quoted. She went on to discussglucose homeostasis and why maintenance of adequate blood glucoselevels is critical. Her talk included the metabolic, endocrine andneonatal causes of hypoglycaemia, as well as sample requirements forthe investigation of this phenomenon both during and after ahypoglycaemic episode. Metabolic causes of hypoglycaemia includefatty acid oxidation defects (FAODs), such as MCADD. Whilst thebiochemical hallmark of MCADD is hypoketotic hypoglycaemia, MaryAnne reminded us that MCADD patients can sometimes produceketones. BCH is in the process of developing ‘Hypo-packs’, with usefulinformation on specimen requirements and labels, for investigatinghypoglycaemia. The National Metabolic Biochemistry Network hasdeveloped guidelines for investigating hypoglycaemia (available onwww.metbio.net). Copies of a useful review ‘The management of thechild with a decreased conscious level’ developed by the PaediatricAccident and Emergency Research Group were provided for allattendees. Further copies of these guidelines are available atwww.nottingham.ac.uk/paediatric-guideline

Anupam Chakrapani, Consultant in Inherited Metabolic Disease(IMD) at BCH, gave us some insight into the various inborn errors ofmetabolism diagnosed in adolescents and adults. Inborn errors ofmetabolism affect enzyme and cofactor activities, resulting inmetabolite accumulation and product deficiencies, contributing todisorders of metabolism and organelle disease. Dr Chakrapani described



the pathogenesis, atypical clinical presentations and management ofpatients with inborn errors of metabolism. There are over 500different types of known IMDs, any of which can present inadulthood with variations in severity. Pregnancy is an addedcomplication in such patients, but appropriate monitoring andmanagement can allow them to have healthy children. There areincreasing numbers of adults with IMD as a result of improveddiagnosis and survival in paediatric patients. However, provision ofservices for adults is currently limited and so there is a need todevelop adult IMD centre.

The morning session was closed by Mark Taylor, a Consultant inPaediatric Nephrology at BCH. Dr Taylor was concerned that anepidemic of renal disease was about to occur and felt it importantto educate the audience in the early recognition of kidney diseasein children. He covered kidney nephron physiology, use of markerssuch as eGFR, proteinuria and the Schwartz formula to assesskidney function and damage. He also discussed the effects ofhypertension, obesity and diabetes on kidney disease in children.Studies show that obesity in youth is itself a risk factor towardsrenal insufficiency, a major concern given the present obese statusof the paediatric population.

Lunch was provided in the form of an appetising buffet to relievethe delegates of their hypoglycaemic symptoms and allow a chanceto network. There were also stands set up by the sponsors of theevent, Olympus and DPC, with a variety of their own literature andgoodies on display, all of which disappeared like hot cakes!

Newborn Screening for CFThe afternoon session was chaired by George Gray, PrincipalBiochemist at BCH. George invited Professor Rodney Pollitt to talkon newborn bloodspot screening for cystic fibrosis (CF). ProfessorPollitt discussed the issues and progress in screening for CF since amethod was developed in the late 1970s to the present. Newbornscreening allows diagnostic odysseys to be avoided, alerts familiesto the risk of CF in future pregnancies and can prevent early onsetof severe, irreversible damage in some affected infants. At presentin the UK there are seven CF screening programmes, using fivedifferent protocols. Most of these protocols are based on detectingincreased levels of immunoreactive trypsin (IRT) and DNA analysisof the Cystic Fibrosis Transmembrane Conductance Regulator(CFTR) gene. The gold standard test, the sweat test, is beingreplaced by molecular genetics but there is poor genotype –phenotype correlation. Professor Pollitt questioned whether wewish to detect milder forms of CF in newborn screening, and if aDNA based screen is ethically acceptable. There is a need for astandard protocol for newborn screening of CF but itsimplementation will be a long process.

Professor Pollitt was followed by Helen Roper, a ConsultantPaediatrician at Birmingham Heartlands Hospital and one of theleading experts in Paediatric Muscle Disease in the UK. Dr Roper



discussed the presentation and investigation of muscle disease inchildren. Clinical presentations include floppy infants, poormuscle tone and control of limbs, characteristic facial features,brain malformation, motor symptoms, hypotonia, weakness,presence of lesions, failure to thrive and muscle pain often precipitated by exercise. The best approach to investigate muscledisease is to do a clinical assessment of the patient (check theeyes, brain and swallowing action), measure CK (not in the firstfew days of life), store DNA, and request tests specific to muscledisease suspected and biopsy if clinically urgent. Histochemicaland immunohistochemical investigations may also be beneficial.

Paediatric Endocrine ConditionsThe final speaker of the day was Neil Fraser, a ConsultantPaediatrician in Hereford. Dr Fraser focused on paediatricendocrinology and the DGH. He described the causes andinvestigations of neonatal conditions such as hypothyroidism,hypoglycaemia and prolonged jaundice, micropenis, bilateralundescended testes and ambiguous genitalia. Dr Fraser then discussed childhood and adolescent endocrineconditions usually investigated in DGH settings. These includeshort stature, severe growth hormone deficiency, tall stature,precocious puberty, Cushing’s Disease, adrenarche and obesityrisk factors. Investigations vary from height velocity tostimulation tests. Stimulation tests with insulin and glucagonshould only be performed in recognised endocrine centres. It isnecessary to select an investigation most appropriate to theworking diagnosis, and be aware of the presence of multiplehormone deficiencies.

Concluding remarks for the meeting were made by Mr MikeHallworth, Royal Shrewsbury Hospital, who highlighted the keythemes of the day’s presentations. In particular he emphasisedhow paediatric biochemistry exemplified what was varied andrewarding in being a Duty Biochemist. He also described a chainof discovery, research, dissemination, application and audit whichwill lead to better patient care. Clinical Scientists need to cover allthese links and support one another, since no-one can know it all.The meeting allowed delegates to learn more about paediatricbiochemistry, meet new colleagues and I am sure all enjoyed themeeting as I did. For those who couldn’t make this meeting, all ofthe presentations will be appearing on the West MidlandsAssociation for Clinical Biochemistry website in the near future. ■

Poster Abstract Deadline Approaches

Do remember that the deadline for poster abstracts for Focus in Manchester is 12th January 2007.

Abstracts are best submitted electronically on the website: www.focus-ACB.org.uk

Getting to Know Getting to Know Getting to Know Getting to Know


Many ACB members are probably not aware of an Annual Meeting ofthe Heads of Departments for Clinical Biochemistry. This groupinitially started as a meeting of Professors in Clinical Biochemistry to

support and promote academic developments in the specialty. With a smallernumber of academic departments, membership has been expanded.

What Did We Discuss at Our Last Meeting

and Some Key Actions?

Professors’ Prize

For a number of years the Professors’ Prize has been supported by anendowment arising from contributions made by academic heads. The prize isa prestigious award given to young Clinical Biochemists who havedistinguished themselves academically. Previous awardees have all continuedto flourish and progress on the academic scale, some to chairs in ClinicalBiochemistry. The Award lecture is now an established feature of the nationalFocus meeting. The heads have agreed to continue with the scheme byagreeing to make a further financial commitment to cover the costs of theaward for the next few years.

Planned Diagnostic Trials

There is currently no mechanism for introducing new diagnostic tests into theNHS. Partly as a result of lobbying by this group and other members of theprofession we were able to have significant input into a document producedby a working group of the Royal College of Pathologist (NK as member andcontributor to this group). The recommendation is that the Department ofHealth set up a committee under the aegis of NICE to look at how newdiagnostic tests are evaluated and introduced into clinical practice. Rather thanintroduce tests ad hoc, a systematic evaluation should be considered prior totheir introduction. We are all aware of the difficulties many departments haveexperienced in introducing troponins and brain natriuretic peptide forexample.

The Cooksey Report on NHS R&D Funding

The Association of Heads contributed to the ACB response to the Cookseyreport. All NHS/R&D funding will go into a central pot and hospitals will haveto bid for resources. This is a major shift in the funding mechanism and manyTrusts will lose significant R & D income when this is implemented.

Association of Heads

of Departments for

Clinical BiochemistryBy Professor Noor Kalsheker

Getting to Know Getting to Know Getting to Know Getting to Know


Department of Health Funding for Academic Posts

The Department of Health has established Academic ClinicalFellowships (ACF) and Clinical Lectureships (CL) with partnershipfunding from the Department of Health and local Deaneries. For ACFsthe DoH provides 25% central funding with 75% of funding comingfrom SpR posts. At least three departments are bidding for such postsin Chemical Pathology/Clinical Biochemistry which has beenidentified as a priority speciality.

Undergraduate Teaching

There was variation in the amount and method of teaching medicalundergraduates in the United Kingdom. An attempt is being made tocollate information to look at the diversity of teaching and identifyessential core teaching such as, emergency management of fluidbalance and integrating this with work undertaken by the RoyalCollege of Pathologists. ■

ACB News Crossword ACB News Crossword ACB News Crossword


Colley’s ChristmasCrossword

The clues are arranged in alphabetical order of their solutions.The grid has mirror symmetry in two planes. Fill in the black squares as required.

1 Accountant with spies is sensitive (6)2 Almost stupid monster dangles tailless in an inherited unit of

reorganisation (6,3,6)3 Amino acid loses full boat crew in process (3)4 Non-U books for records (6)5 Not available in reverse,first letter belonging to us for frogs (6)6 It takes endless skill to give gas (2)7 Traits of a confused painter (6)8 Consumed but not audibly one over (3)9 A male particle (4)10 National Adviser advances end, could lose this (6)11 Incubate in this city (4)12 By dumb read the extent is shown (7) 13 Could be eccentric flower (3)14 It is once a change to paddle it (5)15 Rush to job (6)16 Transporter of Pathology review (6)17 Copies a bit of 29 (2) 18 Metal approved in Europe (2)19 Stuff second letter to Birmingham pathologist (5)20 If it’s not this, 29 won’t care (7)21 European noble is a gas! (6)22 Turn out retired tennis player (5)23 Concentrate on annual meeting (5)24 Sounds like a nasty pest (4)25 Separate proteins in this for your hair (3)26 Is he married to the ACB (5)27 Given a hint, Ron didn't carry code (6)28 One from Hawaii (3)29 A litre for club (3)30 Second a bird that’s extinct (3)31 Have Academy in backward sick-bay (3)32 Note this metal (2)33 Gas back working (2)34 Anonymous preterminal change to hydrocarbon (6)35 Nearly half dead report of witchcraft (3)36 Go here for 41 (3)37 Surgery as an Out-patient (2)38 Steal to cook (5)39 The cost of a reviewer? (5)40 Valuable exercise? (2)41 The sound of 16 (6)42 Curling captain almost helps to slide (3)43 Crisis at forty-seven (5)44 Will this paper illuminate the subject? (3)45 46 finally changes to hold the work together (5)46 The tone of a singer (5)47 Abbreviated recent guidelines on this (2)48 You nearly and I have a subject (5)49 It's there in the web! (3)50 It's pigmented and waste product is against for a second (4)51 Three letters and it's standard (3)52 Cassandra’s review? (6)

Answers to Last Month’s CrosswordAcross: 1 Angina pectoris, 10 Petit, 11 Myoglobin, 12 Heparin, 13 Handset, 14 Tapes, 15 Seat, 16 Term, 19 Cure, 20 Beat, 21 Reels, 24 Records, 26 Topical, 29 Nosey, 30 Creatine kinase

Down: 2 Notepaper, 3 Interest, 4 Administers, 5 EPO, 6 Talent, 7 Rebus, 8 Sanctum, 9 Upshot, 13 Heart attack,17 Exercises, 18 Troponin, 19/27 Cardiac ischaemia, 22 Splays, 23 Arrant, 25 Cache, 28 Man

Lucky Winners . . .John Stevens Tanya Hart

A special Christmas prize for everyone who manages tocomplete, or indeed submit a half decent effort, for thisexample of crossword minimalism! Fax to 0121-765-4224by end of December.

Obituary Obituary Obituary Obituary Obituary Obituary Obituary


Gemmell was born in 1922 into a medical family inDundee and it was natural that he should also followthat career path. He graduated from the University of St

Andrews with a BSc (1943) and an MBChB withcommendation (1946). He was attracted to the challenges ofPathology but he eschewed the established specialty of MorbidAnatomy (Histopathology) in favour of the developing field ofClinical Biochemistry – a decision which he regularly recalledwith pride over the ensuing 60 years. His ability and drive ledhim to be appointed in independent charge of ClinicalBiochemistry at Dundee Royal Infirmary in 1952 and heresponded by immediately designing an extensive final yearundergraduate teaching course. He developed an interest incalcium and bone disease and took a short break from Dundeespending time in Baltimore USA working as a FullbrightResearch Fellow.

Gemmell left Dundee in 1965 to take up the newly establishedChair of Pathological Biochemistry in Glasgow. At appointmenthe was apparently recognised as a ‘firebrand’ and his selectionwas ‘risky, but well worth making’ – a judgement that proved tobe extremely wise. His energy and enthusiasm led to a rapidexpansion of both the University and NHS parts of his integrateddepartment and he recruited a series of key people who heactively encouraged to develop research interests and to teachClinical Biochemistry to medical and science undergraduates.The Glasgow undergraduate teaching programme was developedinto a textbook that is used worldwide, having been translatedinto several languages. As both the research and service sides ofClinical Biochemistry in Glasgow thrived Gemmell presided overthe design and direction of the Institute of Biochemistry, whichopened at Glasgow Royal Infirmary in 1977, and he acquired asignificant presence in the nearby University Tower a few yearslater. Success bred success and with Gemmell’s dynamicleadership Glasgow became one of the foremost centres forClinical Biochemistry in the world with an impressivepublication portfolio.

A Visionary with

Boundless Enthusiasm,

Energy and CommitmentProfessor Gemmell Morgan, Glasgow

With the death ofGemmell Morgan on31st October 2006Clinical Biochemistry

in the UK lost aninspirational

character and one of its

greatest champions



Made in Glasgow . . .

Perhaps Gemmell’s greatest achievement during his working lifewas that his department trained, inspired and empowered morethan 100 individuals who went on to be professors, academicsand consultants in Clinical Biochemistry around the world.Included in this impressive list are many Clinical Scientists – forGemmell was a champion for the cause of excellent scientistsworking in harmony with medical consultants. ‘Made inGlasgow’ still applies to many of today’s leaders in ClinicalBiochemistry.

Throughout his career Gemmell held many influentialpositions but it was his contribution to the Association of ClinicalBiochemists (ACB) that will be his legacy outside Glasgow. Hewas Chairman from 1982-85 and President from 1985-87.During this period the ACB changed from a scientific society intoa true professional body. Workforce planning was introduced,training was made more professional and the annual nationalmeeting (now called Focus) was introduced. The ACB becameincreasingly listened to and respected and links werestrengthened with professional bodies around the world and withthe diagnostics industry.

Gemmell retired in 1988 but that did not stop him being analmost ‘ever present’ at national, regional and local clinicalbiochemistry meetings. He could always be relied on toprovide some wisdom from the past and some encouragementfor the future, especially to the new generation of ClinicalBiochemists who impressed him greatly. He spoke passionatelyat the 2006 Annual General Meeting of the ACB urging us totake pride in our achievements and to better publicise thecontribution that Clinical Biochemistry makes to healthcare. Heattended a local meeting two weeks before he died and he wasscheduled to join the gathering of Scottish Consultants just afew days later.

One of the reasons that Gemmell kept himself in theprofessional loop was that he relished a discussion, a debate oreven an argument – on Clinical Biochemistry certainly, but alsoon domestic and international politics. He used to judge peopleby the way that they responded to his often deliberately extremestatements. A ‘score draw’ was a great result from any discussionwith Gemmell.

Outside his professional career Gemmell was dedicated to hisfamily. He is survived by his wife and best friend Margaret; hisdaughter Imogen is a distinguished Paediatrician; and he wasproud of his two grandchildren, Iona (a medical student inGlasgow) and Alasdair. Gemmell experienced health problemsfrom the age of 18, culminating in major surgery to his leftfemoral artery and lower aorta almost thirty years ago. It was theultimate acute failure of this graft that brought about hisuntimely end.



When paying tribute to Gemmell, as he retired as ACB Presidentin 1987, Professor Peter Griffiths read out the entry fromGemmell’s medical school year book. It included the sentence“Gemmell Morgan jumped on his white horse and rode off inevery direction”. For those of us that knew Gemmell it was anapt and prophetic description of someone whose vision, coupledwith boundless enthusiasm, energy and commitment, left alasting impression on all that met him and on the profession ofClinical Biochemistry. ■

GHB

Chief Scientific Officer Awards

Congratulations to Kevin Spencer

who has been awarded

HealthCare Scientist of the Year for 2006

and to Roger Ekins who received a

Lifetime Achievement Award.

We hope to have more details and a report

of the meeting in the January issue.

Letters Letters Letters Letters Letters Letters Letters Letters


LettersReaders speak out

?

Forget Sacred Cows and

Agree Some Reference

Ranges!Returning from a pathology modernisationconference last night it struck me that the mainconstraint for an integrated laboratory informationsystem for Wales, at least for Biochemistry, is ourfailure to standardise our laboratory reference ranges.

When I started in the profession (longer ago than Icare to admit) I was foolish enough to ask whyreference ranges for certain common enzymesweren’t the same in all laboratories: I was told thatthere were obvious reasons – local flexibility toquote valid statistically derived ranges was acornerstone of our work to establish a reliablescientific service.

I think we can all agree that times have moved on.The drivers for change today such as the CarterReport and Pathology Modernisation in Wales arequestioning our reluctance to standardise ourapproach to the service; one of the frequently askedquestions to Lab Tests On-line is “why are there noreference ranges attached to the tests on the website”. Perhaps the public (as well as our medicalcolleagues) deserve better.

I know that the profession is starting to moveforward to deal with this issue – much work hasalready been done to provide statistically valid ageand gender related ranges. Unfortunately I feel theadvent of large analytical platforms and the IVD

Directive has obstructed our path to a morestandardised approach.

How valid are these obstructions? Informationgathered over many years for the Wales ClinicalBiochemistry Audit group has revealed that quotedreference ranges are often from “kit insert” or astandard text, (at least one major diagnosticsmanufacturer quotes most general chemistry rangesstraight from Tietz). How much confidence do mostof us have that our reference ranges are “right”?

Could this be the time for a more pragmaticapproach? There is a wealth of data in EQA schemesshowing what bias exists between methods for manyanalytes; the variations are frequently smaller thanwe imagine and standardising adjustments may causelittle upheaval. When there have been significantexternal forces to standardise (such as DCCT alignedHbA1c and eGFR) we have co-operated withsurprising success despite our scientific reservations.A lot of the other work we could do is likely to be“no brainer” in comparison.

It is time to accept that when we measure mostanalytes we are not looking at apples and pears, butCoxes and Russets and we could, and should, be ableagree an age related reference range for “Apple”.

Gethin RobertsConsultant Clinical BiochemistBronglais HospitalAberystwyth

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Documents

Ne...•Jonathan has edited ACB News now for quite a while – as always he pointed out that their comes a time when editors need to retire. Sue, Chair of ACB Publications Committee,