An Update on Helicobacter pyloriDr Renu Vohra, QML Pathology

INSIDE THIS ISSUE:> An update on Helicobacter pylori> Faecal Occult Blood Collection

Instructions

> Cervical Screening Update

Helicobacter pylori (H. pylori) is one of the most prevalent pathogens found in humans, with half of the world’s population carrying this organism in their stomach. Many investigators in late 19th and early 20th century described the presence of spiral organisms in the stomach of humans, however these organisms were considered as bacterial overgrowth or food contaminants. The etiologic role of H. pylori in peptic ulcer disease and gastric cancer was established after the groundbreaking research of Barry Marshall and Robin Warren for which they were awarded the Nobel Prize in 2005.

EPIDEMIOLOGY

H. pylori is present worldwide; however, the highest prevalence is seen in developing countries with poor sanitation and overcrowding. In developing countries infections occur in early childhood with most children infected by the age of 10 and prevalence can be as high as 90% by adulthood. In contrast, in developed countries prevalence is lower in children and adolescents and increases to 40-50% in adults and elderly. In developed countries the prevalence is declining due to better living conditions and sanitation.

In Australia the pooled prevalence is around 24%, however there are areas of geographic variations with high prevalence (76%) in the rural western indigenous communities. Figure 1 shows prevalence of H. pylori worldwide. Continents with high prevalence include Africa, South America and Western Asia.

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ISSUE 1, 2018

Figure 1. World Map of H. pylori prevalence. *Source: Hooi, 2017. p424

FEATURE ARTICLE

TRANSMISSION

Transmission of H. pylori is an area of great debate. Most new infections are thought to be due to direct human to human transmission through oral-oral, oro-faecal route or both. Most transmission occurs during childhood from close family members, prior to adult contact with the organism. Childhood overcrowding is a definite risk factor for acquisition of H. pylori.

Rarely, iatrogenic transmission through the use of contaminated endoscopes has been reported.

Faecal contamination of water and food has also been implicated as possible sources of transmission but not proven definitively.

PATHOGENESIS

H. pylori is a highly motile, spiral shaped Gram negative bacterium that is found in the deep mucus layer of the stomach where the pH is 5-6 (optimum for its growth). The antibacterial properties of the stomach that prevent colonisation of most bacteria include the high acidity in the stomach lumen (pH 1-2), antibacterial peptides that inactivate a range of bacterial species, lactoferrin that inhibits bacterial growth and gastric epithelial cells that serve as a barrier. H. pylori has specific virulence factors that overcome these antibacterial properties of the stomach. The highly motile organism escapes the highly acidic environment of the lumen by quickly moving into the deep mucus layer. Production of urease, an enzyme which breaks down urea into ammonia, contributes to the acid resistance, and several outer membrane proteins mediate adhesion to the gastric epithelial cells. Virulence factors such as vacuolating cytotoxin (Vac A) and cytotoxin associated gene (Cag A) induce inflammatory response contributing to the spectrum of H. pylori disease.

CLINICAL OUTCOMES OF H. PYLORI INFECTION

Clinical features range from asymptomatic gastritis to gastric cancer.

In almost all patients, persistent colonisation with H. pylori leads to chronic gastritis. However 90% of these patients remain asymptomatic. Between 10 to 20% of patients with chronic gastritis develop peptic ulcer disease, 1-2% will develop gastric cancer and <1% develop MALT lymphoma. The clinical course following chronic gastritis is variable and depends on bacterial virulence factors, host factors (genetic and immune response) and environmental factors (smoking, alcohol, NSAID and proton pump inhibitor [PPI] usage) that mostly relate to the pattern and severity of gastritis.

In patients with increased acid production, an antral predominant gastritis develops which predisposes to duodenal ulcers. In patients with low acid production, gastritis develops in the body of the stomach which predisposes to gastric ulcer, which can later lead to gastric

metaplasia, dysplasia and in rare cases to gastric cancer. Figure 2 shows the outcomes of H. pylori infection.

LABORATORY DIAGNOSIS

Non-invasive tests: No endoscopy needed. Table 1. Non Invasive tests for diagnosis of H. pylori infection.

Diagnostic method

Sensitivity %

Specificity %

Remarks

Urease Breath Test

95 95 Very useful to diagnose current infection; reliable test to evaluate success of eradication treatment of H. pylori after 4-8 weeks

Faecal Antigen Test

94 97 Simple and non invasive test. Useful to diagnose current infection. Most valuable for assessing response to eradication therapy after 6-8weeks. Recommended test to diagnose current infection in children and pregnant women

Serology 86-94 78-95 Insufficient reliability for routine screening; cannot prove ongoing infection due to immunological memory

Urea Breath Test (UBT):

UBT is considered to be the ”Gold standard” non-invasive test for diagnosing current infection with H. pylori.

This test involves the patient taking a drink of 14C radiolabelled-urea. The patient swallows a capsule of 14C-labelled urea with a drink of water. The urease

Figure 2. Clinical Outcomes following infection with H. pylori. *Source: Diaconu, 2017. p113.

FEATURE ARTICLE

produced by H. pylori breaks down the 14C-labelled urea in the test capsule to produce labelled CO

2 which is

measured in the breath sample. This test offers highly accurate and reliable diagnosis of H. pylori infection with excellent sensitivity and specificity of 95%. This test is also used as test of cure to detect eradication of H. pylori following treatment.

The radiation dose is extremely small and is regarded as safe for children and possibly even pregnant and breast-feeding women. However, to avoid any concern in these groups, we recommend that the test NOT BE PERFORMED on these women and on children under 16 years of age.

In these groups, the faecal H. pylori antigen test is advisable and is without risk.

False negative results may be obtained in patients who are on PPI’s and antibiotics, therefore it is important to cease PPI’s for 1 week and antibiotics 4 weeks prior to the UBT.

The test is Medicare rebatable and is widely available by appointment at QML Pathology.

Faecal Antigen Test (FAT):

This is an ELISA based assay using monoclonal antibodies to detect the H. pylori antigen in the stool. Presence of H. pylori antigen in the stool confirms active infection with H. pylori. The sensitivity and specificity of the test is comparable to UBT.

QML Pathology introduced H. pylori Faecal antigen testing in June 2015. From June 2015 to June 2016 QML Pathology performed 4726 H. pylori faecal antigen tests and the overall percent positive was 12% (586/4726). As seen in Figure 3 and 4, the group with the highest percent positive was those 31-40 years of age.

This test is recommended for diagnosing active infection in pregnant women and children, and also those who may have difficulty swallowing the tablet/following instructions for the UBT.

This test is simple, safe and is Medicare rebatable. The test is available Tuesday and Friday at QML Pathology.

Serology

Following H. pylori infection a systemic immune response is induced with a transient rise in IgM antibodies followed by IgG and IgA antibodies. IgG antibodies to H. pylori typically become present 3 weeks after infection and can remain present long after eradication. Sensitivity varies from 86-94% and specificity varies from 78-95%. A positive H. pylori IgG antibody result cannot differentiate past from current infection, and H. pylori serology should not be used as a test of cure following treatment.

Figure 5 shows the percent positivity by age group from January 2012 to November 2017 for H. pylori at QML Pathology.

The test is Medicare rebatable and is available Monday to Saturday.

Figure 3. H. pylori Faecal antigen test results from QML Pathology.

Figure 4. H. pylori antigen test results from QML Pathology.

Figures 5. QML Pathology data showing percent positive for H. pylori IgG by age group from 2012 to 2017.

>>> CONTINUED OVERLEAF

Percent Positive by Age Group Tested

Percent Positive by Age Group Tested

H. Pylori Faecal Antigen Test Data 2015-2016

FEATURE ARTICLE

Invasive tests: Endoscopy needed. Table 2. Invasive tests for diagnosis of H. pylori infection.

Diagnostic method

Sensitivity %

Specificity %

Remarks

Histology 93-96 98-99 Requires expert pathologist; also provides histological data on inflammation and atrophy and presence of dysplasia

Culture of biopsy

85-95 10 Allows for antimicrobial susceptibility testing; requires specific microbiological expertise

Rapid urease (CLO)

88-95 95-100 Requires an additional test for confirmation of H. pylori infection

PCR >95 >95 Detects presence of H. pylori and detects certain resistance markers

Histology:

Histological examination of gastric biopsy is useful as it provides information on the type of gastritis and its distribution, intestinal metaplasia and cancer. Sensitivity and specificity of the test is >90%, however sensitivity is improved when multiple gastric biopsies are collected from both the fundus and antrum. More than 2 sites should be biopsied for maximum yield as the distribution of gastritis can be patchy. Helicobacter is recognised in biopsy specimens by using special stains such as haemotoxylin and eosin or Giemsa. Specificity can be further increased by using immunohistochemistry which uses monoclonal antibodies to detect the organism.

Culture and sensitivity testing:

Culture is recommended in patients who fail first line therapy. As the organism is very fastidious, the biopsy needs to be transported to the laboratory in special media. “Portagerm pylori” is a special H. pylori transport media that is provided by QML Pathology to a clinician performing endoscopic biopsies. Sensitivity and specificity of culture is >85% and 100% respectively. However, culture sensitivity is affected by transport media and specimen quality. Due to uneven distribution of gastritis, culture of biopsy specimens from 3 different area is recommended.

Susceptibility testing should be performed in patients who have failed standard first line therapy comprised of a PPI, clarithromycin and amoxicillin or metronidazole. A snapshot of culture and sensitivity from 2012 to 2014 at QML Pathology revealed resistance rates of 8%, 66% and 75% for amoxicillin, metronidazole and clarithromycin respectively. No resistance was detected in cultured

isolates for ciprofloxacin, rifampicin or tetracycline. The most common reason for failure of first line therapy, apart from non-adherence, is antibiotic resistance.

CLO test:

Gastric biopsy is placed in a urea-based medium with a pH indicator. If H. pylori is present in the biopsy, urea in the medium is broken down by the urease produced by H. pylori into ammonia leading to a visible colour change of the medium. This can be detected quickly (some within 30 minutes).

A number of commercial kits are available to perform this test. They are a relatively cheap and reliable method with good sensitivity and specificity.

PCR:

QML Pathology offers PCR for simultaneous detection of H. pylori and clarithromycin resistance gastric biopsy specimens. Sensitivity and specificity for detection of both H. pylori and detection of clarithromycin resistance is >95%.

Clarithromycin resistance is due to mutations in domain V of H. pylori 23S rRNA. Three mutations in the 23S rRNA region (A2142G, A2142C, A2143C) are responsible for >90% of clarithromycin resistance. Other mechanisms which can lead to clarithromycin resistance are point mutations, RNA methylation and efflux pumps.

At QML Pathology the PCR detection of clarithromycin resistance is based on detection of mutations in the three regions A2142G, A2142C, A2143C.

An example of the sample report is shown below.

Helicobacter pylori DNA PCR (NAAT) Specimen . . . . . . . : Faeces Helicobacter pylori DNA: DETECTED *Helicobacter pylori detected by PCR in this specimen23s rRNA Gene Testing for Clarithromycin ResistanceWild Type 23s rRNA . . : NOT Detected2142G Gene Mutation. . : NOT Detected2142C Gene Mutation. . : NOT Detected2143G Gene Mutation. . : DETECTED

REFERENCESDiaconu S et al. Helicobacter pylori infection: old and new. J Med Life 2017 Apr-Jun;10(2):112-117

Hooi JKY et al. Global Prevalence of Helicobacter pylori Infection: Systematic Review and Meta-Analysis. Gastroenterology. 2017 Aug;153(2):420-429

Kusters JG et al. Pathogenesis of Helicobacter pylori Infection. Clin Microbiol Rev. 2006 Jul; 19(3): 449-490

Mozsik G (Ed). 2013. Current Topics in Gastritis – 2012. https://www.intechopen.com/books/citations/current-topics-in-gastritis-2012 Last accessed 13 Dec 2017

Roesler BM et al. Virulence Factors of Helicobacter pylori: A Review. Clin Med Insights Gastroenterol. 2014; 7:9-17

van Duynhoven YTHP, de Jonge R. Transmission of Helicobacter pylori: a role for food? Bull WorldHealth Organ. 2001; 79(5):355-60

Figure 6: An example of a report from QML Pathology showing H. pylori detected by PCR and detection of Clarithromycin resistance.

QML PATHOLOGY UPDATES

Faecal Occult Blood Collection Instructions

From 1st of February, QML Pathology will perform Faecal Occult Blood testing only when samples are submitted in the specific green-top FOB tubes. These specific tubes contain a buffer to prevent degradation of haemoglobin and therefore improves detection rate in this screening test. When a Faeces MCS OCP is requested with a FOB, both the kit of three green top FOB tubes and a brown lid faeces container will need to be submitted for the requested testing to be performed. The tubes can be obtained as a three tube kit from QML Pathology collection centres, along with a patient information sheet. The tubes do not need to be refrigerated.

Cervical Screening UpdateDr Jason Stone, QML Pathology

The renewed National Cervical Screening Program commenced on 1 December 2017, with replacement of the glass Pap smear with the liquid-based Cervical Screening Test. The first two months have been an exciting and interesting learning experience for all involved. With such a significant change, it is not surprising that the transition has experienced four recurring issues, so I am taking this opportunity to provide more clarification:

1. The screening program is not aimed at women under 25 years of age.

• The incidence of HPV infection in this population is very high, whereas clinically significant cervical lesions are very rare. Unnecessary screening of this younger population will lead to increased inappropriate colposcopy referrals, increased patient costs and anxiety.

• The only exception is for women between 20 and 24 years old, who commenced sexual activity before they were 14 years old. These women are eligible for a one-off Cervical Screening Test. It is important that you transcribe this specific fact on the pathology request form, to ensure your patient is eligible for a Medicare rebate.

2. Follow up investigation of previous Low Grade Squamous Intraepithelial Lesion (LSIL) or possible LSIL is not a Cervical Co-Test.

• A Cervical Co-Test is when the laboratory performs both an HPV test and a cytology test on the sample, regardless of the HPV result.

• The one-year follow up of a previous low-grade lesion is an HPV test only - the laboratory will arrange any reflex cytology if this HPV test is positive.

• The correct term to write on the pathology request form is “Cervical Test, follow up”

• The same term applies to the one-year follow up of those patients deemed Intermediate Risk on the renewed screening program after a positive HPV result (not type 16/18).

3. Requesting a “Cervical Co-Test” is only appropriate for:

• Patients who are undergoing Test of Cure following treatment for High Grade Squamous Intraepithelial Lesion (HSIL).

• Patients with symptoms that are genuinely concerning for cancer i.e. more than one episode of post-coital bleeding or abnormal intermenstrual bleeding. Investigation of more innocuous symptoms e.g. itch or discharge do not require a Cervical Co-Test.

• Patients on annual follow up for treated endocervical adenocarcinoma in-situ (AIS)

• Patients with a history of DES exposure in-utero.

4. Follow up for patients with previous invasive cancer:

• Some women will require continued surveillance after treatment for an invasive cancer (cervical, endometrial or other).

• It is important to note that these patients fall outside the routine screening program, and are not covered by the National Cervical Screening Program guidelines.

• The duration and frequency of surveillance or follow-up is determined by the gynaecology oncologist who originally treated the patient. It varies from patient to patient and is determined by the tumour type, grade, stage and treatment.

• In these cases, it is best that you liaise with the original treating gynaecological oncologist for clarification on the specific follow-up protocol required for your patient.

• This scenario can potentially lead to some confusion with billing and recommendations on the pathology report.

Please do not hesitate to contact the QML Pathology Cytology Department if you wish to discuss/clarify a specific case.

More detailed information can be found on the QML Pathology website qml.com.au.

QML PATHOLOGY UPDATES

From the Education Desk - January 2018

Happy New Year and welcome to 2018. We in education are busy planning and preparing for the year ahead. We are wasting no time by getting underway in early February with one of our exclusive invitation-only Skin events which, over the years continue to be a great success and enjoyed by many practitioners. If you received your invitation in December 2017 and have yet to respond please do so as soon as possible to avoid disappointment as we have limited spots remaining.

THE CYTOLOGY PAP SMEARS AUDIT

As of December 1st 2017 our QML Pathology Cytology Pap Audit ceased in line with National Cervical Screening Program’s “The Renewal” and this audit will not be replaced at this time. You should have received by now your final report which would be end November 2017. We are currently finalising points, uploads to ACRRM & RACGP and will be forwarding certificates of completion to all successful Doctors. I would like to thank all participants over the years and hope that the statistical findings, + HPV & STI component included over the existence of this audit has been beneficial to you.

THE SURGICAL SKIN AUDIT

The QML Pathology Surgical Skin Audit continues into 2018, if you are not registered please contact your Medical Liaison Officer or education directly for information and registration details. This audit has specialised request forms which must be utilised with the reverse completed for every histology specimen. This data takes a different pathway in the computer system to collate your statistics that you receive in your monthly report. To order request forms please use your stores request forms via your local laboratory or order via the website. We have new literature available on Merkel Cell & What’s New in Skin Cancer staging as well as updated material on Basal & Squamous Cell Carcinoma to view on our website. You will find all publications available on the Surgical Skin Audit page of the website in PDF format for you to either view on screen or download for your reference.

THE DYSGLYCAEMIC AND DIABETES MELLITUS AUDIT

The Dysglycaemic and Diabetes Mellitus audit released for the 2017 Triennium has seen a record number of registrations with qualifiers gaining their Cat 1 points. As this audit is reflective in nature we request all qualifiers to review their cumulative report and complete the compulsory evaluation.

Please Note:

• If you are registered for this Audit please ensure your surgery staff are aware that you will be receiving two documents, your 3 monthly report and the non-presenting patient report via post/courier. This report carries patient names and other personal details therefore cannot be emailed.

• Patient figures and statistics included in the reporting can only reflect those patients who have been referred and presented for testing at QML Pathology. Gestational diabetes is excluded from this audit.

New events that we are introducing for 2018, have been in the planning since mid-2017 and you will be seeing some regular monthly events for some areas including our regular Cat 2 evening events so please keep a watch out for your notification.

For further information on all of our upcoming educational activities please visit our website at www.qml.com.au or contact your local Medical Liaison officer or education directly via email at education@qml.com.

Warm regards to all for 2018 and hope to see you soon at our events. The QML Pathology Education team

Dr Alan Freeman MD, FRANZCOG

Dr Alan Freeman has been delivering babies and practising Obstetrics and Gynaecology since 1989. He specialises in high risk pregnancy and complicated obstetrics. He also has a special interest in fertility & IVF, advanced laparoscopic surgery, advanced vaginal surgery and ultrasound. He regularly gives presentations at national and

international conferences on advanced laparoscopic surgery in gynaecology. Practice location is at Stafford, and bulk billing is available for consultations.

P: 07 3355 1188 / W: dralanfreeman.com.au

Kindred Midwifery, Obstetrics & Gynaecology

Kindred provides traditional obstetric care with either Dr Will Milford or Dr Petrina Duncan and offers a unique and innovative model of private maternity care to women and families. Kindred has brought together private midwifery

DOCTOR NOTICEBOARD

QML PATHOLOGY UPDATES

and obstetric care to allow access to and continuity from known care providers throughout the entire pregnancy and postpartum period.

P: 07 3188 7915 / F: 07 3319 7397 W: kindredmog.com.au / E: info@kindredmog.com.au

Dr Ashleigh Hennessey BSc MBBS (Qld) FRACP

Dr Ashleigh Hennessey joined Redcliffe and Northside Rheumatology in early July 2017. She has recently been awarded her FRACP, completing the final year of her training

at University College London Hospital, with Professor David Isenberg, a world leader in SLE. As we further develop local rheumatology services we welcome any referrals to Dr Hennessey via Medical Objects or facsimile.

P: (07) 3284 5035 / F: (07) 3883 1628

Welcome to the Online QML Pathology Test Reference Manual

This manual contains information on tests that QML Pathology can perform as well as general testing information. The online test reference manual is located on qml.com.au/iamadoctor/testingguide/referencemanual.

To search simply enter a test name or keyword into the search bar and click the “search” button

Please note: In most instances throughout our test reference manual, a $ sign will appear after the test name to indicate where an out-of-pocket fee may apply. Please ensure when discussing testing options with your patients, to be mindful of the MBS criteria and possible out-of-pocket fees that may be charged. Up-to-date MBS criteria can be sourced on-line via mbsonline.

CLINICAL DATA

This newsletter has been prepared and published by QML Pathology for the information of referring doctors. Although every effort has been made to ensure that the newsletter is free from error or omission, readers are advised that the newsletter is not a substitute for detailed professional advice. © Copyright 2016.

Infectious Diseases ReportGEOGRAPHIC DISTRIBUTION - DEC 2017

ORGANISMRegions (as per key below) TOTAL

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 DEC NOV OCTAdenovirus (not typed) 1 14 7 11 2 13 4 2 54 94 127

Adenovirus (typing pending) 1 1 1 2 3 2 1 1 2 14 21 12

Barmah Forest virus 3 1 1 1 6 4 3

Bordetella pertussis 12 16 5 4 11 6 3 29 22 3 2 11 124 155 143

Brucella species 1 2 3 1 4

Campylobacter jejuni 1

Chlamydia pneumoniae

Chlamydia trachomatis, not typed 57 100 60 18 9 1 92 2 64 31 172 58 23 32 14 733 922 983

Coxiella burnetii 1 3 1 1 1 2 2 1 12 15 16

Cryptococcus species 1 1 3 1 6 1 2

Cytomegalovirus (CMV) 1 4 1 2 8 5 1 12 3 1 2 40 50 37

Entamoeba histolytica

Enterovirus - not typed 1 1 2 1

Epstein-Barr virus (EBV) 5 15 8 6 18 11 6 33 22 3 3 3 133 178 156

Flavivirus unspecified 1 3 1 5 19 15

Hepatitis A virus 3 4

Hepatitis B virus 6 9 8 1 16 7 3 44 3 2 99 144 131

Hepatitis C virus 13 42 26 6 2 25 19 8 72 29 7 10 13 272 370 365

Hepatitis D virus 1

Hepatitis E virus 1 1

Herpes simplex Type 1 18 61 22 6 45 60 23 87 56 11 17 4 410 457 452

Herpes simplex Type 2 14 35 10 8 24 9 6 53 21 8 5 6 199 238 241

Herpes simplex virus - not typed

HIV-1 1 1 8 2 4 1 17 16 21

HTLV-1

Human Metapneumovirus 9 38 9 4 1 15 21 4 28 44 3 9 6 191 244 307

Influenza A virus 13 33 2 5 25 2 10 3 32 29 2 7 11 174 170 502

Influenza B virus 8 12 3 3 9 5 1 12 12 1 2 68 142 575

Legionella pneumophila (all serogroups) 1 1 2

Legionella species 1 1

Leptospira species 1 1 2 3

Measles virus 1 1

Mumps virus 1 1 2 6

Mycoplasma pneumoniae 1 11 1 2 1 8 8 4 13 4 1 2 2 58 111 89

Neisseria gonorrhoeae 12 8 1 2 19 9 2 15 5 2 1 76 85 84

Parainfluenza virus 10 35 9 2 26 14 3 45 41 10 7 202 352 408

Parvovirus 1 3 5 1 2 10 6 1 29 26 35

Pneumocystis carinii 1 2

Respiratory Syncytial virus 4 32 9 3 16 8 14 42 12 1 3 9 153 115 148

Rhinovirus (all types) 13 59 25 2 34 39 14 82 40 8 16 14 346 698 606

Rickettsia - Spotted Fever Group 1 1 1 3 2 2

Ross River virus 1 2 4 2 1 1 4 4 3 2 2 26 56 36

Rubella virus

Salmonella paratyphi A

Salmonella paratyphi B

Salmonella typhi 2 2 2

Streptococcus Group A 2 15 6 2 2 3 14 57 10 13 7 6 2 2 141 186 243

Toxoplasma gondii 4 2 7 2 4 7 1 13 3 2 1 1 47 29 19

Treponema pallidum 28 12 6 3 8 64 3 11 6 57 5 4 18 3 228 316 321

Trichomonas vaginalis 10 1 5 2 1 1 2 5 1 2 30 40 54

Varicella Zoster virus 19 40 21 10 2 46 2 36 9 83 45 8 14 7 342 333 370

Yersinia enterocolitica

TOTAL 264 603 262 91 27 11 549 67 370 154 985 480 103 164 121 4251 5601 6526

FURTHER HISTORICAL CLINICAL DATA CAN BE OBTAINED BY CONTACTING MARKETING ON INFO@QML.COM.AU.

REGIONS:1 Cairns2 Gold Coast/Tweed3 Ipswich

4 Mackay5 Mount Isa6 New England7 North Brisbane

8 Northern Territory9 Redcliffe10 Rockhampton11 South Brisbane

12 Sunshine Coast13 Toowoomba14 Townsville15 Wide Bay/Burnett

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