Events in 2023

Myeloma screening is a high volume investigation pathway, performed by both Biochemsitry and Immunology laboratories. National audit data has shown there to be high variation between laboratories on the implementation of this workflow, leading to potentially inconsistent patient care geographically.

This talk will aim to cover the following areas:

Give brief foundation knowledge on serum electrophoresis/immunodisplacement/immunofixation
Introduce the Myeloma UK Best practice guidelines for Myeloma screening
Discuss Mass spec methods for analysing monoclonal protein
Discuss monitoring of myeloma patients and monitoring of Monoclonal gammopathy of undetermined significance (MGUS) patients.

Food-induced immunotherapy has been practiced with varying success for over 100 years. Over the past 10 - 15 years it has gained a greater recognition in the potential management of children with food allergies. Food-induced immunotherapy can take the form of oral, epicutaneous or sublingual routes and usually results in a short-lived desensitisation rather than the acquisition of tolerance. For this reason, food immunotherapy is not a cure but relies on regular, usually daily, ingestion. Peanut immunotherapy lies mainly within the domain of clinic research however Palforzia (roasted peanut flour), was approved by NICE in February 2022 for the management of peanut allergy in children 4 to 17 years of age. The methodologies and factors associated with successful desensitisation to peanut will be discussed.

Blood Transfusion follows binary guidelines designed to protect against the formation of allo red cell antibodies capable of causing Haemolytic Disease of the Foetus and Newborn. For the first time, in 2021, the England and Wales Census included a gender identity question, ‘Is the gender you identify with the same as your sex registered at birth?’. 0.5% of respondents answered ‘No’ (262 000 people) of which 48 000 identified as a trans man, 30 000 as non-binary and 18 000 as another gender identity. Thus, there is a small, but significant, population of Transgender and Gender Diverse (TGD) individuals in society.

What are the implications for Blood Transfusion? There are several scenarios:

The lab could receive a sample labelled male and issue blood components which fail to meet the requirements of Kell negative and, if applicable, CDE negative red cells to someone with childbearing potential.

The lab could receive an antenatal sample labelled male and the LIMS does not allow staff to perform all the same testing and product issuing as it would for a female.

Some TGD individuals who have transitioned may get a new NHS number. Lab staff may be unaware and lab records are not merged which means all future transfusion requests are relying solely on antibody screening results with no historical transfusion information.

The clinical consequences of these errors are missed incompatibilities, special requirements not met (SRNM) errors and immediate or delayed transfusion reactions with a potential for major morbidity or mortality.?All the circumstances described above illustrate that provision of healthcare is not uniform?for?all patients in the UK and could be described as indirect discrimination - a policy or practice that is identical for all people but has an unfair or disproportionate effect on a people with a protected characteristic.

Coagulopathy has been shown to play an important role in COVID 19 infection. Reported abnormal coagulation laboratory values in severe COVID-19 are most notably a 3-to-4-fold increase in D-Dimer (Yao et al., 2020).

Several studies showed that elevated D-dimer in COVID-19 patients is associated with higher mortality. A retrospective cohort study carried out by Zhou, et al. (2020) also associated D-Dimer > 1000ng/ml with higher odds of in-patient death.

At the onset of the COVID 19 pandemic, there was no consensus as to how D-Dimer levels should be used for the management of COVID-19 patients. In April 2020, PAHT decided to use a D-Dimer cut-off of 1000 ng/ml to determine anticoagulation dosage. The source of reference used by PAHT in their decision making employed a D-Dimer assay with a cut off value of 500 ng/ml for the exclusion of venous thromboembolism (VTE). This raised an issue as the source of reference used by PAHT at the time employed a D Dimer assay with a cut-off value of 230 ng/ml for the exclusion of VTE. This meant the trust was unable to implement the new COVID 19 care bundle at the time. The haematology laboratory wanting to do whatever possible to assist patient care agreed to change the current D-Dimer methodology immediately to support the trust COVID 19 care bundle.

The verification and implementation of the new D-Dimer assay with cut of 500 ng/ml for the exclusion of VTE was completed within four weeks. A risk assessment and a change control were put in place to ensure users were made aware of the change in cut-off limit.

This verification and implementation of the new assay was possible through the hard and collaborative work of the haematology technical team with shared vision, motivation coupled with team engagement and strong leadership.

As the climate health crisis continues to escalate, governments and key NHS leaders are recognising the need for change. There is growing sector awareness of the impact of the lab on the environment and it is now time for laboratory medicine to consider the role POCT can play in achieving NHS net zero carbon targets. Centres for Sustainable Healthcare propose four principles for sustainable healthcare: prevention, patient self-care, lean service delivery and low carbon alternatives.

This presentation considers the role GIRFT and POCT can have, in supporting these principles of sustainable healthcare and promoting greener diagnostic pathways.

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 and highlight the analytical strategies to develop validated assays to detect and measure both novel opioids and other novel psychoactive substances.

Perspectives on the Borderline Endocervical Cell Classification

Transfusion outside the NHS – jobs for Biomedical Scientists

Mark Lundy was convicted of killing his wife and daughter in 2002 and again in 2015 after a retrial ordered by the Privy Council. His conviction continues to divide public opinion in New Zealand. A key piece of evidence was the presence of small smears on a shirt which prosecution experts identified as central nervous system tissue relying on immunohistochemistry.

The successful challenge to his original conviction was part motivated by arguments challenging the reliability of the latter in forensic practice. This has again come under scrutiny following a 2016 report by the US President’s Council of Advisors on Science and Technology. The PCAST concluded that there were two important deficiencies in ensuring scientific validity of so-called ‘feature-comparison methods’. These are procedures by which an examiner seeks to determine whether an evidentiary sample is or is not associated with a source sample based on similar features. Proponents of Lundy’s innocence argue that the application of immunohistochemistry must be regarded as a subjective feature-comparison method.

There was a need for (1) clarity about the scientific standards for the validity and reliability of forensic methods and (2) the need to evaluate specific forensic methods to determine whether they have been scientifically established to be valid and reliable. The report emphasized 2 key elements that are required to meet the scientific criteria of foundation validity; (1) a reproducible and consistent procedure and (2) empirical measurements from multiple independent studies of a method’s false positive rate and sensitivity.

It is this author’s position that the manner in which the immunohistochemistry was applied in the Lundy case to identify central nervous system tissue was sufficiently robust in terms of rigor and reproducibility and that to insist otherwise would be tantamount to believing in biological alchemy.

The session will provide an overview of the Histopathology Reporting qualifications outlining the success so far and then will focus on the two new limited scope Reporting qualifications. It will provide guidance on the eligibility criteria for these qualifications, the portfolio requirements and the support needed by candidates from colleagues in order to undertake the qualification.