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ORIGINAL ARTICLETraining organisations and their perceptions of graduate work skills

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Australian Journal of Medical Science November 2010 Vol. 31 No. 4 121

November 2010 Vol. 31 No. 4

Original Article

Training organisations and their perceptions of graduate work skillsGeorge S Streitberg, Lyndall Angel, Kenneth Sikaris, Phillip Bwititi

122

Regular FeaturesHaematology Update 131Convention & Congress Calendar 135Book Reviews 137Books for Review 143Journal-based CPD No. 26 147

AIMSObituary 133AIMS/RCPA Morphology Scholarship Winners 136

AIMS AACB NSM 2010 Abstracts 150

AIMS NSM SPC 2011 134

Medical training solutions online 146

AIMS NSM SPC 2011 IBC

Advertising IndexDiagnostica Stago IFCReed Global Resourcing 206

Copyright: All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic, mechanical, including photocopying, recording, or by an information storage and retrieval system, without permission in writing from the AIMS. Copyright by the Australian Institute of Medical Scientists, 2010.

Disclaimer: The opinions expressed in this Journal including those of the technological and advertisement sections are not necessarily those of the Editorial Board.

A u s t r a l i a n J o u r n a l o f

C O N T E N T S

M e d i c a l S c i e n c eA D M I N I S T R A T I O N

AIMS National Office

Chief Executive: Ms Meredith Liddy, BSc GradDipMedTech GradCertManAdministration: Dr Adele Fletcher, BA(Hons) MA PhDEmail: [email protected]: www.aims.org.auTelephone: 61 7 3876 2988Facsimile: 61 7 3876 2999Address: PO Box 1911, Milton, Qld 4064, Australia

Editorial Board

EditorsMr John Stirling, BSc(Hons) MLett AFRCPA MAIMSPrincipal Medical Scientist and LecturerSA Pathology and Flinders University

Assoc Prof Tony Woods, BA BSc(Hons) PhD MAIMSSchool of Pharmacy and Medical SciencesUniversity of South Australia

Board MembersDr Ross Brown, PhD MSc MBA FAIMSPrincipal Hospital ScientistRoyal Prince Alfred Hospital

Ms Robyn Wells, BAppSc MAIMSCore HaematologyPathology Queensland Central Laboratory

Dr Christopher McIver, PhD MPH GMQ(AGSM) MAIMSPrincipal Hospital Scientist, Conjoint Senior Lecturer UNSWPrince of Wales Hospital

Assoc Prof Rob SiebersPGCertPH, FNZIC, FNZIMLS, CBiol FSBResearch Associate ProfessorSchool of Medicine and Health Sciences, University of Otago, Wellington, New Zealand Editor, NZ Journal of Medical Laboratory Science

Prof Adrian Esterman, PhD AStat DLSHTMFoundation Chair of Biostatistics School of Nursing and MidwiferyUniversity of South AustraliaAJMS Statistical Adviser

The Australian Journal of Medical Science is the official publication of the Australian Institute of Medical Scientists.

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Instructions to Authors available on the AIMS website http://www.aims.org.au/c/index.php?page=ajms---instructions-authors

Australian Journal of Medical Science November 2010 Vol. 31 No. 4122

ORIGINAL ARTICLE

Training organisations and their perceptions of graduate work skills

George S Streitberg1, Lyndall Angel2, Kenneth Sikaris3, Phillip Bwititi2

1Biochemistry Unit, Department of Pathology, Monash Medical Centre, Clayton.2School of Biomedical Sciences, Charles Sturt University, Wagga Wagga.3Department of Chemical Pathology, Melbourne Pathology, Melbourne.

Introduction

In the last decade, clinical biochemistry laboratories have undergone considerable change with regard to automation and expert systems. The level of automation ranges from work-cell stations to total laboratory automation systems. Total laboratory automation includes:

• in the pre-analytical phase, centrifugation and sample aliquoting;

• in the analytical phase, automated and/or manual loading of analysers with embedded computers that not only control the analytical process but also contain algorithms for the acceptance of calibrations as well as quality control programs; and

• in the post-analytical phase, sample storage and retrieval, retrospective and reflex testing, and reporting of results.

The analytical instruments are usually bi-directionally interfaced with the laboratory information system to allow requested tests to be downloaded into the instruments and the results uploaded into the laboratory information system.

Expert systems or decision support computer algorithms are increasingly becoming a part of pathology laboratories’ information systems. The embedded algorithms permit the knowledge of senior staff to be applied so that patient results can be released at any time and in multiple locations (NPAAC 2007). Algorithms in some laboratories permit validation of up to 85% of patient results (Paxton 2008). In addition, algorithms for acceptance of quality control results are widely used. Westgard Rules are often incorporated into a laboratory’s information system, and there are commercially available quality control software products that can be added onto those systems.

This situation creates ongoing issues about the role of entry level scientific staff in a laboratory. In Australia, apart from the qualifications required of those who are in charge of laboratories, there are no formal qualifications required of staff in pathology laboratories (NPAAC 2007). Furthermore, there are no formal stipulations concerning the relative numbers of scientific and technical staff with regard to workload and complexity of work within a particular laboratory. In the absence of such requirements, preservation of required scientific experience and expertise,

Abstract

Given the increased automation and use of expert systems in pathology laboratories, especially within clinical biochemistry laboratories, syllabi for degree, diploma, and certificate courses need to keep pace with work requirements. The aim of this study was to determine the skills expectations held by tertiary institutions of their pathology graduates when they initially enter the workforce. Australian universities with AIMS accredited undergraduate degree courses, and TAFE colleges with courses leading to work in pathology laboratories, were surveyed by mailed questionnaires. The data obtained indicate that TAFE colleges expect their diploma and certificate graduates to be able to prepare reagents and samples and to perform analyses independently, but these institutions anticipate more supervision of their graduates e.g. for checking results. Universities and TAFE colleges have similarly high expectations of their degree and diploma graduates respectively with regard to having an understanding of quality control. There were differences in expectations relating to more complex activities such as evaluation of new assays, suggesting that university graduates are better equipped to carry out research.

Keywords: Automation, expert systems, graduate staff

Address correspondence to:George StreitbergBiochemistry Unit, Department of PathologySouthern Cross Pathology Australia Monash Medical Centre 246 Clayton Rd Clayton Victoria 3168E-mail: [email protected]


and balance of graduate and non-graduate staff within a laboratory, are the most common important management goals (Kent 1999). Lord Carter of Coles (2006) found that a priority for change was to match the workforce to volume and workflow and the roles and functions needed to achieve it. Lord Carter further suggested that more flexible staffing patterns, including skill mix in terms of supervision and maintenance, need to be considered in a laboratory that is open for the most part of the day.

Today much of the work formerly performed by the scientific staff with regard to preparation of calibrators and reagents is now the province of diagnostic companies. Lord Carter (2006) suggested that one benefit of automation was a reduction in use of qualified staff. Reagent kits which, according to Hoffman (1998) may be regarded as first generation automation, are now used for the majority of assays. These are usually specifically formulated for a particular instrument (Hoffman’s second generation automation). The high level analytical skills of the graduate scientist in terms of reagent preparation have been replaced by the predominantly closed-system mainframe analysers using reagents and calibrators manufactured specifically for them. Dominiczak (1999) has therefore argued that there is a greater need for skills in system control and support as opposed to analytical skills. Hence, a new role has emerged for the scientist — that of a controller of the total laboratory automation instrumentation. This often involves a team approach to solving problems, with complex interaction between the various components.

Total laboratory automation (Hoffman’s third generation automation) has resulted in staff at central reception or registration loading samples onto an automated line for centrifugation, aliquoting, analysis, and finally storage. Total laboratory automation also encompasses sample retrieval for retrospective tests as well as reflex testing. Therefore, the role of the majority of scientific staff in laboratories that have total laboratory automation has been modified to encompass the analytical process, patient result validation and problem solving skills, chemistry instrumentation, quality assurance, and data interpretation. Castillo et al (1997) believe that a four year degree will not be required for non-supervisory staff in a highly automated core laboratory and that there will be a limited job market for graduates who possess the skills that are necessary for work in non-automated, esoteric testing of core laboratories. This perspective highlights the need to monitor the relevant training and expectations of both educational institutions.

One of the criteria for determining the number of graduate staff in a clinical biochemistry laboratory with significant automation is the laboratory’s workload as stated in a report to the Association of Clinical Biochemists (Working Party 2005) (http://acb.org.uk/federation/

information/conditions/staffing.htm). Additional factors that may be used to determine the skill and knowledge base required of the staff are the range of investigations (e.g. assays for liver, renal, cardiac, reproductive system, and endocrine organ status, tumour markers, therapeutic drugs, and drugs of abuse); the analytical techniques (e.g. mainframe chemistry analysers, blood gas, HPLC, electrophoresis, and atomic absorption); the health centre’s organisation (e.g. hours of operation); specialist units supported by the laboratory (e.g. emergency department, intensive care, coronary care, neonatal intensive care, operating theatres, and renal units); and finally, the use of expert systems or decision support software.

In view of the changing role of scientific staff in clinical biochemistry, it is important to determine whether students who undertake courses leading to employment in pathology are appropriately prepared for their subsequent workplaces. Efficient operation of a laboratory is enhanced if there is an appropriate fit of staff to the analytical work, the level of automation, and the use of expert systems. To this end, as part of a larger study, staff from universities with courses that are accredited by the Australian Institute of Medical Scientists (AIMS) and technical and further education (TAFE) colleges throughout Australia were asked to identify the skills they expect their graduates to possess on entry to the pathology workforce.

Materials and methods

Senior staff from eight universities with AIMS accredited undergraduate degree courses and 17 TAFE colleges with courses leading to work in pathology laboratories were surveyed by mailed questionnaires. The mailed package, addressed to heads or course coordinators, consisted of an information sheet about the research as well as a questionnaire, a postage-paid return envelope, and the principal researcher’s business card. Completion of the questionnaire, which was expected to take 45 minutes, was self-administered and voluntary.

The mailed package employed personalisation in order to increase the response rate (McCoy and Hargie 2007). Personalisation suggests to recipients that they are individually important and in this case, handwritten elements, addressing specific individuals, and using postage stamps were used. If it was necessary, prospective respondents were contacted up to four times in order to maximise the response rate, with the second to fourth contacts made only if a reply had not been received previously. The mailed packages consisted of the following:

Contact 1 Covering letter with questionnaire, return envelope, and business cardContact 2 Reminder letter


Contact 3 Covering letter with another questionnaire, return envelope, and business cardContact 4 Reminder letter

Follow-up contacts were separated by six weeks to allow sufficient time for a questionnaire to be returned to the university and then mailed to the principal researcher.

The questionnaires sought information regarding the structure of the courses and the expectations held by the institutions of their graduates when they enter the workforce. At the conclusion of the questionnaire respondents were given the opportunity to make comments about anything that was additional to what had been directly elicited by the questionnaire. The university questionnaire consisted of seven pages on which there were nine questions, seven being multi-part. The TAFE college questionnaire consisted of five pages on which there were ten questions, nine being multi-part. Response options were either Yes or No, or one of five points on a Likert scale of 1 to 5 that corresponded to always, mostly, often, occasionally, and never, respectively.

The model of Heberlein and Baumgartner (1978) was used to predict response rates. Using this model it was predicted that universities would yield a 93%, and TAFE colleges a 93.9%, response rate.

The data were analysed using SPSS v16. The percentages of non-completed questions were calculated using the criteria set by The American Association for Public Opinion Research (2008) for accepting each of the surveys as completed.

The research was approved by the Human Research Ethics Committee, Charles Sturt University, protocol 2007/242, and data were collected between November 2007 and March 2009.

ResultsThe response rates for universities and TAFE

colleges were both 100%. This exceeds the predicted values obtained using the Heberlein and Baumgartner model. The percentage of non-completed questions was low: 1.4% for university respondents and 2.4% for TAFE college respondents, and both were within the criteria set by The American Association for Public Opinion Research (2008, p.24). Fourteen TAFE colleges offered diploma and certificate courses, two offered the diploma only, and one offered only the certificate course. Seven TAFE colleges specifically mentioned that the Diploma of Laboratory Technology (Pathology Testing) was offered, with the remaining eight colleges offering the more generic Diploma of Laboratory Testing. The universities offered only degree courses. Figures 1 to 12 present the responses to the following multi-part question:

What are the expectations of the institution with regard to the level of expertise of graduates of the course?

• Preparation of samples for analytical work• Preparation of reagents from documented

chemistries• Understanding of internal quality control.

Acceptance of internal quality control results• Understanding of external quality control• Independent analytical work (working alone)• Analytical work under supervision• Submission of results to graduate staff for

checking• Running analysers alone• Running analysers under supervision• Validation of results for release into the

laboratory information system

• Development of new assays under supervision

Expertise includes skill (the practised ability to perform given tasks) and knowledge (the theoretical knowledge required to perform tasks) and understanding was also specifically required in the crucial areas of internal and external quality control. Percentages in the graphs do not necessarily add to 100% because the data do not include respondents who failed to answer individual questions.

Figures 1 to 3 show that to varying extents universities and TAFE colleges view their graduating students as being equipped for preparing samples and reagents as well as having some understanding of quality control. Figure 1 indicates that TAFE diploma graduates are seen by their institutions as possessing the ability to prepare samples for analysis to a greater extent than do universities of their bachelor degree graduates. From Figure 2 it may be inferred that university graduates, while regarded as capable of preparing reagents for analytical work, are not viewed as possessing this ability to the same extent as are TAFE diploma graduates. TAFE colleges view their diploma graduates as being better prepared than their certificate graduates to undertake the preparation of reagents.

High proportions of university degree and TAFE diploma graduates were regarded as having an understanding of the use of internal quality control in monitoring the analytical performance of assays (88%). In contrast, 50% of the respondents perceived certificate graduates as having an understanding of the use of internal quality control (Fig. 3). The knowledge base of both degree and diploma graduates regarding use and interpretation of internal quality control results was seen as being almost equal (88% vs 81% respectively) (Fig. 4). Compared with


the university and diploma graduates, certificate graduates are regarded as being less likely to accept internal quality control (36%). Figure 5 indicates that for both degree and diploma graduates the ability to understand use of external quality control is regarded as being almost equally high (88% vs 81%). In contrast, only 14% of the respondents regarded certificate graduates as having an understanding of external quality control.

Figure 1 Expectations of institutions with regard to preparation of samples for analysis

Figure 2 Preparation of reagents for analysis

Figure 3 Understanding of internal quality controls

Figure 4Acceptance of internal quality control

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Upon graduation, most degree and diploma graduates are viewed by their respective institutions as being able to perform analytical work while working alone (75% vs 88%) (Fig.6). Unsupervised analytical work is viewed by 14% of respondents as being within the capability of certificate graduates. Figure 7 indicates that both degree and diploma graduates are seen as being more appropriately prepared to work under supervision (75% and 69% respectively). The certificate graduates are seen as predominantly working under supervision (43%) rather than working alone (14%).

Sixty-three per cent of university respondents expected that their graduates would always submit results to a more experienced scientist before release into the laboratory information system (Fig.8). Eighty one per cent of TAFE respondents indicated that they expect their diploma graduates to always submit assay results for checking by graduate staff. However, that

Figure 6 Independent analytical work (working alone)

Figure 7Performance of analytical work under supervision

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expectation was slightly lower for certificate graduates (57%) (Fig.8). Eighteen per cent responded that they did not expect the TAFE diploma graduates to submit assay results to graduates for checking; the response was 14% regarding certificate graduates. From Figures 6 and 7 it is evident that certificate graduates do perform analytical work. Figure 6 indicates that for certificate graduates there is a 14% positive (always and mostly) and 14% negative (occasionally and never) response to independent analytical work (working alone). Figure 7 indicates that 43% of the respondents support the proposition that certificate graduates would work under supervision.

Figure 9 indicates a greater expectation that diploma graduates than university graduates are capable of running analysers in the laboratory (56% vs 38% respectively); the expectation for certificate graduates to perform

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Figure 9Capable of running analysers alone

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this type of work is much lower (21%) than for either university or diploma graduates. Figure 10 indicates that degree and diploma graduates are viewed as being likely to operate analysers under supervision (75% and 88% respectively). A comparison between Figures 9 and 10 indicates that both degree and diploma graduates are more likely to work under supervision. These figures indicate an expectation that certificate graduates are less likely to operate analysers, even under supervision, than are degree or diploma graduates.

Degree and diploma graduates are seen as predominantly capable of releasing results into a laboratory’s information system (50% and 56% respectively). Interestingly, 25% of the university graduates are regarded as not being sufficiently prepared to perform this duty, in contrast to only 13% of TAFE diploma graduates (Fig. 11). Only 29% of the respondents indicated that the release of results into the laboratory information system was within the work ambit of certificate graduates. Figure 12 indicates that university graduates are expected to have the skills to undertake evaluation of new assays (50%). In contrast, diploma graduates are less likely to undertake this work (25%), and this is more evident with certificate graduates (7%).

Table 1 provides the responses to the 12 questions relating to work capability of degree, diploma, and certificate holders using a Likert scale of 1 to 5, where 1

Figure 10 Capable of running analysers under supervision

Figure 11 Validation of results for release into the laboratory information system

Figure 12 Evaluation of new assays under supervision


was Yes (always) and 5 was No (never). The intermediate options on the scale were 2 (mostly), 3 (often) and 4 (occasionally). The lowest possible total score across all items is 12 indicating positivity (the work characteristic is viewed as being within the capability of the entry level worker) and highest is 60 indicating negativity (the work characteristic is not viewed as being within the capability of the entry level worker). Table 1 suggests that the summed Likert scores indicate that the perception of work preparedness, according to those facets studied, of diploma graduates exceeds that of degree graduates which exceeds that of certificate graduates.

Table 1 Total Likert score on expectations of universities and TAFE colleges with regard to level of expertise of their graduates

Task Degree Diploma Certificate

Preparation of samples for analytical work

13 10 15

Preparation of reagents for documented chemistries

18 9.5 15

Understanding of internal quality control

11 12 17

Acceptance of internal quality control

11 11.5 19

Understanding external quality control

14 12 22

Independent analytical work (work alone)

16 13.5 22

Analytical work under supervision

15 14.5 18

Running analysers alone 24 18 22

Running analysers under supervision

16 12.5 13

Validation of results for release into laboratory information system

21 17 19

Development of new assays under supervision

21 28 30

Table 2 shows that universities’ expectations are highest when placement is at 26 weeks and lowest when there is no placement. Adding up the Likert scores for the tasks using a Likert scale of 1 to 5 where 1 is Yes (always), 2 (mostly), 3 (often), 4 (occasionally), and 5 is No (never) most universities preferred 26 weeks during the training of graduates, and this had a mean Likert score of 1.0. The second highest mean Likert score of 1.3 was for a professional placement of 40 weeks. Training with no placement had the lowest mean Likert score of 2.9 and second lowest mean Likert score of 2.3 was for 4 and 6 weeks.

Table 2 Summary of the overall Likert score for the tasks in Table 1 in relation to weeks of professional placement

Weeks of professional placement 40 26 20 12 6 4 0

Total Likert score 16 12 25 22 28 27 35

DiscussionGiven the 100% response rate, the results can be

viewed as representative of current thinking about the role of graduates from degree, diploma, and certificate courses. The defined outcomes for each of the courses may be broadly correlated with the questions asked of the course coordinators. The following discussion combines the two affirmative responses (always and mostly), the two negative responses (occasionally and never), and rounds the average response to the nearest 1%. The middle response (3) was omitted from the calculations. This highlights the differences between the degree, diploma, and certificate graduates in order to demonstrate which work and actions may be expected at the entry level into the pathology workforce.

The Certificate III, Certificate IV, and diploma are part of the vocational educational and training sector in the Australian Qualifications Framework (AQF Advisory Board 2007). Each of these has distinct educational outcomes. The following text in italics indicates the distinguishing features of the competencies between qualifications.

Expectations of the Certificate III graduates are that they be able to:

• demonstrate some relevant theoretical knowledge

• apply a range of well developed skills;• apply known solutions to a variety of predictable

problems• perform processes that require a range of well

developed skills where some; discretion and judgement is required

• interpret available information, using discretion and judgement

• take responsibility for own outputs in work and learning

• take limited responsibility for the output of others

Expectations of the Certificate IV graduates are that they are able to, or have:

• an understanding of a broad knowledge base incorporating some theoretical concepts

• apply solutions to a defined range of unpredictable problems

• identify and apply skill and knowledge areas to a wide variety of contexts with depth in some areas

• identify, analyse and evaluate information from a variety of sources

• take responsibility for own outputs in relation to specified quality standards


• take limited responsibility for the quantity and quality of the output of others

Expectations of the diploma graduates are that they are able to:

• demonstrate understanding of a broad knowledge base incorporating theoretical concepts, with substantial depth in some areas

• analyse and plan approaches to technical problems or management requirements

• transfer and apply theoretical concepts and/or technical or creative skills to a range of situations

• evaluate information using it to forecast for planning or research purposes

• take responsibility for [their] own outputs in relation to broad quantity and quality parameters

• take limited responsibility for the achievement of group outcomes

Characteristics of learning outcomes at the bachelor degree level include:

• the acquisition of a systematic and coherent body of knowledge, the underlying principles and concepts, and the associated communication and problem-solving skills

• development of the academic skills and attributes necessary to undertake research, and comprehend and evaluate new information, concepts, and evidence from a range of sources

• development of the ability to review, consolidate, extend, and apply the knowledge and techniques learnt, including in a professional context

• a foundation for self-directed and lifelong learning

• interpersonal and teamwork skills appropriate to employment and/or further study

A course leading to this qualification also usually involves major studies in which a significant literature is available. Course content is taken to a significant depth and progressively developed to a high level that provides a basis for postgraduate study. Objectives and academic requirements of courses are set by higher education institutions having regard for requirements set by peer review and the requirements of relevant professional bodies and employer groups.

The depth of teaching can be seen to increase from the certificate to degree level. Skills are emphasised more in the certificate courses and the theoretical knowledge base becomes more in-depth and extensive from certificate through to degree courses. There is also increasing responsibility expected of graduates from the certificate,

then diploma, and finally degree courses. The Certificate III course recognises responsibility for one’s own work, the Certificate IV course recognises limited responsibility for others, the diploma recognises responsibility for group outcomes, and the degree recognises the individual in a teamwork environment.

The Pathology Associations Council (PAC) Workforce Sub-committee released a document “Competency-based Standards for Medical Scientists” (PAC 2009). This lists 10 competencies expected of graduates from degrees of science or applied science with specialisations relevant to pathology as well as two years of workplace experience. This is defined as the entry level of a scientist to the medical science profession. The first six competencies are regarded as the minimum requirements for all medical scientists and the last four are expected of scientists appointed to the role of a supervisor. The first six competencies are listed as:

• collection, preparation and analysis of clinical material

• correlation and validation of results of investigations using knowledge of method(s) including analytical principles and clinical information.

• Interpretation, reporting and issuing of laboratory results

• maintenance of documentation, equipment, resources and stock

• maintenance of safe working practices• professional accountability and participation in

continuing professional developmentThe data presented in this research relate to the first

three of the above competencies. These areas of expertise were regarded as core abilities for staff commencing work in a pathology laboratory. The remaining three were not addressed in the questionnaires and these may have identified additional differences between the degree, diploma, and certificate graduates.

Universities and TAFE colleges all expect most of their graduates to be able to prepare samples for analysis (100% degree, 94% diploma, and 64% certificate graduates respectively). Preparation of samples is the first undertaking in the analytical process and the accuracy of analytical work depends upon the quality of the sample. In large laboratories this work may be performed by clerical and technical staff. It is essential that the scientific staff can also undertake this work. The ability to prepare reagents, either from commercial kits or from chemicals, is expected of most laboratory staff. The results of this research indicate that, while both streams have strong support for these work activities, diploma graduates are seen as being more readily able to undertake this work

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than are university and certificate graduates (100%, 63% and 64% respectively).

Both university and TAFE colleges expect their graduates to understand quality control. Degree and diploma graduates are seen as having equal ability in this regard (88%) and certificate graduates to a lesser extent (50%). It is reassuring to note that all students are taught the important concepts of quality control. Use of internal quality control assists scientists to ensure that assays remain within acceptable parameters. This requires a basic understanding of Levey-Jennings charts to plot internal quality control results and Westgard Rules to indicate the actions needed for addressing problems in a particular assay. For the acceptance of internal quality control, both the degree and diploma graduates are seen as having comparable ability (88% and 81% respectively), while the certificate graduates are viewed as having this ability to a considerably lesser extent (36%). Degree and diploma graduates are viewed by their educational institutions as having almost the same understanding of the use of external quality control (88% and 81% respectively). Certificate graduates are perceived as being less likely to have this knowledge (14%, see Fig.5). Understanding external quality control may be regarded as requiring a sophisticated understanding of analytical work which would encompass imprecision and accuracy. Also essential is a comprehensive understanding of calibration, traceability of the calibrator to reference material, and stability of the curve; reagents in terms of stability and lot number changes; analytical peer group, matrix effects, and interferents.

In Figure 6, most degree and diploma graduates are perceived as having the ability to work independently (75% and 88% respectively). However, in Figure 7 diploma graduates are seen as being more likely than are university graduates to perform work that is supervised (62.5% vs 37.5% respectively), which is perhaps a reflection of the higher academic qualifications of university students. This distinction is reduced when the two positive responses (1 and 2) for the degree and diploma graduates are combined for each group (75% and 69%). Nardella (2003) quotes Eastern Health (main campus Box Hill Hospital) as having stated that “the vast majority of pathology tests, particularly in the disciplines of chemical pathology (biochemistry) and haematology, are performed by sophisticated automated analysers with on-board computers linked to laboratory information systems capable of data validation and ensuring quality assurance” indicating that staff with qualifications less than those required for a medical scientist are suitable for operators of pathology analysers. Nardella also reports that a number of submissions indicated that direct supervision of staff is not required given the improvements in electronic communication.

Table 1 indicates that the TAFE diploma graduates are viewed as having greater competence for laboratory work than certificate graduates, a reflection of the depth of curriculum of the former. This is in accord with the outcomes listed in the Australian Qualifications Framework (AQF Advisory Board 2007). The length of professional placements has an impact on how the universities view the capabilities of their graduates when they enter the workforce. Table 2 shows that as the length of the professional placement decreases there is a trend away from responses of 1 (always) and 2 (mostly) on the Likert scale with regard to the perception that staff are able to perform the duties listed. The expectation about graduates’ capabilities decreases as the duration of the professional placement decreases. The 40 and 26 week professional placements were regarded positively while the absence of any professional placement was associated with less satisfaction (Table 2).

Course coordinators view their graduates in different ways. Degree graduates are regarded as the most competent on higher level activities as well as practical work when the professional practice placement is equal to, or exceeds, 26 weeks. Course coordinators at TAFE colleges indicate that diploma graduates are more highly competent than are certificate graduates (Table 1). This is perhaps in accord with the length and depth of teaching in the respective courses.

Seven of the TAFE colleges require a professional placement for their diploma courses (eight stated that a professional placement was not required, and two did not provide the relevant information). The time required for placements among the TAFE colleges was variable, but always of short duration. In increasing order, the placement durations were 50 hours, 1 day per week for 8 weeks minimum, 2, 2-4, 3, 4, and 10 weeks during training. The TAFE college courses are competency based and are therefore viewed as preparing graduates in a practical manner for work in laboratories. Due to the course structure and emphasis of the certificate courses, the professional placements would have a less positive influence on the attitude of the coordinators to the work preparedness of the TAFE graduates.

This study shows that to a large extent university and TAFE college course coordinators perceive, upon graduation, that their degree and diploma graduates as having similar skills at the entry level in the pathology workforce. The knowledge base of the degree graduates in comparison to the diploma graduates is more extensive, but that does not translate into perceived different work capabilities. The certificate graduates are perceived by the TAFE colleges as having a more circumscribed work role in the laboratory. This is in accord with the expectations of the defined course outcomes (AQF Advisory Board 2007) and is in agreement with findings reported by


Beck, Briden, and Epner (2008) who noted that in the USA there is considerable overlap in the scope of practice between technicians (with associate degrees) and degree graduates. Beck et al also found that degree graduates at entry level performed core tasks more frequently than they did advanced tasks, and they also noted that the work performed by technicians required problem solving skills and high level reasoning. Referring to the Australian context, Badrick (2007) states that “there is no clear definition [concerning] what medical scientists and technicians actually do in laboratories”. Badrick goes on to observe that a review of positions in pathology laboratories would likely indicate that many of the tasks performed by scientists are now more appropriately performed by technicians. McGregor and Moriarty (2003) reported that 25% of the respondents in their survey agreed with the statement “I do not need a degree to do most of my job”. Retention of graduates of the degree course is difficult if satisfaction with the use of their knowledge base is not realised.

The length of professional placements is regarded by universities as being important for their graduates’ work readiness. Despite the more in-depth theoretical material studied by these students, their preparedness for entry level work in laboratories is strongly correlated with the length of their professional placements. It seems, therefore, that universities with short professional placements might work towards providing their students with longer placements to achieve the highest level of work entry preparedness.

Position descriptions should accurately reflect the responsibilities of the work expected of incumbents. Snyder (1992) stated that it is important for position descriptions to keep pace with changing technology. The depth of knowledge required for problem solving, and the ability to recognise unusual sets of patient results, are important differentials in the expectations concerning different graduates. It is important for the efficiency of the laboratory and the satisfaction of the staff in pathology that graduates of degree, diploma, and certificate courses be employed in positions that use their knowledge and technical skills to full advantage.

AcknowledgementsWe would like to acknowledge the valuable suggestions

of Dr. Robert Trevethan, Written Impressions.

ReferencesAAPOR. 2008. The American Association for Public Opinion Research

Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys. Lenexa, Kansas, The American Association for Public Opinion Research.

AQF Advisory Board. 2007. The Australian Qualifications Framework Implementation Handbook. 4th Ed. AQF Advisory Board.

Badrick T. 2007. Is there a future for medical scientists and their associations? Aust J Med Sci 28: 3-14.

Beck S, Briden M, Epner PL. 2008. Practice levels and educational needs for clinical laboratory personnel. Clin Lab Sci 21: 68-77.

Carter. 2006. Report of the Review of NHS Pathology Services in England, Department of Health: 1-89.

Castillo J, Lien J, Steiner J. 1997. Integrated regional laboratory systems: implications for staffing and skill mix requirements. Clin Lab Manage Rev 11: 6-14.

De Rada VD. 2005. The effect of follow-up mailings on the response rate and response quality in mail surveys. Qual Quant 39: 1-18.

Dominiczak MH. 1999. Laboratory medicine: the need for a broader view - the "multiple bundle" model of clinical laboratory function. Clin Chem Lab Med 37: 97-100.

Heberlein TA, Baumgartner RA. 1978). Factors Affecting Response Rates to Mailed Questionnaires: A Quantitative Analysis of the Published Literature. Am Sociol Rev 43: 447-462.

Hoffmann GE. 1998). Concepts for the third generation of laboratory systems. Clini Chim Acta 278: 203-216.

Kent G. 1999. Automation & Core Labs - Lessons Learned. Clin Biochem News: 15-16.

McCoy M, Hargie O. 2007. Effects of personalization and envelope color on response rate, speed and quality among a business population. Industr Market Manage 36: 799-809.

McGregor L, Moriarty H. 2003. The professional status of medical scientists in Australia: a nationwide survey of medical scientists, other health professionals and the general public. Aust J Med Sci 24: 140-155.

Nardella D. 2003. Review of the Victorian Pathology Services Accreditation Act 1984: Final Report. Melbourne, Victorian Government Department of Human Services: 1-69.

NPAAC 2007. Requirements for the Supervision of Pathology Laboratories (2007 Edition). Canberra, National Pathology Accreditation Advisory Council.

PAC 2009. Scope of Practice of the Scientific Workforce of the Pathology Laboratory. <http://www.aims.org.au/c/uploads/file/documents/nat/Scopev9Aug2010.pdf>. Accessed 30 November 2010.

Paxton A. 2008. Flexing connectivity muscle with middleware. CAP Today, March. College of American Pathologists.

Snyder J. 1992. Technician or technologist? Sorting out overlapping roles in the lab. Med Lab Observ 24 (June): 36-36,39-41.

Working-Party 2005. A Model for Determining Minimum Senior Staffing in Departments of Clinical Biochemistry (Chemical Pathology): 1-10. http://acb.org.uk/federation/information/conditions/staffing.htm. Accessed 19 March 2006


Paroxysmal Nocturnal HaemoglobinuriaAt last a Haematology Update with a positive outcome!

Gillian Rozenberg

South Eastern Sydney and Illawarra Area Health Services, Prince of Wales Hospital, Sydney, NSW

In February 1999 a 29-year-old female attended the Haematology Clinic at the Prince of Wales Hospital. She had a history of anaemia, neutropenia and thrombocytopenia. She was passing dark urine. A full blood count, reticulocyte count and coagulation studies were performed. The results were as follows:

Haemoglobin 66 g/L Reticulocyte count 16.2% (absolute count 356 x 109/L)

Mean Cell Volume 113.6 fL White Blood Cells 3.1 x 109/L Platelets 55 x 109/L

PT 41.5 sec INR 4.2 APTT 45.7 sec

Fibrinogen 5.6 g/L D-Dimer LIA <0.19 mg/L

A urinary haemosiderin was performed which was strongly positive.

A clinical chemistry profile was also performed with the lactate dehydrogenase (LDH) raised at 3436 U/L.

The test results, together with the clinical symptoms of the patient indicated that she had a severe haemolytic anaemia suggestive of paroxysmal nocturnal haemoglobinuria (PNH). A Ham’s test was performed. This is an acidified serum test which detects a population of red cells with sensitivity to complement-mediated lysis. The Ham’s test was positive. A diagnosis of PNH was confirmed on the above patient.

PNH is a rare, acquired, clonal disorder of the bone marrow characterised by a total or partial lack of proteins normally attached to the haemopoietic cell membrane by the glycosylphosphatidylinositol (GPI) anchor. This defect is due to a somatic mutation of the phosphatidylinositol glycan class A (PIG-A) gene on the X chromosome which encodes for a protein needed for the synthesis of GPI anchor. Without GPI anchor, an essential group of membrane proteins are either reduced or absent in all haemopoietic cell lines. These proteins include complement-regulating surface proteins namely decay-accelerating factor or CD55, membrane inhibitor of reactive lysis protein or CD59 and the homologous restriction factor or CD8 binding protein. All of these proteins interact with complement, particularly C3b and C4b, protecting cells against lysis. In their absence, haemopoietic cells are exposed to complement leading to uncontrolled amplification of the complement cascade and destruction of the red cell membrane leading to intravascular haemolysis.

HAEMATOLOGY UPDATE

Figure 1A Peripheral blood film showing a raised MCV secondary to an increased reticulocyte response ( x1000)

Figure 1BStrongly positive urinary haemosiderin ( x400)


PNH cells are classified as PNH Type I, Type II and Type III cells. PNH Type I cells have normal levels of CD59; PNH Type II cells have reduced levels while PNH Type III cells completely lack CD59 expression.

Patients with PNH present with symptoms of haemolysis, namely, low haemoglobin, raised reticulocyte count and raised LDH. The direct antiglobulin test is negative as there are no antibodies involved. They also present with isolated or multiple cytopenias and/or a history of thrombosis.

It is important to note that in 1999 the Ham’s test was used to make the diagnosis of PNH. Today flow cytometry must be used to make that diagnosis. The presence and size of both red blood cell and granulocyte clones as defined by reduced or absent GPI-linked proteins must be determined. The Australian Flow Cytometry Group has issued guidelines for the most appropriate flow testing (AFCG Guidelines at http://www.afcg.org.au/home.asp). The guidelines recommend that CD59 expression should be determined on red blood cells and that for granulocytes and monocytes the first step is a lineage gate (eg CD33/SS) followed by expression of CD24/FLAER (granulocytes) and CD14/FLAER (monocytes).

Until recently, the treatment for PNH was supportive. Patients were managed with iron and folate supplementation. They were also transfused when appropriate. Transfused red cells do not lack GPI anchor thus are not vulnerable to complement lysis. About 50% of patients responded to corticosteroids. Allogeneic stem cell or bone marrow transplantation was and still is the only cure for PNH.

In March 2007 the use of eculizumab (Soliris) was approved by the FDA. Eculizumab is a monoclonal antibody that targets and prevents cleavage of the terminal complement protein C5. In so doing it inhibits other complement components thus preventing haemolysis. Eculizumab has given patients with PNH a significant improvement in quality of life as well as a marked reduction in the frequency of thrombotic episodes. Many patients are no longer transfusion dependent. Long term treatment with eculizumab is well tolerated however it comes with significant cost consideration.

The above patient was commenced on eculizumab in 2009. It is now September 2010 and she is 39 years old. She has had a remarkable improvement in her quality of life whilst on eculizumab, so much so that she delivered a healthy baby girl on the 23rd of September.

At last a Haematology Update with a positive outcome!

Figure 2

A. CD59 expression on red blood cells of the patient in 2010 showing a Type III PNH clone of 56.5%, a small Type II clone (8.3%) and

a clone of Type I red blood cells.

B. A PNH monocyte clone with reduced CD14 and FLAER expression – about 95% of monocytes.

C. A PNH granulocyte clone with reduced CD24 and FLAER expression – about 95% of granulocytes.

Address correspondence to:Gillian Rozenberg FAIMSSenior Scientist Department of HaematologyPrince of Wales HospitalBarker StreetRandwick NSW 2031Email: [email protected]

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Vale Associate Professor Alan Henry Turner (1953-2010)It was with deep sadness that we were informed of the untimely death of Alan on the 1st June 2010. Alan had

retired from RMIT due to ill health at the end of 2007. Between 1989 when he arrived as a lecturer in Haematology and 2007 when he retired as Associate Professor of Haematology Alan played a very significant role in the development of the Medical Laboratory Science/Laboratory Medicine programs at RMIT University.

Prior to taking the big step of migrating with his family half the way around the world, he had been actively involved with the profession in Northern Ireland lecturing in the professional development program preparing Biomedical Scientists to sit the IBMS Fellowship in Haematology. He had recently completed his Masters degree from the University of Ulster and his engagement with the profession and an interest in teaching and research made him an ideal appointment to the position at RMIT.

Alan’s initial responsibilities were to coordinate and lecture in the haematology courses in the first and second year of the undergraduate degree. His soft Irish accent along with his relaxed lecturing style very quickly endeared him to the students. One of the challenges he gave himself each year was to be able to address by name every student taking the second year Haematology 1 course by the end of the semester. This often meant he would be remembering 80 or more students and their names each year.

His links to the University of Ulster and awareness of their student placement program played an important part in the establishment and structure of the Professional Practice program in the RMIT Laboratory Medicine degree. He initiated the student exchange program with the University of Ulster which allowed many RMIT students to be placed at Belfast City Hospital. The University of Ulster students who came to RMIT undertook projects with the research group that Alan had initiated in the areas of Haemostasis and Nutrition.

Alan was good at bringing people together to undertake multidisciplinary research projects. Along with his collaborators, research funding was obtained from a range of industries to explore the links between diet and haemostasis, the focus largely being on antioxidants and platelet function. In this regard, his main claim to fame was on the beneficial effects of chocolate on platelet function and its possible influence on cardiovascular function. For a number of years just before Easter, Alan could be heard and seen in the media talking on what was his favorite topic – why chocolate could be good for you.

In the mid 1990s a course work Masters degree was introduced at RMIT and Alan was given the role of coordinating the program. Initially the degree was conducted as an on campus program but in 2001 it was converted to a fully online program. Alan negotiated with the IBMS for the continued accreditation of the degree in its new format and it became one of only two fully online Masters degrees accredited by the IBMS at that time, the other one being conducted at the University of Ulster.

Since his retirement Alan maintained his interest in the role of antioxidants in health and the use of information technology to keep in touch with colleagues and past students. He regularly communicated with his more than 150 Facebook friends letting them know of his travels and hearing what they were doing with their lives in the many different places they lived around the world. Tributes on Alan’s Facebook page are still being posted months after his untimely death.

The AIMS Victorian Branch committee acknowledge Alan for all his hard work with RMIT and with AIMS over the years, as a committee member and then as Chair of the Victorian Branch. Alan was central to the organising of the AIMS National Scientific Meeting in Melbourne in 2001 and contributed much to the profession in Victoria. Alan was the recipient of the George Swanson Christie Memorial Award from the AIMS Vic Branch in 2008.

Alan will be remembered as a committed academic who could spend hours talking about the profession, teaching practices and developments in information technology. He will be sorely missed by medical scientists, friends, former students and colleagues around Victoria. Our sincere condolences go to his family.

Ralph Green and Anne Johnston

OBITUARY


AIMS NZIMLS South Pacific Congress8-12 August 2011Gold Coast Convention Centre Queensland Australia

The Australian Institute of Medical Scientists and the New Zealand Institute of Medical Laboratory Science is proud to host and invite you to the South Pacific Congress, 8-12 August 2011. The Congress will bring to the Gold Coast Convention Centre a top level forum of leading national and international speakers to address topical issues in the medical science industry.

Keynote speakers include:• Dr Barbara Bain (UK)

Haematology• Associate Professor Mark Shephard

PoCT• Dr Robert Webb

Director, Hyperbaric Medicine Service• Carol Turnbull(UK)

Anatomical pathology• Professor Peter Rathjen Stem cell research

The Congress theme ‘Lights! Camera! Action!’ has been chosen as a call to action for delegates to spend a focussed 41/2 days in the vibrant Gold Coast at a Congress filled with topical and relevant presentations. Daily sub-themes will logically group presentations and have a little fun based on the Congress theme!

• ‘Waterworld’ – Water trauma/diseases • ‘Basic Instinct’ – Back to basics • ‘Aliens’ – The immune system • ‘Back to the future’ – New technology • ‘That’s all folks!’ – Closing day

In the spirit of the joint AIMS and NZIMLS South Pacific Congress, the Inaugural Bloodisloe Cup held on the final day of the Congress, will be an event not to be missed!

Be Noticed – Become a Sponsor!Sponsorship opportunities are available for organisations interested in this important Congress. Please contact All Occasions Management for more information.

FoR FuRTheR INFoRMATIoN ABouT The CoNGReSS PLeASe CoNTACT:

ALL OCCASIONS MANAGeMeNT 41 ANDerSON ST THeBArTON 5031 SOUTH AUSTrALIA

T. +61 8 8125 2200 f. +61 8 8125 2233 e. [email protected]

W. WWW.ALLOCCASIONSGrOUP.COM/AIMSNZIMLS11


YEAR 2011

FEBRUARY 4-6: International Workshop in Immunohistochemistry, Griffith University School of Medicine,Southport Queensland. http://www.diagnosticimmunohistochemistry.com

FEBRUARY 7-11: RMIT Intermediate Transfusion Science Workshop, RMIT Bundoora campus http://www.rmit.edu.au/medicalsciences/labmedcpd

MARCH 4-6: Pathology Update 2011Melbourne Convention Centre South Wharf - Melbourne http://www.rcpa.edu.au

MARCH 13-16: 11th National Rural Health Conference, Perth Convention Centre, Perth, Western Australia http://11nrhc.ruralhealth.org.au/

MARCH 18-20: Laboratory Diagnosis of Infectious Diseases: From Basics to Molecular Methods Centre for Infectious Diseases and Microbiology (CIDM) Workshop Enquiries: Ms Lou Orszulak Email: [email protected]

APRIL 4-8: RCPA AACB Chemical Pathology Course 2011 Hotel Grand Chancellor on Hindley, Adelaide SA http://www.aacb.asn.au/

APRIL 8-10: AIMS NSW South West Division 2011 Conference, Batemans Bay Soldiers Club, 2 Beach Road, Bateman’s Bay http://www.aims.org.au/

MAY 6-8: ISLH XXIV International Symposium on Technological Innovations in Laboratory Hematology The Marriott, New Orleans http://www.islh.org/ISLH_2011/

MAY 11-12: ISBT – 2nd International Congress on Transfusion Medicine-Plasma Industry, Tehran, Iran http://www.isbtweb.org

JULY 4-8: ASM Annual Scientific Meeting & Exhibition ASM 2011 Hobart - Microbiology on the Edge Hotel Grand Chancellor - Hobart http://www.theasm.org.au

JULY 23-28: XXIII Congress of the International Society on Thrombosis and Haemostasis. Kyoto, Japan http://www.isth2011.com/

AUGUST 8-12: SPC 2011 AIMS/NZIMLS combined scientific meeting Gold Coast Queensland

http://www.alloccasionsgroup.com/aimsnzimls11/

OCTOBER 10-13: AACB 49th Annual Scientific Conference & Golden Jubilee. Sydney Convention & Exhibition Centre, Sydney NSW http://aacb.asn.au/

OCTOBER 19-23: XXVI World Congress of the World Association of Societies of Pathology and Laboratory Medicine (WASPaLM), Las Vegas. Hosted by the American Society for Clinical Pathology. http://www.waspalm.org

OCTOBER 30 - NOVEMBER 2:The Combined Annual Scientific Meeting of HSANZ, ANZSBT and ASTH. Sydney, Australia http://www.hsanz.org.au/news/events.cfm

DECEMBER 9-13: 53rd American Society of Hematology Annual Meeting and Exposition. San Diego, CA, USA . http://www.hematology.org

CONVENTION & CONGRESS CALENDAR

















AIMS Scholarship winnersCongratulations to the two winners of the 2010 AIMS/RCPA Morphology Scholarships.

Deborah Howe and Farah McCoy attended workshops

at Australian Technology Park in Sydney this year.

AIMS/RCPA BLOOD CELL MORPHOLOGY WORKSHOP

Deborah Howe

Farah McCoy

Firstly I would like to thank AIMS for awarding the AIMS/RCPA Morphology Scholarship to me. It was a wonderful opportunity and I am very grateful. This year it was held at Australian Technology Park in Sydney. The practical set up and organisation was excellent. Each participant had their own microscope, case of slides and set of notes.

The presenters were scientists and haematologists who were all experts in their fields. Their knowledge including clinical applications and case studies made this two-day intensive workshop both interesting and informative. The topics covered just about everything you need to know, from setting up your microscope and staining blood films to haematological malignancies, myelodyplastic syndromes, malaria parasites, paediatric haematology, haemoglobinopathies, and bone marrows.

AIMS and the RCPA have put together a great practical workshop which would be beneficial for those Scientists with some knowledge of morphology or those seeking a refresher. I thoroughly enjoyed this workshop. My knowledge increased and new friendships were made. Thanks again AIMS for an enjoyable and rewarding experience.

I would like to state my sincere appreciation to AIMS for granting me a Blood Cell Morphology Workshop scholarship award in Sydney. The two-day workshop was absolutely valuable and supportive and the teaching technique was professional and productive.

We had a clear review of almost all aspects of blood cells morphology including red cell inclusions, platelet abnormalities, malarial parasites, myelodysplastic syndromes, paediatric haematology, haematological malignancies and haemoglobinopaties. We also had an informative presentation of bone marrow changes in malignancies. For every topic we had practice on blood slides provided by AIMS in a friendly atmosphere with no judgement.

Thanks again for the opportunity. It was great. I highly recommend this workshop to all my fellow colleagues.


Antimicrobial Resistance: Beyond the Breakpoint Issues in Infectious Diseases, Vol. 6.

Edited by JT Weber Karger 2010

Hard cover, x+174 pages ISBN: 978-3-8055-9323-6

EUR €135.00

Antimicrobial Resistance – Beyond the Breakpoint is the sixth volume in a series of books that deal with issues in infectious diseases (edited by Brian Mahy, CDC Atlanta, Ga). In his preface to this volume, JT Weber (European Centre for Disease Prevention and Control, Stockholm) introduces the reader to the topic of antimicrobial resistance and summarizes the potential global impacts that this will have in both human and economic terms on the effectiveness of antimicrobial treatment and control of infectious diseases in the future.

This collection comprises 10 individual reviews that have been written by experts in their field. Whilst each review provides a comprehensive overview of emerging antimicrobial resistance within a specific organism group or clinical setting, the primary focus of each discussion is on the specific drivers for resistance development and/or strategies to effectively manage these.

For example, topics covered in this volume include the epidemiology of newly emerging community associated infections due to Methicillin Resistant Staphylococcus aureus (LG Miller), the lack of therapeutic options for the treatment of multi-drug resistant gram negative bacteria (DL Paterson and Y Doi) and the potential global impact of treatment failures resulting from resistant organisms associated with food borne gastrointestinal disease (CM Parry), sexually transmitted diseases (DE Bennet) and secondary bacterial pneumonia arising as a potential consequence of an influenza pandemic (MR Moore and CG Whitney).

The management of emerging antimicrobial resistance through appropriate interventions is also a key theme throughout this series. There are two excellent reviews by Belongia et al and Rezai et al that examine the effectiveness of controlled antibiotic prescribing practices as a means of addressing the “human factor” associated with the development of antimicrobial resistance. A focus on optimal antimicrobial selection and dosing, duration of therapy and patient acceptance of non-antimicrobial treatments plans are also proposed as part of a successful multi-faceted approach to changing the behavior of patients and clinicians in the outpatient setting. However, effective hand hygiene and control of environmental contamination remain the cornerstones of infection control practices in the hospital environment.

There are also three additional reviews that highlight the need for effective use of antimicrobial agents to control infection with organisms other than bacteria – i.e. antifungal drug prophylaxis and treatment of invasive disease, resistance to antiretroviral therapy in HIV positive patients and helminth control via implementation of mass treatment plans. These later two reviews deal with the issues of controlling resistance development in third world nations where the lack of infrastructure and resource allocation have a direct effect on the success of treatment programs.

Obviously, there are significant cost implications for the resourcing of programs to control the spread of antimicrobial resistance. There is an excellent review by Merz et al critically reviewing the costing models, or lack thereof, for assessing the financial burden associated with the management of antimicrobial resistant organisms within the healthcare setting.

However, in the context of this series on emerging antimicrobial resistance, an introductory section on the key roles of the clinical microbiology laboratory in this process would have improved the range of topics covered and expanded the appeal of this book to a wider audience (i.e. laboratory scientists). Although the title, Beyond the Breakpoint, suggests to potential readers that laboratory detection of antimicrobial resistance is not covered in this text, the diagnostic microbiology laboratory plays a pivotal role in supporting strategies to manage antimicrobial resistance and this role should not be underestimated. Whilst a detailed discussion of routine laboratory susceptibility methods (AST) is not required, there are a variety of new techniques (e.g. nucleic acid amplification methods) that can reduce the time to detection of multi-drug resistant organisms and thus facilitate earlier intervention and initiation of infection control strategies. Likewise, computerized expert systems that now form part of automated AST platforms can ensure that laboratory staff are consistently alerted to unusual or multi-resistant phenotypes. Computerization of AST data in the laboratory can also provide greater access to epidemiological and susceptibility trend data which can then guide better prophylactic choices for antimicrobial therapy.

Additionally, there are organisms that were not included that could have been considered as part of this series (e.g. Mycobacterium tuberculosis, Vancomycin Resistant Enterococcus sp and Plasmodium sp).

Despite this, each of the 10 reviews presented in this volume is a concise but detailed summary (15-20 pages in length) of a specific aspect pertaining to antimicrobial resistance. At the beginning of each review, there is a succinct overview (abstract) of the information presented

BOOK REVIEWS


and how this relates to the overall theme of emerging resistance. Each review is presented in a comprehensive manner and only a basic knowledge of the antimicrobials and resistance mechanisms is required to understand the concepts discussed. Detailed scientific data is summarized in table format for those requiring additional information. There are a total of 18 tables and 4 figures in this series of 10 reviews. An extensive list of references is provided to support the material presented by each author. These references are drawn from scientific literature published within the past decade; an essential requirement in this field of science where the emergence of antimicrobial resistance is a rapidly evolving process.

Overall, Antimicrobial Resistance: Beyond the Breakpoint would have a broad appeal to those seeking to read more widely within the field of emerging antimicrobial resistance. As this text also provides useful strategies for managing the spread of resistant organisms and effective utilization of antibiotics, this book would also be suitable for a wide range of allied health professionals including laboratory scientists, infection control practitioners, public health officers, clinicians and primary health care providers in both the outpatient (GPs) and hospital setting.

This text succeeds in drawing attention to the limited antimicrobial resource that is being constantly eroded by the ongoing development of antimicrobial resistance. There is an urgent need to ensure that society effectively manages the few remaining antimicrobials that retain activity against common infectious agents.

I found this book a useful adjunct to other microbiological texts that cover topics relating to antimicrobial resistance. The information presented in this volume is wide-ranging, topical and easy to read. It would be a valuable resource for allied health professionals wishing to expand their knowledge in the area of antimicrobial resistance.

Narelle George Supervising Scientist, Microbiology, Central Laboratory Pathology Queensland, Herston

Bone and Soft Tissue Pathology A Volume in the Series Foundations in Diagnostic

Pathology Expert Consult – Online and Print.

Saunders Elsevier 2010 Edited by AL Folpe & CY Inwards – 1st ed

Series editor: John R. Goldblum Hard cover, 462 pages

ISBN: 978-0-4430-6688-7 Price: AU$310.00

This text is the very first edition of Bone and Soft Tissue Pathology. It is one of the volumes in the series Foundation in Diagnostic Pathology. The goal of every book in this series is to provide the essential information to the reader. The chapters in the text are contributed altogether by 21 experienced and world-renowned authors in this field. It contains updated essentials in bone and soft tissue pathology in a very concise presentation. It is also complemented by 650 full-color, high-quality illustrations, tables and boxes, making it user-friendly and the information easily accessible.

The outstanding feature is that the full text is searchable online from the expertconsult.com upon purchase. This allows access to the text until the next edition is published, or until the current edition is no longer on sale by Elsevier. The web access permits rapid searching on any topic with links to PubMed abstracts for most bibliographical references, which is very useful for researchers and scientists who want to make a quick reference search.

The study and practice of anatomic pathology is exciting and overwhelming. Surgical pathology and cytopathology have become increasingly complex and complicated. It is not possible for any individual to master the skills and knowledge required to perform all of these tasks at the highest level. It is a great challenge for today's practicing pathologists to get to a correct final diagnosis though the standard of care has far surpassed merely providing a diagnosis. Pathologists are now asked to provide large amounts of ancillary information, both diagnostic and prognostic and it can be daunting even to the most experienced pathologist. For this reason, this text book is very useful not only for pathologists, but also for radiologists, orthopaedic surgeons and medical scientists working in the field of immunohistochemistry, cytogenetics and molecular genetics.

The text is organised into three major sections: including general aspects (clinical and radiologic approach to the diagnosis of bone and soft tissue tumors and the use of adjuvant diagnostic techniques) followed by 11 chapters each on soft tissue and bone pathology. All of the chapters incorporate the latest updated nomenclature and specific entities. It reviews normal histology before examining pathological findings, thus enabling convenient


comparison in one place at a time. It covers a wide range of diagnostic challenges in daily clinical practice, on both neoplastic and non-neoplastic conditions of bone and soft tissue. It is arranged in an easily searchable format to explore each entity’s clinical features, pathological features (gross and microscopic), ancillary studies, differential diagnoses, as well as prognostic and therapeutic considerations.

This is an ideal text book mainly for clinicians and practicing pathologists, primarily intended to be a day-to-day supplement to larger and more comprehensive bone and soft tissue pathology textbooks. It is also a very useful reference textbook for medical scientists working on immunohistochemistry, cytogenetics and molecular genetics.

Lavender Than Than HtweAssociate Professor, Pathology Discipline,University Kuala Lumpur – Royal College of Medicine PerakMALAYSIA

Congenital Endocrinopathies: New Insights into Endocrine Diseases and Diabetes

Endocrine Development, Volume 11 Edited by R Lorini, M Maghnie, G D'Annunzio, S

Loche and M O Savage Karger 2007

Hard cover, 156 pages ISBN: 978-3-8055-8347-3

GB £105.50The endocrine system constitutes several ductless

glands secreting different hormones with specific functions on target cells. Essentially hormones are endogenic chemicals whose activities are biochemical reactions aimed at maintaining homeostasis. However, the biochemical activities also manifest in a variety of cellular metabolic and physiologic responses. For instance, discussion on stress-related bodily disorders and immune mechanisms involved in adaptation processes would be incomplete without inclusion of the endocrine system. By default congenital endocrinopathies, being abnormalities or dysfunctions of the endocrine system at birth, would manifest in metabolic and physiologic responses that deviate from homeostasis. For instance, discussion of body-clock or circadian rhythm physiology, strongly related to glucose metabolism and hypothalamic-pituitary-adrenalin axis (HPAA) hormones, is impacted by diabetes.

This book is a compendium of proceedings of a symposium on the subject of congenital endocrinopathies, but with emphasis on “new insight into endocrine disease and diabetes”. It is a handy, hardcover book. The contents include fourteen chapters, which are separate journal

articles each contributed by different authors from around the world. There is a subject index to enable easy search of items of interest.

The first chapter is a discussion on the genomic approach to gene-directed endocrine research. The next three chapters of the book review the subject of abnormal and normal growth hormone secretion as it may be impacted by insulin-like growth hormone, including intrauterine and postnatal growth retardation as well as controversies and outcomes of growth hormone treatment considerations. The fifth chapter touches on adrenal failures that present in childhood under the topic “genetic disorders involving adrenal development”. The discussion includes the different classes of adrenal hypoplasia with a nice illustration to show the relation with HPAA. Following the discussion on adrenal hypoplasia are two chapters/topics on adrenal hyperplasia as the commonest factor in hermaphroditism. The discussions include management strategies.

The next five key topics include discussions on neonatal and type-1 diabetes. The implication of ATP-sensitive potassium channels, diagnosis and therapy are presented; as well as congenital insulin resistance syndrome and persistent hyperinsulism of infancy amongst others. The last two topics discuss applicability of genetic and stem cell research.

The book is a collection of articles that collate well into a series. As at publication date (2007), it was very up-to-date with the literature. The book is targeted to provide clinicians, researchers, scientists and students with an overview of progress that has been achieved in the areas of congenital disease and genetics in diabetic endocrinology. The major strength of the book is in the advances in diagnostic and therapeutic capabilities as well as improved elucidation of the pathogenesis of diabetic endocrinology in paediatrics. The sequential discussion of adrenal hypoplasia and adrenal hyperplasia is very valuable as it makes for on-the-spot holistic understanding of the differential impact of the adrenal gland on glucose metabolism and the HPAA.

For the purpose of following up on clinical research in diabetes endocrinology with a view to be prepared to expanding one's horizons in diagnostic pathology, this book is an invaluable resource. It is good for lab managers/supervisors who develop new techniques based on research developments. It is a must-read self-help book for every medical scientist considering clinical research on diabetes and/or related topics.

E Uba Nwose (PhD, CSci, FIBMS, MAIMS)Western Pathology Cluster – NSW HealthSouth West Pathology Service590 Smollett Street, Albury NSW 2640.


Development of the Pancreas and Neonatal Diabetes Endocrine Development, Volume 12

Edited by R Scharfmann and J P H Shield Karger 2007

Hard cover 142 pages ISBN: 978-3-8055-8385-5

Price: EUR €98.50

Neonatal diabetes mellitus is being increasingly recognised in paediatric diabetes. By definition, it is a form of insulin-sensitive hyperglycemia that is diagnosed within six months of birth. Epidemiology, its prevalence is speculated to be 1 in 200,000 to 1 in 400,000 births. It can be either transient or permanent. The main known cause is failure of the pancreas to response to hyperglycaemia with adequate insulin. However, permanent neonatal diabetes is known to have three different genetic causes including

1. GCK: This gene codes for glucokinase enzyme that functions in glycolysis, and has an effect opposite to KNNJ11. Gain or Loss of GCK function leads to congenital hyperinsulinism or diabetes respectively. The latter (DM) apparently develops as a result of higher-than-normal blood glucose levels being necessary to generate an intracellular ATP concentration sufficient to trigger pancreatic response to release insulin.

2. IPF1: This gene codes for the insulin promoter factor 1 (IPF-1) transcription factor, which is required for embryonic normal development of the pancreas. In mature pancreatic ß-cells, IPF-1 stimulates transcription of the insulin gene in response to high blood glucose concentrations. The dysfunctional gene leads to congenital malformation of the pancreas, which leads to endocrine and exocrine insufficiency - whereby insufficient pancreatic endocrine function at birth amounts to neonatal diabetes.

3. KCNJ11: This gene codes for ATP-sensitive potassium (KATP) channel in the pancreatic ß-cells membrane. The activated gene reduces the sensitivity of the KATP channel to ATP. Thereby preventing insulin release in response to hyperglycaemia.

It is already known that diagnosis is by insulin-sensitive hyperglycaemia in the neonate. Otherwise, genetic testing is required to differentiate the permanent and transient forms. Therapy is apparently predominantly insulin.

Assuming prior basic knowledge, this book is a compendium of monographs based on proceedings of a two-day symposium held May 2007 in Paris on behalf of the European Society for Paediatric Endocrinologists. The subject was developmental biology, including discussion

on pancreatic development and its implications for human disease and treatment. The contents include work on human and animal pancreatic developmental biology, genetics and imprinting. Also included are the investigation, management and treatment of congenital hyperinsulinism and neonatal diabetes.

Every chapter has its own abstract and reference list. There are figure illustrations which make for interesting reading. Bearing in mind that neonatal diabetes differs from type-I diabetes in some ways, the strength of this book is in its further clarification that congenital pancreatic malformation gives rise to specific forms of diabetes as well as definition of new treatments for diabetes. For instance, the first and seventh chapters are on ‘pancreatic development as a basis for the definition of new therapies for diabetes’ and ‘insulin pump therapy in neonatal diabetes’ respectively. The eight and ninth chapters discuss “generating new candidate genes” and “potassium channel genes: therapeutic consequences” respectively. The special emphasis on the in vivo and in vitro investigation techniques, plus the last topic on clinical management are interesting and valuable.

This collection of articles that make up a series on Endocrine development was very up-to-date with the literature when published (2007). The book is targeted to provide a “reference for endocrinologists, geneticists and pancreatic developmental scientists.” Nevertheless, for the purpose of following up on clinical research in diabetes endocrinology with a view to expanding the horizon of diagnostic pathology, this book is an invaluable reading resource for medical scientists in diagnostic pathology. This book will surely be interesting and valuable to research scientists who may be considering clinical research in embryology and/or pancreatic development.

E Uba Nwose (PhD, CSci, FIBMS, MAIMS)Western Pathology Cluster – NSW HealthSouth West Pathology Service590 Smollett Street Albury, NSW 2640

Diagnostic Surgical Pathology of the Head and Neck Edited by DR Gnepp

Saunders (an imprint of Elsevier), 2009 Hardcover, xviii+1205 pages ISBN: 978-1-4160-2589-4

AUD$590.00The second edition of Diagnostic Surgical Pathology

of the Head and Neck is an authoritative guide to diagnostic interpretation in the region of the head and neck (H&N) for surgical pathologists. Although the general organisation of the text remains unchanged from the first edition, the molecular biology content has been expanded; enabling the contributors to provide an up-to-date molecular classification of many of the lesions arising in this region. Relevant molecular information was incorporated into each chapter under the appropriate


topics. The text has been edited by an anatomic pathology subject matter expert: Douglas R Gnepp MD, Professor of Pathology at Brown University School of Medicine, and widely published in the field of H&N, and salivary gland pathology. The text is of the quality one would expect from Saunders, an imprint of Elsevier. Readers may be interested to know that Elsevier Foundation recently formed alliances with the European-based group Book Aid International and United States-based Saber Foundation to facilitate the distribution of books in developing countries.

The text is logically divided into 15 chapters and is contributed by 32 expert authors. Each chapter is well supported by a sufficient number of figures, tables and illustrations. Almost all figures are in colour including both gross and light microscopic analyses of key diagnostic images. Most light microscopic analyses were based on haematoxylin-eosin stained sections. Several monochromatic magnetic resonance and radiologic images are also included to aid interpretations. As an Expert Consult title (www.expertconsultbook.com), this edition comes with full search functionality allowing readers to gain access to the complete, fully searchable contents of the text. The chapters are generally presented in four main divisions. Starting from precancerous lesions from all mucosal sites; mucosal squamous carcinomas, non-squamous cancers, and other lesions on a regional basis. Chapters 1 to 3 concentrate on pathologic diagnosis of neoplastic changes of the upper aerodigestive tract. These disorders remain the most studied and researched malignancies. Chapters 4 and 5 contain oral cavity, hypopharynx, larynx, and trachea-related neoplastic lesions and pathologic diseases. These chapters provide an excellent understanding of these disorders, especially in their aetiology and pathogenesis. Chapters 6 and 7 contain salivary and thyroid gland-related disorders. Chapters 8 to 10 contain four individually presented sub-chapters: from tumours of the H&N to odontogenic cysts and tumours. Chapters 12 to 14 cover ear and haematopoietic lesions. Chapter 15 covers fine-needle aspiration biopsy providing an excellent overview on the technique itself and issues associated with the interpretation of results.

Three appendices are included in this edition: Appendix I (pp 1131-1143) on H&N malignant tumour classification by DR Gnepp has been completely revised, Appendix II (pp 1145-1155) on guidelines for the dissection of H&N specimens by PJ Slootweg and DR Gnepp is newly added, and Appendix III (pp 1157-1205) is a comprehensive subject index. These three appendices provide very useful support to the main text. The addition of a list of abbreviations (pp xiii-xv) further assists the readers in clarifying commonly used terms.

This text is well written, aiming to provide a comprehensive aid to surgical pathologists when dealing

with difficult cases, and providing an in-depth reference for the surgical pathologist, H&N surgeon, general otolaryngologist or dentist, or postgraduate students in reviewing the H&N literature. However, the only weakness of this text is the physical weight of it. A total of 7639 reference titles are presented in the text. Chapter six alone presents 1299 references. A smaller font size could have reduced the number of pages significantly. Nevertheless, the writing style of the text is appropriate for the target audience. Medical scientists who specalise in H&N cytopathology or plan to engage in H&N morphological research will find this text valuable. The cost for this text is justifiable for such well-compiled literature. In sum, this publication is well compiled and has certainly achieved the aim of the editor and authors.

Captain Dennis Mok, MAIMSStaff OfficerHealth Services - New South WalesVictoria Barracks, Paddington NSW

Obesity and Metabolism Frontiers of Hormone Research ,Volume 36

Edited by M Korbonits Karger 2008

Hard cover, x+294 pages ISBN: 978-3-8055-8429-6

Price: EUR €206.50

This book is the 36th volume of the “Frontiers of Hormone Research” series which gives a comprehensive examination of obesity and metabolism, summarising key advances in many facets; clinical, pathophysiological, psychosocial and genetic contributions. The book comprises 18 chapters, including 43 figures (25 in colour), of literature reviews by 35 contributors who cover the broad field of obesity and metabolism quite well. These chapters discuss several aetiologies of genetic contribution in obesity, foetal and neonatal pathways, childhood obesity, and obesity in old age and emerging concepts in the medical and surgical treatments. The discussion also extends to animal models to elaborate the mechanisms. Remarkably the final two chapters tackle the sociology of obesity and obesity in art, particularly by inclusion of pictures of sculptural and paintings of body image representations.

The first chapter written by Sadaf Farooqi, on “Monogenic Human Obesity”, identifies several single gene defects that disrupt the molecules in the leptin melanocortin pathway which subsequently cause obesity in human, followed by a descriptive elaboration of “polygenic contribution to obesity” by Körner et al. The subject of childhood obesity is discussed by MA Sabin and JPH Shield, exploring the higher prevalence of childhood obesity and its associated global health implications. It also gives descriptive definitions used to define obesity


in children along with causes, co-morbidities and management.

The discussion on “Genetic obesity syndromes” takes a novel approach to the dialogue on obesity. The characteristic presentations of co-existing multiple genetic disorders which share a common underlying mechanism or pathway are a feature of this phenomenon. This chapter gives extended view on common obesity related genetic disorders such as Prader-Willi syndrome and Alstrom syndrome as well as rare Bardet-Biedle syndrome.

The chapter on “Developmental origins of obesity and metabolic syndrome” is an excellent examination of the epidemiological, socioeconomic, lifestyle, dietary and behavioural factors that have contributed to the global epidemic of obesity. Furthermore the chapter provides the background evidence and epidemiological data that leads to the conceptual framework for proposing the “foetal origin hypothesis” (foetal programming concept) by Lucas, Baker and Osmond.

The authors have written a book that conveys information about the scientific dialogues and controversies related to obesity and metabolism that appeals to healthcare professionals, academics and researchers.

Dr. Ananda Chandrasekara PhD, MSc, BSc (Hons), RMO, RNutr)Research FellowSchool of Medicine, Faculty of Health Medicine Nursing & Behavioural SciencesGeelong Campus at Waurn PondsDeakin University, Geelong Vic 3217

Pathogenic Fungi: Insights in Molecular Biology Edited by G San-Blas and RA Calderone

Caister Academic Press, 2008 264 pages

ISBN: 978-1-904455-32-5 GB £160.00

The book, Pathogenic Fungi: Insights in Molecular Biology, is made up of eight chapters, each written by different expert authors. Each chapter is a review of current topics, finishing with an extensive reference section, written with the aim of providing scientists with information pertaining to advances in the field of fungal pathogenicity from a molecular point of view. The book certainly succeeds in its aim, although as would be expected in a book of this type, the most up-to-date references (2008 onwards) are not present.

The book is 264 pages long, of standard hardcover book size (octavo), and contains very few diagrams. As indicated in the book’s preface, the whole point of the book is to help busy research scientists or teachers keep abreast of the latest advances in the molecular biology of fungal pathogenesis without having to wade through the volumes of information that are available. This

reviewer will emphasise that this book does presuppose an understanding of molecular biology, and is not aimed at the casual reader.

Every chapter in this book is self-contained, and does not depend on information present in the other chapters. This makes it easy to focus only on the information that may be of interest, while ignoring the rest. A broad summary of each chapter is as follows:

Chapter 1 is a review of gene expression studies that focus on disease-associated fungal mechanisms with the objective of designing novel diagnostics and antifungal therapies.

Chapter 2 looks at heterozygosity in Candida albicans, and its role in virulence.

Chapter 3 is an overview of the molecular level approach to the understanding of fungal virulence factors (i.e. melanin, biofilms, cell wall components and secreted proteins), and how they work during the infective process.

Chapter 4 concentrates on invasive candidiasis, and biomarkers that may be used for diagnosis and prognosis of this disease.

Chapter 5 looks at signal transduction pathways (that transmit environmental information from the environment to the cell’s nucleus) in Candida albicans and Cryptococcus neoformans, with special emphasis on MAPK signalling.

Chapter 6 shows how molecular biology can be used to develop new antifungals. For example, essential proteins, or the genes that code for them, can be used as antifungal targets. In addition, there are non-essential genes that potentiate current antifungals that can be targeted.

Chapter 7 looks at molecular mechanisms leading to multidrug resistance, employing both DNA microarrays and proteonomics to understand the mechanisms involved.

Chapter 8 is an overview of the diagnosis of fungal infections using molecular techniques.In summary, the authors have done a good job in bringing together disparate references pertaining to a fascinating but technically involved area of study. The book is squarely aimed at molecular biologists, but for those brave enough to plough through the highly technical nature of this book, it has insights for those who just want to understand the mechanisms underlying fungal virulence.

Stephen R. Davis Senior Medical Scientist Mycology Unit Women’s and Children’s Hospital SA Pathology


1. Anaerobic Parasitic Protozoa: Genomics and Molecular Biology edited by CG Clark, P J Johnson and RD Adam. Caister Academic Press. x+222 pages.

2. Anaphylaxis edited by J Ring Karger (Series title: Chemical Immunology and Allergy) 2010 xxvi+228 pages..

3. Aspergillus: Molecular Biology and Genomics edited by Masayuki Machida and Katsuya Gomi. Caister Academic Press. 238 pages.

4. Bifidobacteria: Genomics and Molecular Aspects edited by B Mayo, D van Sinderen. Caister Academic Press. XII + 260 pages.

5. BioValley Monographs: New Animal Models of Human Neurological Diseases edited by P Poindron and P Piguet. Karger. 100 pages.

6. Brittle Bones, Stout Hearts and Minds: Adults with Osteogenesis Imperfecta author Joan Ablon. Jones and Bartlett (available through Elsevier Australia). 256 pages.

7. Brucella: Molecular and Cellular Biology edited by L Goni and I Moriyon. Horizon Bioscience. 432 pages.

8. Case Files:Neuroscience authors EC Toy, R Jandial, EY Snyder and MT Paukert. McGraw-Hill Australia. 393 pages.

9. Clinical Cases in Infectious Diseases by: Sanjaya Senanayake. McGraw-Hill. 398 pages.

10. Clostridia: Molecular Biology in the Post-genomic Era edited by H Brüggeman and G Gottschalk. Caister Academic Press. 240 pages.

11. Contributions to Microbiology Volume 16: Bacterial Sensing and Signalling edited by M Collin and R Schuch. Karger. 238 pages.

12. Contributions to Nephrology Volume 156: Acute Kidney Injury edited by C Ronco, R Bellomo and JA Kellum. Karger. 464 pages.

13. Contributions to Nephrology Volume 156: 1gA Nephropathy Today edited by Y Tomino. Karger. 256 pages.

14. Current Problems in Dermatology Vol. 37: Lyme Borreliosis: Biological and Clinical Aspects edited by P Itin (series editor), D Lipsker, B Jaulhac. Karger. 212 pages.

15. Cytokines, Growth Mediators and Physical Activity in Children during Puberty edited by J Jurimae, AP Hills, T Jurimae.Karger. viii+178 pages

16. DNA Sequencing II Optimising Preparation and Cleanup edited by J Kieleczawa. Elsevier. 362 pages.

17. Emerging Issues on HPV Infections edited by J Monsonego. Karger. 276 pages.

18. Endocrine Development Volume 16: Calcium and Bone Disorders in Children and Adolescents edited by J Allgrove and NJ Shaw. Karger. 300 pages.

BOOKS FOR REVIEW

Following is a list of books available for review by resource consultants and members of the Institute with particular expertise in the field.

The reviewer is invited to retain the complimentary copy of the book once the review is received.

As per our agreement with the book publishing companies, complimentary books are submitted to the Institute provided that all reviews are published in the Australian Journal of Medical Science. These reviews must be of a high quality as buying decisions and the reputation of the book and author are important considerations.

Books not requested will be allocated at discretion of the Editors for the Australian Journal of Medical Science. Reviews should be 300 to 700 words depending on the volume of the book. Time limit for return of review is six weeks.

Requests to: Australian Institute of Medical Scientists, PO Box 1911, Milton, Qld 4064. Tel: (07) 3876 2988. Fax: (07) 3876 2999. Email: [email protected]


19. Endocrine Development Volume 17: Pediatric Neuroendocrinology edited by S Loche, M Cappa, L Ghizzoni, M Maghnie, MO Savage. Karger. 228 pages.

20. Epstein-Barr Virus: Latency and Transformation edited by ES Robertson. Caister Academic Press. viii+200 pages.

21. Fighting Cancer with Knowledge & Hope: A Guide for Patients, Families and Health Care Providers author RC Frank MD. Black Inc. 257 pages.

22. Frontiers of Hormone Research Volume 33: Growth Hormone Deficiency in Adults edited by JOL Jorgensen and JS Christiansen. Karger. 228 pages.

23. Frontiers of Hormone Research Volume 35: Pituitary Today: Molecular, Physiological and Clinical Aspects edited by E Arzt, M Bronstein and M Guitelman. Karger. 184 pages.

24. Frontiers of Hormone Research Volume 39: Kallmann Syndrome and Hypogonadotropic Hypogonadism edited by R. Quinton. Karger. x+174 pages.

25. Frontiers of Neurology and Neuroscience Volume 20: Handbook on Cerebral Artery Dissection edited by J Bogousslavsky (also series editor), RW Baumgartner, V Caso and M Pasciaroni. Karger. 178 pages.

26. Frontiers of Neurology and Neuroscience Volume 27: Neurological Disorders in Famous Artists: Part 3 edited by J Bogousslavsky, MG Hennerici, H Bäzner, C Bassetti. Karger. 240 pages.

27. Frontiers of Neurology and Neuroscience Volume 26: Immune-Mediated Neuromuscular Diseases edited by J Bogousslavsky (series editor), R Pourmand. Karger. 170 pages.

28. Frontiers of Neurology and Neuroscience Volume 28: The Mystery of Yawning in Physiology and Disease edited by J Bogousslavsky (series editor),O Walusinski, Karger. xiv+160 pages.

29. Helicobacter Pylori: Molecular Genetics and Cellular Biology edited byYoshio Yamaoka. Caister Academic Press. 261 pages.

30. Ichthyoses: Clinical, Biochemical, Pathogenic and Diagnostic Assessment edited by PM Elias, ML Williams, D Crumrine and M Schmuth. Karger. x+144 pages.

31. Iron Uptake and Homeostasis in Microorganisms edited by P Cornelis and SC Andrews, Caister Academic Press. x+292 pages.

32. Kallmann Syndrome and Hypogonadotropic Hypogonadism edited by R. Quinton. Karger. x+174 pages.

33. The Keys to IBD 2010: Treatment, Diagnosis and Pathophysiology. Special Issue: Digestive Diseases 2010, Vol. 28, No. 3 edited by G Rogler, W Sandborn. Karger. 188 pages.

34. Laboratory Diagnosis in Neurology edited by B Wildemann, P Oschmann and H Reiber.Thieme (available through Elsevier Australia) 296 pages.

35. Lactobacillus: Molecular Biology – From Genomics to Probiotics edited by Asa Ljungh and Torkel Wadstrom. 206 pages.

36. Lentiviruses and Macrophages: Molecular and Cellular Interactions by Moira Desport. Caister Academic Press. xii+346 pages.

37. Manipulation and Expression of Recombinant DNA, second edition by S Carson and D Robertson. Elsevier Australia. 151 pages.

38. Metagenomics : Theory, Methods and Applications edited by D Marco. Caister Academic Press. 222 pages.

39. Microbial-Host Interaction: Tolerance versus Allergy. 64th Nestlé Nutrition Institute Workshop, Pediatric Program, Sydney, November 2008 edited by P Brandtzaeg, E Isolauri and SL Prescott. Karger. 272 pages.

40. Microbial Toxins: Current Research and Future Trends edited by T Proft. Caister Academic Press. 192 pages.


41. Molecular Mechanisms of Adult Stem Cell Aging (Else Kröner-Fresenius-Symposia volume 1) edited by KL Rudolph. Karger. xii+108 pages.

42. Monographs in Clinical Cytology Volume 18: FNA Cytology in the Diagnosis of Lymphoma SR Orell (series editor) authors L Skoog and E Tani. Karger. 77 pages.

43. Monographs in Clinical Cytology, Vol 19: Fine Needle Aspiration of Bone Tumours.: The Clinical Radiological, Cytological Approach. SR Orell (series editor), authors M Akerman, HA Domanski, K Jonsson. Karger. 103 pages.

44. Monographs in Virology Volume 26: Herpes Zoster: Recent Aspects of Diagnosis and Control edited by G Gross and HW Doerr. Karger. 193 pages.

45. Mycobacterium: Genomics and Molecular Biology edited by T Parish and A Brown. Caister Academic Press. 222 pages.

46. MRI Atlas of Human White Matter edited by S More, S Wakana, LM Nagae-Poetscher. Elsevier Australia. 239 pages.

47. Neis ser ia : Molecular Mechanisms of Pathogenesis. Edited by C Genco and L Wetzler.Caister Academic Press. 280 pages.

48. Neuromuscular Disorders authors Anthony A Amato and James A Russell. McGraw-Hill Medical. 775 pages.

49. New Concepts for Human Disorders of Sexual Development edited by S Bertelloni and O Hiort Karger. 128 pages.

50. Papillomavirus Research author M Saveria Campo. Caister Academic Press. 423 pages.

51. Pathophysiology for the Health Professions, 4th Edition by BE Gould and RM Dyer. Saunders Elsevier 707 pages.

52. Pediatric Neuroendocrinology edited by S Loche, M Cappa, L Ghizzoni, M Maghnie, MO Savage. Series title: Endocrine development vol. 17. Karger. viii+220 pages.

53. Post Genomic Cardiology by J Marin-Garcia. Elsevier Australia. 680 pages.

54. The Regulatory Genome: Gene Regulatory Networks in Development and Evolution author EH Davidson. Elsevier Australia. 289 pages. Nick Saunders. 284 pages.

55. Retroviruses: Molecular Biology, Genomics and Pathogenesis edited by Reinhard Kurth and Norbert Bannert. Caister Academic Press. xviii+ 454 pages.

56. Staphylococcus: Molecular Genetics edited by JA Lindsay. Caister Academic Press. 278 pages.

57. Tumors and Tumor-like Conditions of the Lung and Pleura (Expert Consult: Online and Print) by CA Moran and S Suster. Saunders Elsevier. 465 pages.

58. Vibrio cholerae: Genomics and Molecular Biology edited by Shah M Faruque and G Balakrish Nair. Caister Academic Press. 218 pages.

59. Year Book of Nuclear Medicine 2005 edited by RE Coleman, MD Blaufox, HD Royal, HW Strauss and IG Zubal. Elsevier Australia. 359 pages.

60. Year Book of Pediatric Endocrinology 2005 edited by JC Carel, Z Hochberg. Karger. 232 pages.


Building competency in today's cl inical laboratory

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Training• Award-winning course content for initial training and cross training • Engaging video, animation and narration of procedures and concepts • Database of high-resolution specimen images

Medical Training Solutions (MTS) Online available for all AIMS Members

AIMS members receive unlimited access to Clinical Laboratory Training and Competency Assessment from MTS provided by the University of Washington.

More than 30 training courses and 20 Competency assessments in:• Safety• Phlebotomy• Haematology• Microbiology• Body fluids• Coagulation• Transfusion Services• And more

• Image-based multiple-choice questions by expert authors for objective testing of staff • New sets of questions every six months on January 1st and July 1st • Test results from previous periods stored in archives • Thorough explanations for education and remediation provided after test completion.• More information is available on the AIMS website. Members will need to register at MTS to

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• 1 APACE Credit for each hour of on-line instruction.• 5 APACE Credit for each examination unit passed. Save certificate for APACE audit and training records.


A P A C EAustralian Professional Acknowledgement

of Continuing Education(APACE)

5 APACE Group 1 credits per set of questions will be awarded if at least 8 out of 10 questions are answered correctly. 40 credits maximum per year can be claimed.

Please photocopy this page or print it from the AJMS on the AIMS Member Library in the AIMS Member Lounge at www.aims.org.au, circle your answers and post or fax by 31 May 2011 to:

AJMS APACE Questions, AIMS National Office, PO Box 1911, Milton Qld 4064. Facsimile: 61 7 3876 2999

Journal-based CPD No.26Page 1 of 1

Name: ______________________________________ Membership No:_________________________

Email:______________________________________________________________________________

Questions relating to Training organisations and their perceptions of graduate work skills. Page 122 of this issue.

1. Results from the survey suggest that the degree and diploma graduates are seen to have a greater understanding of internal and external quality control.

True/False

2. The first six of the 10 competencies listed in the PAC 2009 “Competency-based Standards for Medical Scientists” are regarded as the minimum requirements for all medical scientists.

True/False

3. Theoretical knowledge becomes more extensive from certificate through to degree courses

True/False

4. The “Likert scale of 1 to 5” describes a score of 5 for Yes (always) and 1 for No (never) True/False

5. TAFE college expectations of their diploma and certificate graduates to have the skills necessary to undertake evaluation of a new analyser are the same as those expectations of the degree graduates of universities.

True/False

6. Universities have greater expectations of their degree graduates for understanding of external QC than do TAFE colleges of their certificate graduates.

True/False

7. TAFE college expectations of their diploma and certificate graduates for reagent preparation are greater than the expectations for university degree graduates.

True/False

8. Response rates to the questionnaire were less than that anticipated. True/False

9. Mailed questionnaires were posted to senior staff from eight universities with AIMS-accredited undergraduate degree courses and 17 TAFE colleges with relevant pathology-related courses.

True/False

10. Total laboratory automation includes the post-analytical phase which encompasses sample storage, additional reflex testing & result reporting.

True/False


AIMS AACB COMBINED SCIENTIFIC MEETING

Perth 2010 25-29 October

SCIENTIFIC ABSTRACTS PRESENTER INDEX

A1 Adams L

A2 Arentz S

A3 Armbruster D

A4 Arthur I

A5 Badman S, Byers D, R Escott R

A6 Baker R, Gilmore G, Thom J

A7 Beilby J, Newbound C, McCaulay C, Greenwood L, Ravine D

A8 Bentel J

A9 Bonar R

A10 Boscato L

A11 Bromilow IM

A12 Brown T, Tyack S, Ungerer J

A13 Buck A

A14 Carter, WD

A15 Caterina P

A16 Charles A

A17 Chiriano AS

A18 Chow N, Romeo G, Le Viellez A, Ivey J

A19 Christiansen K

A20 Clausen D

A21 Cooke, B

A22 Coombs, G

A23 Crook M, Peverall J, Baker E , Charles A

A24, A25 David R

A26, A27 Davis BH

A28 Davis T

A29 de Boer B

A30, A31 Devenish R

A32 Dixon T, Leahy MF, Chiu SK, Bruce J

A33 Doré JL

A34 Earl G

A35 Earl J

A36 Edwards G

A37 Farrell C

A38 Flicker L

A39 Florkowski C

A40 French M

A41 Fryk J , Faddy H, McBride J, Ritchie S, Hyland C, Flower R, Christensen A

A42 Gan SK

A43 Gardner I

A44 Georgiou A

A45, A46, A47 Gill J

A48 Glendenning P

A49 Goodrich R

A50 Gormley BM

A51 Gray J, Rawlinson

A52, A53, A54 Greaves RF

A55, A56 Grebe SKG, Singh RJ

A57 Grebe SKG, Cradic KW, Algeciras-Schimnich A, Reddi HV, McIver B

A58, A59 Green R

A60 Groth D

A61 Hadlow N

A62 Hale V

A63 Hammett-Stabler CA

A64 Han X, McShan M, Chan Y, Hussain Z, Chen K, White C

A65, A66 Haremza E

A67 Harwood C, Kaylock P, Gardner G

A68 Haverkort F

A69 Havlat M

A70 Heal N

A71 Herrmann NR

A72 Herrmann R

A73 Hoad K

A74 Isbister GK

A75 Jacobsen M

A76 Jones, G 109, 110

A77 Jones, G 109, 110

A78 Joske, D 110

A79 Kay I

A80 Koerbin G

A81 Laing N

A82 Le Viellez A

A83 Legg M

A84 Lenzo NP


A85 Lim EM

A86 Lo YMD

A87 Lu ZX, Sikaris KA, Briganti EM

A88 Lu ZX, Calleja J, Sikaris K, Streitberg G, Newman J, Doery J

A89 Macdonald S

A90 Mackay R

A91 Mandelt C

A92, A93 Martin HD

A94 McCloskey J, I Kay I, Williams V, French MA,Metcalf C, Flexman J

A95, A96 Metz M

A97 Mollee P

A98 Morris H

A99 Nagree Y

A100 Nelson D

A101 Neville S

A102 Newbound C

A103 O'Brien H, Gardener GJ, Hyland CA, Millard GM, Tremellen AE, Hyett JA

A104 Ojeda VJ

A105 Olliffe L

A106 Olynyk JK

A107 Parvin CA

A108 Peck M, Little E

A109 Petinos P

A110 Pfeffer S, Sikaris K

A111 Platten M

A112, A113 Price CP

A114 Purwanto, D 126

A115 Riley TV

A116 Robins H

A117, A118 Rodwell R

A119 Romeo, G 129

A120 Ross J

A121 Rossi R

A122 Saunders, C 131

A123 Schoof AD, Ford J, Jago JD, Cole CH, Beesley AH, Gottardo NG, Kees UR

A124, A125 Scott S

A126 Shephard MDS

A127 Sinnadurai R

A128 Smith DW

A129 Spagnolo D

A130 Speers DJ

A131 Starkstein S

A132 Stuckey BGA

A133 Sturm M, Shaw K, Fogarty J, Herrmann R

A134 Thom J

A135 Vanhaeften R , Romeo G, Dickinson J, Warner T, Edkins E, Higgins M, le Viellez A, Ivey J, P Cannell P

A136 Vasikaran S

A137 Vasikaran S, Lee MKV, Prentice D

A138 Walters M

A139 Waring JA

A140 Wells R

A141 Wheatland L

A142 Williams V

A143 Willis C

A144 Witt C

A145 Zeps N


A1. NONALCOHOLIC FATTY LIVER DISEASE

L Adams

School of Medicine and Pharmacology, University of Western Australia; Consultant Hepatologist, Liver Transplant Unit, Sir Charles Gairdner Hospital, Perth, WA

Nonalcoholic fatty liver disease (NAFLD) refers to accumulation of hepatic fat in the absence of excessive alcohol ingestion. NAFLD is now the commonest chronic liver condition in the world, affecting up to 9% of people in developing countries and up to 30% in the developed world. NAFLD is pathogenically associated with central obesity and insulin resistance, with recent evidence highlighting a direct role of toxic lipids and oxidative stress in causing progressive disease. Histologically, NAFLD may be divided into simple steatosis and nonalcoholic steatohepatitis (NASH), with the latter being the more aggressive sub-type. In a few individuals, NAFLD may progress to cirrhosis with sequelae of liver failure and hepatocellular carcinoma which may lead to death or requirement for liver transplantation. Subjects with NAFLD may also be at increased risk of developing metabolic complication such as diabetes as well as dying from cardiovascular disease. Currently NAFLD is diagnosed by confirming the presence of hepatic steatosis by imaging and excluding secondary causes of hepatic steatosis clinically. Traditional liver biochemistry is insensitive and non-specific for diagnosing NAFLD or evaluating its severity, however, novel serum markers reflecting apoptosis and fibrogenesis are promising as non-invasive clinical tools for the future. Treatment currently revolves around reversing weight gain, correcting metabolic abnormalities such as insulin resistance and targeting oxidative stress.A2. HAEMATOLOGY MOLECULAR DIAGNOSTICS REPORTS: AN OVERVIEW

S Arentz

RCPA Haematology QAP, Northmead, NSW, [email protected]

IntroductionWith the continued development of the Haematology

Quality Assurance Programs, the reporting system of the Molecular Diagnostics modules has been standardised to allow subscribers to have a more comprehensive review of the results submitted by participants. A number of different formats are used across the Molecular Diagnostics Program options and it is important to present a review of the features so laboratories are able to interpret and understand the reports.Methods

To present a concise review of the Molecular Diagnostics QAP report formats including examples of different styles of reports for the qualitative modules sent. An example of the Chimerism report will also be

demonstrated, which is the only module that utilizes a quantitative component in the data analysis system. This presentation will also provide an introduction to the on-line data entry facility, which will be available to participants in 2011, showing a quick overview of the facilities available.

Conclusions

The review of the different styles of reports in our Molecular Diagnostic Program options is seen as an opportune way to ensure participants are able to fully interpret their reports and thereby derive the most benefit from the information supplied.A3. REFERENCE INTERVALS: THEORY AND PRACTICE

D Armbruster

Global Scientific Affairs, Abbott Diagnostics, Chicago, Illinois, USA [email protected]

IntroductionLaboratory test results must be interpreted in

comparison to expected reference intervals (normal ranges) to determine if patients are healthy or subject to a pathological condition. It’s a challenge for laboratories and IVD manufacturers to conduct meaningful reference interval studies because they do not have ready access to large numbers of suitable healthy subjects, the studies are difficult to perform and resource intensive, and they should be tailored to suit the patient population (e.g., partitioned by age, gender, ethnicity, geography, etc.).Methods

The CLSI and IFCC jointly published CLSI C28-A3 (Defining, Establishing, and Verifying Reference Intervals in the Clinical Laboratory) in 2008. C28 provides reference interval theory, but individual laboratories, regional initiatives, or national programs must apply the theory to generate meaningful intervals. Reference interval studies are direct (subjects preselected for inclusion prior to testing) or indirect (data collected from subjects previously tested but not subject to prescreening). Direct studies are either a priori (subjects vetted prior to sampling) or a posteriori (subjects selected after sampling). Results

Good examples of direct studies include the national Canadian Laboratory Initiative on Paediatric Reference Intervals (CALIPER), the “Aussie Norms” project in Canberra, and the Hong Kong Blood Donors study. Studies using the indirect approach also provide useful data.Conclusions

The direct approach is preferable as it allows for fine partitioning of the data, producing highly specific intervals well suited for various patient populations. The indirect approach requires subjects to be screened


after the fact, but it has the advantage of using data that has already been collected and that is readily available. Both approaches have strengths and weaknesses. Clinical laboratory scientists must understand reference interval theory to make judicious decisions when selecting normal ranges. A4. MYCOLOGY: SOMETHING OLD, SOMETHING NEW

I Arthur

PathWest Laboratory Medicine WA, QEII Medical Centre, Nedlands WA

In the modern age various new technologies are available to the routine diagnostic laboratory for isolation and identification of fungal organisms. Yet time and budgetary pressure may compromise basic methodologies. What is important and what methodologies can we use reliably in Mycology?

Dermatophytosis is the most common group of human fungal infections. To achieve an accurate result starts with specimen collection but also includes the fundamental laboratory techniques of specimen processing, microscopy and culture. We will discuss what is important to obtain a reliable result in an area which is highly prone to false negatives. What phenotypic tests are required to achieve a reliable identification of dermatophytes?

Accurate yeast identification may have significant impact on the choice of antifungal chemotherapy. New techniques include the use of chromogenic media and more rapid identification techniques. The role and limitations of such techniques will be discussed.

There are various commercially available anti-fungal susceptibility testing techniques available to the diagnostic laboratory. What is the role and limitations of antifungal susceptibility testing?

Molecular methodologies have also challenged aspects of fungal taxonomy. So what do we need to know about fungal nomenclature?A5. OVERVIEW OF SEROLOGY QAP: MOLECULAR DIAGNOSTIC RESULTS

S Badman, D Byers, R Escott1RCPA Serology QAP, North Ryde NSW [email protected]

IntroductionQuality Assurance (QA) is an important component

of a working laboratory, where an informed updated approach is beneficial. We see the role of the RCPA Serology QAP (SQAP) as a partnership, working together with participants to solve issues that may arise. This presentation will review results of the 2009 SQAP Molecular modules and outline some case studies where QA has helped identify problem areas, instigated investigation and aided in resolution.

MethodsParticipants enter results via the SQAP website,

results are analysed by SQAP staff and reviewed by collaborators who are experts in their field.Results

In 2009, over 500 sets of results were returned for the seven Molecular Diagnostics Modules and there were various problem areas identified and investigated.Conclusions

The RCPA Serology QAP offers Molecular Diagnostic Quality Assurance that is an effective tool for verifying the accuracy of testing procedures, results and the interpretation of those results. A6 DEFICIENCY OF ADAMTS13 AND ITS RELATIONSHIP TO ISCHAEMIC STROKE AND THROMBOTIC THROMBOCYTOPENIC PURPURA

R Baker, G Gilmore, J Thom

Centre for Thrombosis and Haemophilia, Murdoch University, Department of Haematology, Royal Perth Hospital, Perth

ADAMTS13 plays an important role in preventing arterial thrombosis and thrombotic thrombocytopenic purpura (TTP) by cleaving the thrombogenic ultralarge high molecular weight von Willebrand factor (ULvWF) multimers to less active forms. When the enzyme is deficient, circulating ULvWf causes thrombosis by the formation of intravascular aggregation of platelets in the microcirculation and at sites of high shear flow associated with blood vessel damage. Diagnostic assays for ADAMTS13 antigen, function and autoantibodies are now becoming more widely available but their utility for clinical practice is uncertain.

Generally patients with idiopathic TTP have low ADAMTS13 activity when compared to those with other causes of secondary TTP such as metastatic tumours, organ transplantation or the use of drugs such as mitomycin C or cyclosporine. The secondary causes of TTP do not tend to respond to plasma exchange probably because the TTP is caused by the massive endothelial stimulation and release of ULvWf rather than ADAMTS13 deficiency.

Around 75% of patients with idiopathic TTP have severe deficiency of ADAMTS13 (less than 5%) at diagnosis. Recent data suggests that patients with idiopathic TTP with normal or deficient ADAMTS13 activity had a similar response rate to plasma exchange and short term survival. However, those who have severe ADAMTS13 deficiency had a significant increased risk of relapse. In smaller studies the detection of auto-antibodies to ADAMTS13 was also associated with refractory disease, higher mortality and an increased risk of relapse. Rituximab has been reported to benefit some patients with primary TTP particularly those with detectable auto-antibodies.


During plasma exchange around a third of patients will have persisting ADAMTS13 deficiency despite a good clinical response. Around 60% of these patients will relapse. In those who had severe ADAMTS13 whose levels are corrected with treatment, relapse almost is always associated with a falling ADAMTS13 level.

Low of ADAMTS13 and high vWf are strongly associated with risk of cardiovascular disease and in experimental models infusing recombinant ADAMTS13 reduces mortality without increasing haemorrhage.

Measuring ADAMTS13 activity may provide clinicians with useful biomarker for prognostic information in patients with TTP and a rationale for targeted therapy with recombinant ADAMTS13 in those severely deficient or with a vascular eventA7. SEVERE α-1 ANTITRYPSIN DEFICIENCY ASSOCIATED WITH MZ COMPOUND-HETEROZYGOSITY

J Beilby,1 C Newbound,1 C McCaulay,1

L Greenwood,1 D Ravine1,2

1Molecular Genetics, PathWest Laboratory Medicine Western Australia, QEIIMC, WA 2School of Pathology and Laboratory Medicine, University of Western Australia, Nedlands, WA

[email protected]

Introductionα-1 antitrypsin (AAT) is a serine protease inhibitor

encoded by SERPINA1 gene (also known as PI). AAT deficiency increases the risk of emphysema and liver disease. Severe AAT deficiency mostly arises when two copies of the PI*Z allele have been inherited. Very low AAT levels may also occur when a single PI*Z allele has been co-inherited with a PI*Null allele, however these compound heterozygous cases are not readily distinguished from PI*Z homozygotes on the basis of serum protein levels or isoelectricfocusing electrophoresis. We report here a 43 year old male with early onset degenerative lung disease in whom a very low AAT level was identified together with an unusual MZ genotype. Methods

TaqMan PCR was used to screen for the common PI*Z (GLU342LYS) and PI S (GLU264VAL) gene variants. DNA sequencing of the AAT gene locus (14q32.1) was performed to identify rarer gene variants.Results

The AAT level was 0.2g/L (0.9-2.0). TaqMan PCR yielded a PI*MZ result. DNA sequencing demonstrated a PI*Z allele along with a three base pair deletion (c.486_488del3), which resulted in loss of a phenylalanine at codon 52. This variant is known as PI*M(Malton).Conclusions

Sequencing revealed an unusual PI*M(Malton)Z genotype in a middle-aged male with severe pulmonary

disease and a very low AAT level. The PI*M(Malton) has been previously shown to be associated with hepatocyte inclusions and impaired secretion as a result of AAT protein misfolding, akin to the misfolding associated with the PI*Z allele. This variant would have been missed if the gene had not been sequenced.A8. MUTATION DETECTION IN ANATOMICAL PATHOLOGY

J Bentel

Anatomical Pathology, PathWest Laboratory Medicine, Royal Perth Hospital; School of Pathology & Laboratory Medicine, University of WA, Perth, WA

[email protected] use of molecular biological techniques in

anatomical pathology has been slow to gain acceptance, however, the introduction of rationally designed therapies targeting tumour-specific mutant proteins has mandated the establishment of molecular biology laboratories that operate in conjunction with anatomical pathology departments. The cost of mutation testing can vary widely as a result of the techniques and equipment used, and as there is currently no Medicare rebate for mutation testing, staff, equipment and reagent costs must be absorbed into departmental budgets or testing is only available to those who can afford to pay. Detection of mutations in the epidermal growth factor receptor (EGFR), K-RAS and BRAF genes in non-small cell lung cancers (NSCLC), colorectal tumours and melanomas are commonly requested as their presence (or absence) will direct treatment and/or entry into clinical trials. In addition, mutations in the c-KIT and platelet derived growth factor receptor (PDGFR) genes can assist in establishing the diagnosis or treatment responsiveness of gastrointestinal stromal tumours (GIST) and melanomas. Further analyses of mutations in other genes are also performed in diagnostic laboratories according to the interests and expertise of medical or scientific staff associated with individual departments. Improved methods for DNA extraction and amplification from formalin fixed paraffin embedded (FFPE) specimens has enabled mutation testing to be reliably performed on surgical, biopsy and cytology specimens, although considerable caution is required when negative results are obtained from specimens containing very low proportions of tumour cells. While the pharmaceutical industry has largely dictated the implementation and direction of mutation testing thus far, increased awareness of the significance of molecular biological analyses is ensuring its expanding use in routine diagnostic pathology.


A9. POINT OF CARE INR RESULTS AND UPDATE

R Bonar

RCPA Haematology QAP, Northmead NSW

[email protected]

Introduction The explosion of POC-INR monitors onto the

market place has raised some challenging EQA issues. Due to the importance of the INR result in monitoring of oral anticoagulation for prevention of recurrent thrombosis or bleeding, it is essential to ensure that these instruments and their operators provide correct results. Although the procedure is relatively simple for an experienced operator there can still be unmonitored erroneous results. Most monitors have built-in internal QC checking the quality of the strips or cartridge before testing. However, there is no procedural check equivalent to EQA to check the operator/instrument overall and ongoing performance. Although most POC monitors require a unique sample type for EQA surveys, several EQAs, such as the RCPA QAP have successfully provided survey programs for select monitors including the Roche Coaguchek XS and the ABBOTT i-STAT. Currently there is no Australian government regulation to encourage users of these instruments to participate in EQA.Method

The POC INR program is dispatched 5 times a year with 2 samples in each batch. The samples are lyophilised artificially depleted plasma with a range of INRs between 1.0 and 4.0.Results

118 users participated in the 2010 program including laboratories, doctors’ surgeries, operating theatres and pharmacists. Analysis of results is by robust statistics and participants are sent an interim report every 2 months and an End of Cycle report at the completion of the year. The reports include peer group assessments and lot/instrument/cartridge comparisons. Results will be presented from recent RCPA surveys with an overview of published data.Conclusion External quality assurance is important for users of POC INR devices. Despite specific challenges, a successful EQA program has been developed for two commonly used devices to help ensure that results are clinically safe.

A10. ENDOCRINE WORKING PARTY

L Boscato

Chemical Pathology, St Vincent’s Hospital, Darlinghurst, NSW 2010

[email protected] Endocrine Working Party (EWP) was formed

in 2009. There was an overwhelming response to the

call for expressions of interest for EWP membership published in the September 2009 Clinical Biochemist Newsletter. To maintain the valuable expertise of all those who nominated two levels of membership were initiated; full and corresponding. There are representatives from most states and New Zealand with a wide breadth of knowledge spanning paediatric, clinical and laboratory endocrinology.

The main function of the EWP is to provide advice to the Chemical Pathology QAP on the Endocrine, IGF-1/C-peptide, BNP and Tumour Marker programs. Levels of the low and high pools used to produce the QAP samples are reviewed annually and a number have been adjusted to reflect changes in clinical needs and improvements in assay technology. Allowable limits of performance are currently under review. Discussion has been initiated with a number of relevant professional bodies regarding growth hormone standardisation and the EWP will be assisting the RCPA in defining preferred units for endocrine tests which is a necessary part of the National e-Health initiative. Macroprolactin has been proposed as a potential new analyte. The EWP is investigating the suitability of a synthetic macroprolactin material and has drafted a macroprolactin survey will be sent to QAP participants. Red Cell folate (RCF) is new to the Endocrine program and results indicate a high degree of within and between method variability. The EWP has established a project aimed at improving the measurement of RCF which will include establishing a reference method.

The EWP welcomes all comments, suggestions and problems relating to the relevant QAP programs and endocrine testing. Contact details are found on the AACB website.A11. BLOOD GROUPING AND PHENOTYPING: LATERAL FLOW TECHNOLOGY

IM Bromilow

Lateral Grifols Pty, 5/80 Fairbank Road, Clayton South, Vic 3169

[email protected]

IntroductionABO and D typing are of paramount importance in

transfusion medicine and antenatal care. Other antigens may be of significance for recipients of blood and women of child-bearing age in particular. It is imperative to ensure accurate typing to avoid clinical complications associated with transfusion reactions and to administer the appropriate immunoglobulin prophylaxis to RhD negative women. Guidelines recommend that full ABO/D typing is performed on new donors and patients, with a second test to confirm the blood group and RhD Type if no historical records exist. The most widely-used methodology is Column Agglutination Technology (CAT) such as the Lateral ABO/Rh gel cards. Novel lateral flow technology has been developed to complement this,


along with the STATx Reader, developed and produced in Australia.Methods

Monoclonal antibodies for ABO, RhD and other Rh and K antigen phenotyping are embedded in a membrane, housed in a plastic cassette. A blood sample is introduced into the chamber and after 5 minutes, unagglutinated cells are cleared with the addition of diluent. No centrifugation is required. Results are read, interpreted and recorded either manually or using the STATx Reader.Results

Tests on 819 blood samples, comparing the results of the lateral flow technique with routine gel methods and/or historical data on file, showed no discordant or discrepant results.Conclusions

This rapid, simple method for blood grouping, improves laboratory procedures, providing confirmation of ABO/D plus extended Rh and K phenotyping using the STATx Multicard. The STATx Reader enhances security by reading, merging and correlating blood typing results from both Gel and lateral flow technologies, which can be linked to the laboratory computer system, eliminating potentially life-threatening mistakes for example, due to transcription errors. A12. AND WE THOUGHT IT WAS THE REAGENT!

T Brown,1 S Tyack,1 J Ungerer1

Pathology Queensland, Clinical and Statewide Services, Herston, Qld 4029

[email protected]

IntroductionPathology Queensland consists of 33 laboratories

spread throughout Queensland. Between 2007 and 2008, a common instrument platform was rolled out in all Chemical Pathology laboratories across the state. Tests now had the same collection procedures and could be reported with the same reference ranges and units across the State, a distinct advantage for mobile clinicians and mobile patients. A test result from Thursday Island was now directly comparable with a test result from Toowoomba or the Prince Charles Hospital. Or was it? How could we demonstrate consistency in accuracy and precision across all laboratories when each managed their own internal quality control program?Methods

The answer was to move to the same quality control material and establish state-wide limits of performance for this material based on clinical need rather than traditional statistical analysis. Initially 28 analytes were moved to the new quality control system. The running mean and CV of each analyte at each site was calculated monthly (pre- and

post- change) and analysed against a set of performance indicators.Results

Analytes at some sites initially fell outside the new limits. Priorities were set to determine and resolve the causative issues. Reagent variability was expected to be a major cause but was not. Overall an improvement in accuracy was seen in 10 analytes. No analytes demonstrated a loss of precision. Statewide limits have been extended to all quality control material in use.Conclusions

Statewide standardisation is achievable. It provides a means of demonstrating accuracy and precision in our testing across the State. It improved laboratory processes, fostered a sense of unity and cooperation amongst laboratories and most importantly, improved the quality of our service.A13. FORENSIC PATHOLOGY: THE INDONESIAN AND AUSTRALIAN PARTNERSHIP

A Buck

Forensic Pathology, PathWest, QEII Medical Centre, Nedlands, WA 6009

[email protected] the past decade, Australian and Indonesian

Forensic Services have built a strong and mutually beneficial partnership. Forensic medical and dental specialists from Western Australia have assisted Indonesian authorities in a number of incidents in which there has been the loss of both Australians and Indonesians. These incidents include the 2002 Bali bombings, the Marriott Hotel bombing (2003), the Australian Embassy bombing (2004) and the most recent Jakarta hotel bombings in 2009.

The relationship between Indonesia and Australia has been further strengthened by the introduction of educational programmes that have allowed Indonesian pathologists and dentists the opportunity to train at Australian forensic institutions, whilst sharing their vast experience with the Australian forensic community. Benefits of these exchange programmes were in evidence in the Black Saturday bushfires, where Indonesian pathologists and dentists assisted Australian authorities in the identification process of the victims.

This presentation will provide an overview of this Australian-Indonesian forensic relationship. It will also discuss the current status and future role of the Australian forensic medical specialists in the Asia-Pacific region.


A14. GENERAL CHEMISTRY DILUENT PILOT STUDY

WD Carter

RCQA Chemical Pathology QAP, Adelaide, SAThe RCPA Chemical Pathology QAP is continually

involved in developing, improving, and monitoring the RCPA QAP material. As part of this process opportunities to improve the ease of use of the material by the participant are investigated.

In 2010 the RCPA QAP was provided with a quantity of a new formulation of material for the General Serum Chemistry and Therapeutic Drugs Program. In this new material the bicarbonate was stabilised in the lyophilised vial and therefore a separate diluent vial was not required. The material was distributed to a number of participant laboratories enabling analysis on a range of instrumentation.

This session summarises the evaluation of the new material and illustrates the commitment of the RCPA QAP to continually improve the material used in the EQA programs.A15 MODERNISATION OF ANATOMICAL PATHOLOGY LABORATORIES - INTEGRAL ROLES AND OPPORTUNITIES FOR MEDICAL SCIENTISTS

P Caterina

Division of Tissue Pathology, PathWest Laboratory Medicine WA, Queen Elizabeth II Medical Centre, Nedlands, WA 6009

[email protected] is the only public sector provider of state-

wide pathology services in Western Australia.In planning for modern AP laboratories, it is

imperative to look beyond the current systems of operation to a future when the changing demographics of the population result in wholesale shifts in staff availability.

Challenges to be addressed by the PathWest AP discipline to deliver effective world-class pathology services include:

1. Changing demographic of the existing workforce and population;

2. Integration of new methodologies requiring modified specimen triage;

3. Redesign of laboratories and implementation of lean work practices;

4. Advances in laboratory equipment;5. Relevant IT solutions to facilitate modern work

practices.With these challenges also come opportunities,

particularly for professional development of medical scientists. In late 2008 a working party comprising of

the presenter, a senior medical scientist and consultant pathologist visited medical centres of excellence in the USA to investigate innovative and efficient methods of AP service delivery including:

1. Rapid throughput continuous t i s sue processing;

2. Lean systems in surgical pathology and manufacturing-based continuous quality improvement methods to optimise workflow and turnaround time;

3. AP IT systems, and whole slide digital imaging;

4. Programs for AP Medical Scientist education and responsibilities of Pathologist Assistants/Clinical Scientists.

This presentation outlines the valuable information gained from the USA visit and the funded initiatives currently underway in PathWest AP to implement lean principles of operation and provide opportunities for medical scientists and their professional roles. These roles will continue to evolve, not only due to workforce and workplace remodelling requirements, but also due to the concerted focus for AP modernisation.A16. PAEDIATRIC TUMOURS, LEADING THE MOLECULAR WAY!

A Charles

Dept Paediatric Pathology, PathWest and School of Pathology and Laboratory Medicine, UWA, Perth, WA

[email protected] of paediatric tumours have given insights into

tumour genesis subsequently applied to adult tumours. Paediatric malignancies are different from adult tumours, often sarcomas rather than carcinomas. Tumours that are common in children are rare in adults and vice versa. For some tumours the reason for this may be obvious (e.g. retinoblastoma with developing retina), but why do childhood leukaemias rarely present in adults?

The multistep progression to cancer is well known (e.g. Fearon and Vogelsteins pathway for colorectal carcinoma). Previous researchers had on statistical grounds suggested 7 or so “steps” were needed, with fewer in paediatric tumours. Paediatric tumours show a variety of pathogenetic mechanisms, involving tumour suppressor genes (mutations, allelic losses), oncogenes (methylation, amplification), novel translocation genes and epigenetic changes (chromatin remodelling, non-coding RNA’s). Tumours develop in their own microenvironment and cellular genetic changes within its environment are important.

Knudson showed in retinoblastoma the age of onset of sporadic cases and earlier onset of the familial/bilateral tumours was best explained by a two hit hypothesis.


Tumour suppressor genes, such as Retinoblastoma (involved in cell cycle control), Wilms tumour 1 gene (involved in development, glomerular maintenance, sex determination, tumour suppressor gene and sometimes an oncogene) are well known. Methylation changes around 11p15, (site of a growth promoter), are involved in several paediatric tumours (e.g. Wilms, embryonal rhabdomyosarcomas,) and in tumour predisposition syndromes ( Beckwith-Wiedemann). There are tumour specific translocations (leukaemias, Ewings sarcoma, alveolar rhabdomyosarcoma). N-myc amplification has been routinely assessed in neuroblastomas for nearly 15 years. Recently described tumour genes affect chromatin remodelling (Rhabdoid tumours) or non- coding RNA (Pleuropulmonary blastomas) and stromal interactions. PCR and FISH studies in these tumours are routine, arrays soon.A17. OPTIMISING SWEAT TESTS

AS Chiriano

Laboratory Services, The Royal Children's Hospital, Parkville, Vic 3052

[email protected] fibrosis (CF) is the most common inherited

life-shortening genetic disorder affecting Australians. Other than genetic testing, the sweat test remains the major diagnostic test for the confirmation of CF. The sweat test measures the concentration of electrolytes that are excreted in sweat. An elevated concentration of chloride is the diagnostic analyte for CF.

The laboratory plays a major role in the early diagnosis of CF, and with this comes the responsibility of reporting reliable and accurate results to ensure proper patient management. Firstly, is the patient suitable to test, as there are a number of factors than can affect sweating and therefore the result. It is also important that the staff collecting the sweat are well informed, experienced and trained as they are the first point of contact for the patient after their initial consultation with the doctor. Secondly, the laboratory needs to select the appropriate method for sweat stimulation and collection. A good quality sweat sample is the first step to accurate results. As for the sweat analysis, the methodology must be able to measure chloride in the concentration ranges for both normal and patients with cystic fibrosis. The internal quality control levels should be at the decision points and the analysis performed by trained scientists. Finally sweat test results should be reported with reference intervals and with the option to include interpretative comments on the patient report.

To optimise sweat tests the laboratory must have the appropriate procedural processes for sweat collection, sweat analysis and reporting of results with ongoing assessment of competency to minimise the potential for errors or misdiagnosis.

A18. HUMAN NEUTROPHIL TYPING

NChow, G Romeo, A Le Viellez, J Ivey

Department of Haematology, PathWest Laboratory Medicine WA, Royal Perth Hospital, Perth, WA 6000

[email protected] to neutrophil antigens have been

implicated in a variety of clinical conditions and may cause severe morbidity or mortality in patients. Human neutrophil alloantibodies have been implicated in transfusion related acute lung injury (TRALI), neonatal alloimmune neutropaenia, refractoriness to granulocyte transfusions and febrile transfusion reactions.

The human neutrophil antigen (HNA) system has been characterised and is based on the glycoprotein location of the antigens. At present, the HNA system comprises seven antigens, which are assigned to five glycoproteins. HNA typing is performed both by serological and molecular methodology. The molecular basis of some antigens has not yet been fully defined and serological phenotyping may also be required to determine a null phenotype (HNA 2). The molecular basis for HNA 1, 4, and 5 have been elucidated and the clinical significance of the corresponding alloantibody is well documented for HNA 1 and 4. The molecular basis of HNA 3 has not been well defined, however antibodies to HNA 3 have also been implicated in fatal TRALI cases.

Testing for HNA alloantibodies is technically difficult and no single technique has been shown to be superior in consistently detecting all clinically relevant neutrophil antibodies. The recent advances of molecular genotyping by PCR have become more informative in situations where anti-sera are unavailable for phenotyping. However many barriers still remain in neutrophil antibody testing, including limited availability of reagents and commercially available testing kits, as well as few clinical laboratories specialising in granulocyte immunobiology. The ability to perform HNA typing on patient samples assists in the diagnosis and confirmation of clinical conditions. Further studies in this field will develop diagnostic tools and hopefully facilitate the prevention and management of transfusion reactions and immunological disorders caused by neutrophil antibodies.A19. ANTIMICROBIAL RESISTANCE, CAN WE RISE TO THE CHALLENGE?

K Christiansen

Department of Microbiology & Infectious Diseases, PathWest Laboratory Medicine, Royal Perth Hospital, Perth, WA

Resistance to antibiotics was recognised soon after the introduction of penicillin in the 1940’s. For the following 40 years the development of new antimicrobial agents kept pace with the emergence of resistance. That has now changed and we are potentially facing a future where untreatable infections become common place,


where we return to pre-antibiotic era challenges in patient management.

Resistance genes occur in nature or due to exposure to antibiotics – the use of antibiotics selects for the resistance genes. The higher the use of antibiotics, the greater the selective pressure. Amplification then occurs by transmission of the resistant bacteria between patients or members of the community. Poor infection control, poor hygiene, and crowded conditions facilitate transmission. Resistant bacteria traditionally have been associated with hospitals and certainly there are many examples – Methicillin Resistant Staphylococcus aureus (MRSA), Vancomycin Resistant Enterococcus (VRE), and resistant Gram negatives. Resistant bacteria now also occur within the community – multi drug resistant Streptococcus pneumonia, multi drug resistant tuberculosis and more recently community associated MRSA and ESBL producing Gram negatives.

Management of antimicrobial resistance has been aimed mainly at reducing the selective pressure by stopping unnecessary use of antibiotics and interrupting transmission. Development of new antimicrobials is slow. Infection control in the hospital is extremely important, both to prevent introduction of resistant organisms and in the control and eradication of outbreaks. Antibiotic stewardship programs are also being employed within hospitals. Community programs are less well developed but do exist.A20. ANALYTICAL QUALITY TROPONIN I ON A POINT-OF-CARE ANALYSER

D Clausen

Senior Medical Scientist, Biochemistry Department, Tamworth Base Hospital,Tamworth, NSW

Over 100 samples were assayed in parallel using three point-of-care platforms. These results were then comparedA21. HER-2 AND HERCEPTIN

B Cooke

Head of Department, Cytopathology, St John of God Pathology, Osborne Park, WA

HER-2 (ERB B2, HER2/neu) is one of a family of epidermal growth factor receptors (EGFRs). It is a transmembrane receptor with an external ligand binding site and a cytoplasmic tyrosine kinase domain which is responsible for signal transduction to the nucleus. Overexpression of HER-2 is due to gene amplification is >90% of cases and has been identified in a number of human cancers. It is overexpressed in 10-20% of breast carcinomas with associated decrease in disease free and overall survival. Overexpression can be assessed using immunohistochemistry and in situ hybridization. Herceptin (Trastuzumab) is a monoclonal antibody directed to the external ligand binding domain of the

HER-2 receptor and is an example of targeted therapy. Detection of overexpression/amplification by laboratories now has clinical relevance.A22. RAPID REAL-TIME MOLECULAR-BASED DETECTION OF MRSA NASAL AND THROAT CARRIERS

G Coombs

Department of Microbiology and Infectious Diseases. PathWest laboratory Medicine – WA, Royal Perth Hospital. Perth, WA

[email protected] the burden of healthcare-associated

MRSA disease is high and may be increasing. To minimise nosocomial transmission, hospital infection control programs incorporate a number of key strategies such as hand hygiene and patient isolation. However, up to 70% of hospitalised MRSA colonised patients may only be identified by performing surveillance cultures on muco-cutaneous colonisation sites such as the anterior nares and throat. Subsequently active surveillance screening has become part of the clinical practice recommendations in Europe and the United States of America.

In Australia most laboratories employ culture-based methods for identifying MRSA colonised patients. Recent mathematical modelling studies suggest direct specimen MRSA detection by rapid and accurate molecular-based methods may help prevent nosocomial MRSA transmission and be cost-beneficial in both the endemic and low prevalence setting.

Several rapid real-time MRSA-specific single-locus PCR assays are now commercially available in Australia. These include the BD GeneOhm™ MRSA Assay, the Cepheid Xpert™ MRSA and the Roche LighCycler® MRSA Advanced Test. The sequences targeted in these assays are located within the right extremity of the staphylococcal cassette chromosome mec; a region specific to MRSA. Depending on the number of specimens, assay turn around times range from 60 to 75 minutes, allowing same-day reporting within a few hours of specimen collection.

Although these assays have a high sensitivity and negative predictive value, local epidemiology of MRSA clones should be monitored to minimise the risk of not detecting emerging MRSA clones. The assays’ specificity and positive predictive value however are typically low. Consequently a positive PCR result should not be used to guide or monitor MRSA treatment.

Compared to standard culture tests, rapid real-time molecular based assays significantly reduce laboratory time in identifying MRSA colonised patients. To maximise the full potential of these assays, the laboratory and hospital’s infection control work practices may require re-evaluation and modification.


A23. “FISHING” FORMALIN FIXED PARAFFIN PROCESSED TISSUES - OBTAINING GENETIC INFORMATION FROM PATHOLOGY ARCHIVAL MATERIAL

M Crook,1 J Peverall,2 E Baker,2 A Charles1

1Histopathology Department and2Cytogenetics Department, PathWest Laboratory Medicine WA, Women’s and Children’s Health, Perth

[email protected]

IntroductionIn a wide variety of cases it is important to get

genetic information from tissues sent to histology for diagnosis. Sometimes fresh tissue for cytogenetic preparation is not available. We have recently introduced into diagnostic practice in Western Australia two Fluorescent In Situ Hybridisation (FISH) techniques for examining chromosomal genetic material from formalin fixed, paraffin processed tissue.Methods

These techniques use either a small core biopsy or an extra section from the wax block. From the core sample, separated nuclei are obtained on which standard fluorescent in situ hybridisation techniques can be used for routine FISH probe analysis including chromosome specific probes for aneuploidy, and gene loci specific for deletions and translocations on interphase nuclei. The section based technique also allows the morphology to be compared to the histology. Results

This technique is now being used routinely in aiding the diagnosis of partial moles in products of conception, the diagnosis of Trisomies, and the detection of gene loss such as chromosome 22q11 DiGeorge deletion in both surgical samples and post-mortem archived material.Conclusions

The core sampling technique is time consuming but offers a very useful tool for examining genetic changes in archival histological material when no routine cytogenetic procedure is possible. It has some technical drawbacks but these are greatly outweighed by the advantage of being able to use histological archival material to obtain genetic information for diagnosis, which might not otherwise have been available. A24. PERSONAL PERSPECTIVE OF TROPICAL MEDICINE

R David

St. John of God Health Care, Hospital Nacional Guido Valadares, Dili, Timor Leste

[email protected] John of God Healthcare has been strengthening

laboratory services in Timor Leste in partnership with the Ministry of Health, Timor Leste since 2004. The services

strengthened have been in the disciplines of Biochemistry, Haematology and Serology.

The classical presentations of patients presenting for laboratory investigations, in particular for Haematology will be described in this paper. Over 50 percent of the population in Timor are children and this is reflected in the number of paediatric patients presenting for laboratory investigations.

Patients often present with more severe presentations during the initial laboratory investigations, especially with low haemoglobins and high white cell counts. Most of the population also has low MCVs. Parasitic infestations and eosinophilia are also common presentations together with vector borne diseases such as Malaria and Dengue. There are very few aging disease presentations found in the lab diagnostics.A25. PATHOLOGY LABORATORY IN EAST TIMOR

R David

St. John of God Health Care, Hospital Nacional Guido Valadares, Dili, Timor Leste

[email protected] 2004, St John of God Healthcare has

undertaken a Memorandum of Understanding with the Ministry of Health, to strengthen the laboratory services in Timor Leste. This was delivered through the presence of a long term scientist resident in Timor, supported by visiting teams from Australia working with Timorese laboratory staff who are employed directly by the Ministry of Health.

The program commenced with support to refitting existing labs and then to construction of new lab, together with the strengthening of procurement of reagents and consumables, management of laboratories and the introduction of quality systems to analysis and reporting. The services strengthened have initially been for Biochemistry, Haematology and Serology changing the system from manual methods to automated systems.

Beyond the strengthening of the labs at the National level, the trained Timorese staff assisted with the extension of the program to the remaining 5 regional labs and the introduction of standardised equipment, procedures, reagents and consumables.

Besides routine service, the laboratory has undertaken studies to evaluate the performance of the laboratory and also the profiles of diseases presenting in patients requiring its services.

The constraints of working in Timor are the lack of human resources, lack of management experience and difficulties in obtaining continued supplies and regular maintenance contracts.


A26. HARNESSING NEW TECHNOLOGY: FLOW CYTOMETRY, MATURE OR BLOSSOMING?

BH Davis

Trillium Diagnostics, LLC, 246 Sylvan Road, Bangor, Maine, 04401 USA

[email protected]

IntroductionThe technology of flow cytometry is decades old with

clinical applications clearly in practice by the early 1980s. But being an integration of diagnostic fluorescence probes (monoclonal antibodies, DNA/RNA stains, cell cycle and function indicators, activation markers), computing power, optic quantitative technology, and software analysis the diagnostic potential for cell based analysis is seemingly limitless. Furthermore new technologies such as mass cytometry (CYTOF), improved techniques for quantitation of intracellular enzymatic pathways in a pharmacologically meaningful way, and development of reliable quantitative fluorescent standards could transform flow cytometry from a sophisticated blood cell counter to one of the two most powerful technologies for diagnostic cytoproteomics.Methods

A review was performed of current flow cytometric cell based technologies, sampling both published literature and earlier adopters or beta testers.Results

The current combination of instrumentation advancements, understanding of disease pathophysiology at the protein level, ability for pharmacologic manipulation on a targeted cellular basis, and improved software analytical power for cellular analysis, such as probabilistic modelling offer the potential to develop diagnostically powerful flow cell based assays in support of individualised medicine and drug discovery.Conclusions

Flow cytometric techniques, including mass cytometry, will become increasingly valuable as diagnostic applications and tools for cytoproteomics investigations. Availability of recognized traceable standards for assay quantitation could become a rate limiting factor in the commercial and clinical growth of this diagnostic modality.A27. WHERE DOES A "SIMPLE" NON-NEOPLASTIC QUANTITATIVE 3-COLOUR FLOW ASSAY GET RESPECT?

BH Davis

Trillium Diagnostics, LLC, 246 Sylvan Road, Bangor, Maine, 04401 USA

[email protected]

IntroductionWhile there should be no question that

polyparameter flow cytometry is the preferred approach

to hematopoietic and lymphoid neoplastic evaluation, including myelodysplasia, it is equally true that some cell based assays in the area of laboratory haematology are under-utilised on the same platform that could bring better controlled, more sensitive diagnostic assays. Methods

Published and unpublished assay performance data were reviewed and compared with similar data on manual methodologies. EQA data from published UK NEQAS and College of American Pathologists proficiency testing surveys data was abstracted for intra-group coefficient of variation, as a measure of method imprecision, and accuracy determinations as assessed by the performance definitions for each analyte. The assays where performance differences between manual methods and flow cytometric assays was assessed: fetomaternal haemorrhage (FMH) assessment, detection of infection/sepsis, paroxysmal nocturnal haemoglobinuria (PNH), and heparin induced thrombocytopenia (HIT). Results

In the areas of testing for FMH, detection of infection/sepsis by quantitative assessment of neutrophil activation by CD64, CD35, and other cytoproteomic targets, PNH, and HIT the evidence both at a assay performance level and clinical accuracy and relevance perspective clearly showed significance typically beyond the P<0.01 level with flow cytometric assays out-performing the manual methods, such as the Kleihauer Betke Assay, red cell fragility studies, leukocyte enumeration and morphologic assessment of maturity, and ELISA assays. Conclusions

Despite clear evidence that flow cytometric assays for testing for FMH assessment, detection of infection/sepsis, PNH, and HIT are superior in performance both methodologically and clinical utility to the manual methods remain in clinical practice. This suggests inertia by diagnostic flow cytometry laboratories in implementing such assays, the reimbursement incentives for new testing modalities is lacking, or understanding of clinical and/or economic benefits of cell based diagnostics is currently lacking. Thereby, not getting due respect.A28. CHALLENGES OF LABORATORY TESTING IN THE TROPICS

T Davis

School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, WA

Working in clinical medicine in the tropics, whether it be in a service or research context, can often be a challenge, especially when reliable laboratory testing is limited or absent. Laboratories in tropical hospitals can be donated equipment by charitable organisations without due regard for the cost and availability of reagents and disposables, as well as maintenance and repair. When relatively sophisticated laboratory testing is established


temporarily, such as to support a research project, local staff may become deskilled in the methods they once used to provide the same data. There may be resentment that tests are only available for research patients and not for usual care. The vagaries of the local power supply, of hot and humid ambient conditions, and of unauthorised use of equipment by inadequately trained staff may add to the frustrations associated with trying to provide a regular and reliable laboratory service. There may even be suspicion that the results of newly available tests are inaccurate if they are not in accord with tried-and-tested clinical observations or their application leads to an adverse outcome. The establishment of robust and appropriate technology which is supported by adequate staff training, an affordable supply of reagents and disposables, and which can be repaired, serviced and quality assured within a reasonable timeframe can, however, often be a realistic and rewarding goal.A29. LIVER CYTOPATHOLOGY

B de Boer

Consultant Pathologist, Department of Anatomical Pathology, PathWest, QE II Medical Centre, Perth WA

With the routine use of imaging to investigate patients with abdominal symptoms or to screen patients with cancer, increasing numbers of localised liver lesions are detected. Fine needle aspiration biopsy (FNA) of the liver is commonly performed to investigate these localised mass lesions or “tumours”. The aim of FNA is to provide a diagnosis of neoplasia, benign or malignant, and where possible identify the tumour type. A cytological diagnosis can be made quickly, accurately and safely in a cost effective manner. Many lesions show a classical appearance enabling cytodiagnosis on smear preparations alone. Otherwise techniques such as cytochemistry, immunocytochemistry, flow cytometry, molecular studies and electron microscopy can be utilised to advance the diagnosis. Liver FNA is generally considered not very useful in the diagnosis of diffuse parenchymal disease, eg viral hepatitis.

The FNA is usually “directed” by a radiologist using ultrasound (U/S) or CT scan guidance. More recently, endoscopic ultrasound has been used to target some liver lesions, in particular those involving the hilum and left lobe. Most procedures cause the patient very little discomfort and serious complications are rare.

This talk will outline a practical approach to cytodiagnosis of liver FNA. It will include specimen preparation as well as discussing the cytopathology of key diagnostic entities in the common clinical scenarios encountered in routine practice. The role of ancillary studies such as immunohistochemisty in achieving accurate diagnosis will be highlighted.

A30. CASE STUDIES FROM CAMBODIA: GETTING THE CORRECT DIAGNOSIS IN A RESOURCE POOR COUNTRY

R Devenish

National Paediatric Hospital, Phnom Penh, Cambodia

[email protected]

IntroductionThe health system and particularly diagnostic

laboratory medicine in Cambodia has still not recovered from its total annihilation during the Khmer Rouge holocaust of the 1970s. Any educated people such as laboratory staff were either killed or forced to work as manual labourers. For the most part donor aid is focused on infectious diseases such as HIV, TB and malaria with virtually no funding available or training given to the diagnosis of haematological diseases. Consequently there is a plethora of misdiagnosed patients with families wasting huge amounts of their meagre income on wrong and useless treatments.Methods

Since I began working in Cambodia in 2001, I have tried to address this problem by the introduction of basic “old fashioned” or very simple laboratory tests which entail a minimum of cost. Results

Numerous interesting case studies will be presented to illustrate how correct diagnoses can be made with the minimum of laboratory equipment and reagents.

For example: A 14 year female presented at our hospital with acute haemolytic anaemia. She had been seen at a private clinic and given erythropoietin over several months to treat her refractory anaemia. In this case the diagnosis was easily made after finding numerous Hb H inclusion bodies in the reticulocyte smear. She had Hb H Disease and is now 20 years of age, healthy and receiving regular 6 monthly blood transfusions.Conclusions

State of the art research is essential to improve the outcomes for many diseases but we should never forget that in a resource poor country, often the most basic knowledge is lacking and the introduction of basic laboratory testing can make a huge difference.A31. STRENGTHENING LABORATORY MEDICINE IN CAMBODIA: A 10 YEAR ADVENTURE

R Devenish

National Paediatric Hospital, Phnom Penh, Cambodia

[email protected]

IntroductionIn 2001, I accepted a one year volunteer position

as the laboratory director, at the Angkor Hospital for


Children, in Siem Reap, Cambodia. Words cannot describe how shocked I was at the state of laboratories in Cambodia and lack of diagnostic skills among the clinicians. This was of course largely due to the ravages of the Khmer Rouge during the 1970s. After one year there was still so much to improve I stayed for another two years. Every day was challenging but unbelievably rewarding and full of adventures. In 2004, I went on to work as the laboratory advisor at the National Public Health Laboratory, where I could have more impact at a national level to improve public health laboratories throughout the country. During this time I met a Cambodian paediatric haematologist (the only one in a country of 14 million) who persuaded me to come to work at the National Paediatric Hospital because of my interest in diagnostic laboratory haematology.Methods

The concept of Quality Laboratory Management Systems (QLMS) was introduced and implemented. Standard Operating Procedures (SOPs) were improved and new diagnostic tests introduced along with theoretical lectures to laboratory staff to improve their knowledge. Lectures were also given to the clinicians on how to use the laboratory as a diagnostic tool and when to order newly introduced tests. Results

In 2009, the MOH passed a National Policy and Strategic Plan for Medical Laboratory Services and I am currently working as their laboratory advisor, to help implement it throughout the country. This will also includes a review and upgrade of the curriculum, for training laboratory technicians, to a bachelor degree course in the future.Conclusions

Although the tasks at time seem insurmountable, the Cambodians are delightful people and the Asian way of life is warm and inviting and keeps me here, firmly under its spell.A32. ROTEM®: A GLOBAL HAEMOSTASIS ASSAY

T Dixon,1 MF Leahy,1 SK Chiu,1 J Bruce,2

1Department of Haematology, PathWest Laboratory Medicine-Fremantle Hospital, Fremantle, WA, Australia.2Anaesthetic Department-Fremantle Hospital, Fremantle, WA

[email protected]

IntroductionAs part of addressing the second pillar of patient

blood management, as an element of the WA patient blood management program, Fremantle Hospital has been trialing a ROTEM®analyser to perform thromboelastometry in a number of bleeding and / or surgical cases.

MethodsROTEM®is a form of rotational thromboelastography

which performs a global assessment of clotting; not only in terms of the quantification of clotting factors, but by assessing the amount, function and interaction of fibrinogen, platelets and fibrinolytics; resulting in an indicator of clot quality.

The test is performed on whole, citrated blood and initial results can be available within ten minutes.

Thromboelastograms are transmitted to the requesting doctor in real-time so that rapid interpretation and clinical decision making can occur.Results

In the 150 patients tested to date, thromboelastometry results obtained by the ROTEM® analyser appear to offer timely information on the haemostatic status of the patient. Use of the ROTEM® analyser in cardiac surgery and complex abdominal surgery has allowed rapid assessment of the perioperative coagulation status and can be used to assist with the selection of specific blood component therapy.Conclusions

ROTEM® analyser can assist at point of care in assessing the haemostatic state in the patient allowing timely use of specific, targeted component therapies with improved cost effective patient care.A33. SPECIAL STAINS IN THE DEVELOPING WORLD

JL Doré

OHS Branch, SA Pathology, Adelaide, SA 5000The diagnosis and treatment of illness is not only

a social service for the “civilised world”, but arguably more importantly, it is the “third world” which probably requires a greater health care input.

I have been fortunate during my career to have been twice invited to “non-Western” areas of the world, in order to provide there the technical skills of “Western Histopathology”, firstly in northern Nigeria from 1978 - 1982, and secondly in northern Iraq (Kurdistan), during late 2006 and early 2007.

I found there to be many similarities between the two postings. In both cases, I was “recruited” by a National, each wanting a “better system” for their own country; both were highly qualified and competent pathologists; both had been trained in the Western system; both had successfully practiced pathology; and both wanted to raise the standard of their homeland medical diagnostics to that which they had experienced and practiced in the Western system.

Certainly for me language was a barrier, as was the lack of local scientific and technical knowledge, but given time and patience, these issues were overcome. Far greater barriers were those of political and religious


differences. My greatest hurdle was to overcome my own personal prejudices, and it soon became apparent that I had a great deal of learning to do before I could become the “teacher”.

In both cases, my original brief was to bring Western-styled histological technique to these respective areas.

I soon discovered Bauchi State in northern Nigeria required far more basic pathology services, and not “sophisticated” histology, and my expertise was directed towards haematology and microbiology, rather than histology. My brief changed to providing blood smear and bacteriology film staining.

Kurdistan, however, already had a well established histology department, but only produced H&E sections. There was a need to implement a full menu of “special stains”.A34. VIRTUAL MICROSCOPY: AN RCPA QAP PERSPECTIVE

G Earl, K Marsden, F Intan

RCPA Haematology QAP, Unit 1/1B Kleins Rd, Northmead, NSW 2152

[email protected]

Introduction Virtual Microscopy is rapidly gaining momentum as

a valuable diagnostic and educational tool in laboratories and educational institutions. Although not yet widespread in diagnostic laboratories its use is increasing particularly in networks with remote laboratories. Digital images comprise a significant component of RCPA QAP Anatomical Pathology surveys and are produced with a virtual microscope in their facility. This enables a much wider range of material to be used because it only requires a small amount of diagnostic sample. The technical requirements are higher for producing scans of blood films, cytology and microbiology smears , and the RCPA QAP is now producing high quality scans of blood and other diagnostic material with a more “manual” higher resolution scanner which is located within the RCPA Haematology QAP. Methods

The Virtual Microscopy project officer works with scientists from different branches of the RCPA QAP to produce digital images of a range of samples. These images are being used in some QAP surveys, e.g., Serology, Cytology (trial survey) and Malaria, as the basis for educational packages (Malaria) and as an adjunct to glass slide surveys (Haematology Morphology). Digital images are provided either on DVDs or online. The additional features such as the ability to insert annotations, record measurements, track the viewing of the scan and take snapshots will also be described.

ConclusionAlthough digital images cannot replace the use of

glass slides, we anticipate they will be used increasingly in diagnosis, education and proficiency testing, not just because they can be transferred electronically, but also because of the small amount of material required to provide cases for hundreds of laboratories and the range of value-adding features that can be included.A35. A BIOCHEMICAL WINDOW UPON THE BRAIN: ANALYSIS OF NEUROTRANSMITTERS, VITAMINS, COFACTORS AND INFLAMMATORY MARKERS IN CEREBROSPINAL FLUID

J Earl

Clinical Biochemistry Department, Children’s Hospital at Westmead, NSW 2145

[email protected]

Introduction A wide range of neurotransmitters, metabolites,

cofactors, amino acids, vitamins and inflammatory markers were measured in cerebrospinal fluid (CSF) from children and adults using HPLC analysis. Methods

Deficiencies in Tyrosine Hydroxylase (TH), Aromatic Amino Acid Decarboxylase (AADC), and Tetrahydrobiopterin levels associated with severe movement disorders were identified by CSF metabolite analysis and confirmed by genetic testing. In inflammatory diseases neopterin is elevated and tryptophan may be lowered due to cytokine induction of GTP-cyclohydrolase, and indolamine dioxygenase. CSF analysis was compared with MRI brain scans and neurological assessments.Results

CSF neurotransmitters and biopterin are low in metabolic diseases causing neurotransmitter deficiencies and are also low in neurodegenerative conditions where there is loss of the presynaptic terminals which produce neurotransmitters. Neurotransmitter abnormalities were found in 44% of 67 infantile spasms cases with little evidence for inflammatory involvement, suggesting this disease is due to pre-existing brain structural abnormalities. Of seven severe movement disorder patients with CSF HVA/5-HIAA ratio below 1.5, four had normal MRI and TH deficiency, while the remaining three showed brain stem destruction on MRI. Ongoing elevated neopterin levels and changing neurotransmitter levels over time have been used to follow the progression of Encephalitis Lethargica, an autoimmune disease targeting NMDA receptors. Severe movement disorders in conjunction with normal CSF neurotransmitters are rare and may indicate postsynaptic signal losses.Conclusions

CSF trace-level analysis helps elucidate the biochemistry and physiology of the brain, allows identification of genetic diseases, helps distinguish


between metabolic and neurodegenerative brain diseases, is more sensitive and specific than MRI in detecting and identifying neuronal losses and is useful for diagnosis and monitoring inflammatory brain diseases. A36. INTELLIGENT TOOLS FOR SUPPORTING EVIDENCE-BASED CARE: WHAT IS THE LABORATORY’S ROLE?

G Edwards

Department of Clinical Biochemistry, St John of God Pathology, Osborne Park, WA

[email protected]

IntroductionLaboratory tests are crucial in the diagnosis and

management of chronic diseases, but are not managed consistently according to endorsed guidelines. Clinical pathologists can influence test use with interpretative reporting, but comprehensive interpretation of high volume laboratory tests is beyond the reach of manual review. Support for interpretation via automated expert systems, to a level that meets pathologists’ expectations, requires highly patient-specific criteria that address the entire laboratory record for the patient. This degree of specificity is not met by laboratory information system (LIS) based rules technologies.

LabWizard (Pacific Knowledge Systems, Eveleigh, New South Wales, Australia), an expert system application employing the ripple down rules technology, is designed to support high volume patient-specific interpretation. We sought to evaluate the LabWizard system for supporting the clinical pathologists’ role in chronic disease management.Methods

A clinical pathologist created and managed LabWizard rules for adding opinions (narrative commentary) to laboratory reports, and also monitored and managed auto-validation. These opinions addressed compliance with chronic disease guidelines and included suggestions for remedial action. Performance was analysed after one month of operation.Results

Knowledge management tasks had minimal impact on pathologist workload. No off-line rule testing was required. LabWizard interpreted 20,980 patient reports. For the 8,695 lipid requests, 2,406 different opinions were reported. 2,188 (91%) of these were given on five or fewer occasions. The auto-validation rate reached 92%. The residual manual validation rate of 8% was acceptable to the pathologists. Of the 1,424 patients with known diabetes mellitus, non-compliance with testing guidelines was detected in 9.7% for HbA1c and 34.4% for urine microalbumin. Corrective action was suggested in all cases except where requested by diabetes specialists or nephrologists.

ConclusionsExpert system tools that support patient-specific

analysis enable clinical pathologists to implement a comprehensive interpretative function in a high-volume clinical laboratory. Test-specific (“canned”) comments are replaced with patient-specific opinions based on a temporal assessment of the patient record. Pathologists are better able to support guideline compliance, clinician education and improved test utilization. By focussing their interpretative role on chronic disease prevention, diagnosis and management, clinical pathologists may play a more coherent and relevant role in clinical medicine.A37. ABILITY OF SERUM FOLATE TO SCREEN FOR PATIENTS WITH LOW RED CELL FOLATE

C Farrell

Biochemistry Department, PaLMS, Sydney, NSW

[email protected]

IntroductionThe measurement of red cell folate is a relatively

time-consuming, and thus costly, endeavour. The stages of folate deficiency as described by Herbert portray low serum folate preceding a decrease in red cell folate. This study sought to establish whether serum folate would therefore have utility in identifying patients at increased likelihood of having a red cell folate concentration within the deficient range.Methods

Data was collected from 15,485 patients requiring a red cell folate determination over a 15 month period. Serum and red cell folate were measured using the Roche E170 analyser. The ability of serum folate to predict a low red cell folate was established both at the cut-off routinely used by the laboratory, derived from a population-based lower reference limit, as well as at a cut-off chosen to maximise sensitivity.Results

A poor concordance between serum and red cell folate was demonstrated. The serum folate cut-off routinely used by the laboratory showed poor sensitivity (51%) and positive predictive value (11%) for identifying individuals with low red cell folate concentrations. Specificity (95%) and negative predictive value (99%) were reasonable. Conversely, using a serum cut-off to maximise sensitivity (<25nmol/L, to give sensitivity of 94%) lead to a concomitant decrease in specificity (59%) and positive predictive value (2%). Conclusions

For a hospital-based population, serum folate appears to have limited utility in screening for patients at increased likelihood of having a low red cell folate.


A38. COMMON FORMS OF COGNITIVE DYSFUNCTION IN OLDER PEOPLE

L Flicker1,2,3

1Western Australian Centre for Health & Ageing, CMR, WAIMR, UWA2School of Medicine and Pharmacology, UWA3Department of Geriatric Medicine, Royal Perth Hospital

[email protected] cognitive impairment, involving memory

and other cognitive abilities, that interferes with an older person’s social or occupational activities, fulfils criteria for dementia. It is now realized that cognitive impairment, not fulfilling criteria for dementia (CIND), may be more common than dementia. In one community-based study of older people, the prevalence of CIND was found to be 17%, whereas the prevalence of all types of dementia combined was 8%. Conditions commonly associated with the presence of CIND include delirium, alcohol use, drug intoxication, depression, psychiatric disorders, memory impairment associated with aging and intellectual disability. Recently this category of CIND has undergone reclassification with many people within this category labelled as mild cognitive impairment (MCI). The diagnosis of MCI has not been fully operationalized and the prognosis of this condition is still very uncertain. In view of these limitations the utility of this diagnosis is questionable.

The World Health Organisation’s ICD 10 classification system has classified the common types of dementia manifest in older people as dementia in Alzheimer disease (AD) (either early or late onset), vascular dementia (VD), and dementia in other diseases. Dementia with Lewy bodies is also now commonly diagnosed. Recent neuropathologic studies of older people who have died with dementia, have revealed that pure forms of these disease entities are relatively uncommon, and many older people manifest multiple neuropathologies that lead to cognitive dysfunction. In particular for people with dementia who are older than 80 years, neuropathologic abnormalities are not as clear cut, and many older people who die with dementia, do not have severe Alzheimer or vascular pathology. The future massive increase of cases of dementia is largely due to the increase in the number of people of such age. i.e. over the age of 80 years and the focus should be on addressing the problems of cognitive dysfunction in this age group.

A39. TROPONIN ASSAYS PREDICT CLINICAL OUTCOMES AT TWO YEARS AT LEVELS BELOW THE 99TH PERCENTILE

C Florkowski,1 S Aldous,2 I Crozier,2 M Than,3

R Mackay,1 P George1

1Canterbury Health Laboratories2Department of Cardiology3Emergency Department Christchurch Hospital, Christchurch, New Zealand.

[email protected]

IntroductionNew generation troponin assays have emerged,

with progressively lower detection limits for which we have evaluated their ability to predict clinical outcomes up to 2 years.Methods

We studied 441 patients admitted with chest pain suggestive of acute myocardial infarction (AMI). Blood samples for troponin (Abbott Architect TNI 2nd generation) were taken at 0 and 6–24 hours. Frozen samples were later analysed for Architect TNI 3rd generation (TNI), Roche TNT 4th generation (TNT), Roche high sensitivity TNT (hsTNT) and OCD Vitros TNI (TNI-V). Patients were followed up for 2 years major adverse cardio-vascular events (MACE), being a composite of AMI, revascularisation procedure, and/or cardiac death.Results

156 (35%) were diagnosed with AMI and MACE was seen in 92 (20.9%) patients at 2 years. Comparing ROC curve AUC at baseline, for 2 year MACE, hsTNT (0.75; 95%CI 0.67-0.83) and TNI-V (0.72; 95%CI 0.64-0.81) out performed TNT (0.63; 95%CI 0.53–0.64) (p=0.003 and 0.024 respectively) but were equivalent to each other and TNI (0.69; 95%CI 0.60-0.78), which did not out-perform TNT. ROC curve optimum cut-points for prediction of MACE were 0.016, 0.020, 0.011, 0.01 µg/L for hsTNT, TNI-V, TNI, and TNT respectively, all below the 99th percentile. All troponins above the 99th percentile were predictive of MACE, in multivariate analysis, even when adjusted for age and history of ischaemic heart disease.Conclusions

Detectable troponins are prognostically important, even at levels below the 99th percentile.


A40. HIV AND MYCOBACTERIUM TUBERCULOSIS FORM A DEADLY PARTNERSHIP

M French

Department of Clinical Immunology, Royal Perth Hospital and PathWestLaboratory Medicine;

School of Pathology and Laboratory Medicine, University of Western Australia

[email protected] The World Health Organisation estimates that about

1.4 million people worldwide are infected with both HIV and Mycobacterium tuberculosis (Mtb), of whom 80% reside in sub-Saharan Africa. It is also estimated that about 0.5 million deaths resulted from HIV-Mtb co-infection in 2008. Management of HIV-Mtb co-infection has therefore become one of the most important international health issues.

HIV and Mtb form a deadly partnership because they both cause a persistent infection of cells of the immune system. Infection of CD4+ T cells and monocytes/macrophages by HIV infection impairs cellular immune responses against Mtb whereas infection of macrophages by Mtb induces immune activation that promotes HIV disease. Antiretroviral therapy (ART) for the HIV infection reduces the rate of tuberculosis (TB), presumably by enhancing Mtb-specific immune responses. However, patients with HIV infection and treated TB may experience severe inflammatory reactions when ART is commenced. Research has shown that this is a form of immune restoration disease (IRD) that has become known as TB-associated immune reconstitution inflammatory syndrome (TB-IRIS). Also, some HIV patients with unrecognised Mtb infection may present with TB after ART is commenced. This is referred to ART-associated TB (ART-TB) and also appears to be a form of IRD.

Studies of the immunopathogenesis of TB-IRIS and ART-TB indicate that recovery of type 1 CD4+ T helper (Th1) responses against Mtb antigens are a cause of the immunopathology in both conditions and that innate immune responses are dominant in TB-IRIS. This information should lead to the development of prevention and treatment strategies for IRD in patients with HIV-Mtb co-infection that will enhance ART programs in resource-poor countries.

A41.DENGUE FEVER VIRAL EXPOSURE RATES AMONG BLOOD DONORS DURING OUTBREAKS IN NORTH QUEENSLAND

J Fryk,1 H Faddy,1 J McBride,2 S Ritchie,2,3

C Hyland,1 R Flower,1 Christensen A4

1Research and Business Development, Australian Red Cross Blood Service, Kelvin Grove, Qld 4059, Australia2James Cook University, Cairns Campus, Cairns, Qld 48703Tropical Public Health Unit Network, Queensland Health, Cairns, Qld 48704Queensland University of Technology, Brisbane, Qld 4001

[email protected]

IntroductionDengue poses a problem for safe transfusion of

blood components withconfirmed reports of transfusion-transmission in Hong Kong and Singapore. The largest outbreak in 50 years occurred in North Queensland during 2008/2009 with more than 1,000 confirmed cases in Cairns and Townsville. During this outbreak, supplementary questioning for all donors wasimplemented, and fresh components were not manufactured from at risk donors. We aim to determine the seroprevalence of dengue exposure in thispopulation during this epidemic.Methods

Samples were collected from blood donors during the 2008/2009 epidemicand 3 months after the last confirmed case. These samples were tested foranti-Dengue IgM, IgG and NS1 antigen with commercially available ELISAbasedassay kits from PanBio.Results

Initial analyses revealed 2.7% of samples from deferred donors were IgMrepeat reactive. Of these, 16% were also positive for anti-dengue IgG, whilenone of these were positive for the NS1 viral antigen. However, two NS1 positives were found in samples collected from deferred donors.Conclusions

This initial analysis represents recent and cumulative past exposure in apresumed asymptomatic population, and will provide documentation of the rate of asymptomatic dengue infection during the epidemic. This data can alsobe used to assess the risk of dengue becoming endemic in North Queensland given that the mosquito vector is established in this region.


A42. METABOLIC SYNDROME: AN UPDATE

Seng Khee Gan

School of Medicine and Pharmacology Royal Perth Hospital Unit, The University of Western Australia, WA

The evolution of the concept of the Metabolic Syndrome has been of interest in medical and scientific circles over the last several years. At its core, the Syndrome identifies a cluster of disturbances, primarily those of glucose and lipid metabolism, and blood pressure, which together with central adiposity, predicts an increased future risk of diabetes mellitus and cardiovascular disease. Further interest in clinical research has necessarily generated a number of different definitions over the years and more recently, stimulated attempts at unifying the different confusing criteria into consensus definitions (the latest one by a number of different organisations in late 2009). The use of categorical cut-offs for each criterion remains a weakness of these definitions. Whilst the clinical utility of recognition of the syndrome in patients is an ongoing source of debate and controversy, the concept has nevertheless appropriately driven much clinical and basic research into our understanding of metabolic and cardiovascular disease over recent years. The latest developments in this evolving concept will be discussed.A43. RCPA QUALITY ASSURANCE PROGRAMS: EXPANDING AND DIVERSIFYING

I Gardner

RCPA Quality Assurance Programs Pty Ltd, Surry Hills, NSW 2010

[email protected] Quality Assessment (EQA) is an integral

part of the quality assurance of laboratory performance. Laboratories are accredited against specific international standards, and medical diagnostic laboratories in Australia are accredited to the standard ISO15189. This standard requires that laboratories enrol in a suitable EQA program for all tests for which they release results, if such a program is available. Medicare rebates for pathology tests are only available for tests performed in accredited laboratories.

RCPA Quality Assurance Programs (QAP) provides a comprehensive range of EQA for virtually all pathology disciplines, incorporating both proficiency testing and educational components. Originally serving laboratories in Australia and New Zealand, the Company initially expanded to providing programs for laboratories in SE Asia, but soon found that there were a small number of laboratories in a wide range of other countries that wanted to use some of the programs. More recently there has been a concerted effort to market the programs into other jurisdictions, notably in India and the Middle East, using local agents. This has presented a number of logistic challenges, and required an understanding of the

laboratory systems in these countries and the regulatory requirements or aspirations of their Governments.

The QAP has developed into a highly-respected and professional organisation which occupies a unique position in the maintenance and improvement of laboratory quality. It has recently diversified into areas of financial benchmarking (BiP), pre- and post-analytical error analysis (KIMMS), remote indigenous health testing (QAAMS), point-of-care testing (POCT) and the broader area of poorly performing laboratories. The QAP has established an enviable position of independence, and has highly trained professional staff that enable the organisation to make a significant contribution to the pathology industry in many areas. A44. CAN IT HELP US DOWN THE EVIDENCE BASED PATHWAY?

A Georgiou

Centre for Health Systems & Safety Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW 2052

[email protected]

IntroductionEvidence based medicine (EBM) can be described as

the integration of clinical expertise with the best available evidence from systematic research. Information technology (IT) allows the rapid accumulation of research findings in readily accessible formats. It also provides a vehicle to deliver evidence-based practice through electronic decision support to improve the quality of health care. In this way IT can be seen as EBM’s underlabourer. The aim of this presentation is to critically review the evidence about the development and progress of health IT and to identify the major challenges to its successful uptake.Methods

A review of the research literature about the role of health IT with particular reference to pathology services, drawing upon an extensive 6-year body of Australian-based research into the impact of electronic ordering systems on hospital pathology services.Results

Despite the considerable international enthusiasm for IT systems in health, their diffusion remains slow, barely reaching 20% across major OECD countries. This experience has prompted concerns about the generalisability of the current evidence base. The pioneering randomised controlled trials from the last two decades may have highlighted the huge potential of IT, but a significant proportion of these trials came from relatively few sites that developed their own “home grown” systems with the support of clinical and managerial enthusiasts. This experience is not necessarily replicable across other sites, particularly with the increasing market for commercially-developed “off-the-shelf ” systems. The literature shows that there are complex organisational


and communication processes involved with the implementation of IT in health involving both social and technical dimensions. Conclusion

The challenging task of incorporating IT into the infrastructure of healthcare requires a broader and more inclusive evidence base that is premised on the notion that one size may not necessarily suit all.A45. REVIEW OF QAP ACTIVITIES

J Gill

RCPA Chemical Pathology Quality Assurance Programs, Adelaide, SA 5000

[email protected] RCPA Chemical Pathology Quality Assurance

Programs (QAP) is a worldwide leader in the provision of external quality assurance programs (EQA) offering 42 types of programs to over 5500 participants in 42 different countries. This Review of Activities will focus on the last 12 months, the current status, and new initiatives for 2011. Topics covered will include trace element EQA, point-of-care testing, EQA in emerging nations, ground-breaking revision of allowable limits of performance based on biological variation, and the many challenges involved in ongoing expansion into new areas of the world.A46. AACB PoCT QC/QA GUIDELINES

J Gill

RCPA Chemical Pathology Quality Assurance Programs, Adelaide, SA 5000

[email protected] pathology laboratories internal quality

control (QC) and external quality assurance (QA) are accepted as components of a laboratory’s quality system. They are indicators to ensure that the quality of the results being produced by the laboratory will not compromise patient care. These indicators are still required when the environment moves from the laboratory to the point-of-care and the instrument moves from a large laboratory instrument to a device near the patient.

Whilst the principles of quality assessment will remain the same the applications will vary and the operators performing the assessment may not have the same quality focus as laboratory staff. The AACB PoCT Working Party (WP) recommends all PoCT be conducted within a quality framework to ensure testing is carried out to professional standards that assure fitness for medical purpose. The WP has developed QC/QA Guidelines to provide assistance as PoCT becomes more widely used, The WP recognises that the situations where PoCT can be used and the complexity of the devices will vary and so the guidelines provide minimum requirements specifically targeted at non-laboratory trained operators.

A47. PoCT EQA FOR HBA1C, URINE ACR AND ON-SITE DRUG TESTING

J Gill

RCPA Chemical Pathology Quality Assurance Programs, Adelaide, SA, 5000

[email protected] quality assurance programs (EQA) are an

integral component of the cycle of continuous quality assessment and improvement which is applicable either in the laboratory or the point-of-care testing (PoCT) site. They assess the performance of the instrument and give the operator confidence that the results that are being reported on patients are correct.

The Chemical Pathology Quality Assurance Programs provides a number of PoCT EQA. These include HbA1c, urine ACR, glucose and on-site urine toxicology. Each EQA is adapted to ensure it is suitable for the instrument and the environment in which it is used. Training in the practice of EQA is provided through the web, DVDs, handbooks and practical tuition. The EQA reports have been simplified and colour coded to allow ease of interpretation and support is provided to participants either by telephone or personal visits.A48. VITAMIN D AND AUTOIMMUNITY

P Glendenning

Department of Core Clinical Pathology and Biochemistry, Royal Perth Hospital, Perth, WA

Schools of Medicine, Pharmacology, Pathology and Laboratory Medicine, University of Western Australia

[email protected] vitamin D has well recognised effects on

musculoskeletal health, the effects on non-skeletal health have been equally interesting but more controversial. Vitamin D may exert effects on both innate and adaptive immune function resulting in a possible role in the pathogenesis of a number of autoimmune diseases including Multiple sclerosis, type 1 diabetes, Rheumatoid arthritis and Crohns disease. Indirectly, but possibly through effects on immune function, vitamin D may also play a role in infection and asthma incidence rates. These effects appear to be mediated in a paracrine or autocrine fashion via local synthesis of active vitamin D metabolites. These outcomes are based largely on observational and epidemiological data. Whether dietary fortification or supplementation has the same effect as endogenous vitamin D also needs to be examined. Two small randomised clinical studies to date have demonstrated an effect of cholecalciferol supplementation on infection rates. The dose of vitamin D required to exert beneficial effects on immune function are not known and in the absence of large randomised clinical trial data, it is


premature to recommend universal supplementation for the prevention of non musculoskeletal disease. A49. "IMERSLUND-GRÄSBECK SYNDROME" — A CASE STUDY OF IDENTICAL TWINS

Rebekah Goodrich

Coagulation and Special Investigations, Pathology Queensland, RBWH,Brisbane, Qld

[email protected]

IntroductionImerslund-Gräsbeck Syndrome (IGS) is characterised

by vitamin B12malabsorption due to a genetic defect resulting in the incapacity to transportvitamin B12 across the intestinal wall. This is not related to a lack of intrinsicfactor. IGS usually presents in childhood (few months old up to 14yrs) with non-specific health problems such as fatigue, weakness with a smallproportion experiencing minor neurological symptoms. Laboratory findings include megaloblastic anaemia, low serum B12 levels, normal intrinsic factor and +/- proteinuria.Results

Patient X, 2yr female, presented with Hb = 45g/L, RCC = 1.50x1012 2/L, MCV =95fL, Plts = 134x109/L. The blood film showed numerous tear droppoikilocytes, oval macrocytes and hypersegmented neutrophils. Patient X's identical twin sister, Patient Y was then investigated and found to have very similar FBC and blood film results. Both patients had a serum B12 and red cell folate level performed, with the B12 levels 17 pmol/L and 2 pmol/L (RR 133-680 pmol/L) respectively. Both patients had a normal red cell folate level and no intrinsic factor antibodies were detected. Urine protein studies were also performed, with proteinuria detected in both patients; Patient X = 2000 mg/L and Patient Y = 900 mg/L (RR <100 mg/L).Conclusions

Both patients were diagnosed with IGS by a paediatric Haematologist following the laboratory findings of megaloblastic anaemia with severely low serum B12 levels in the presence of normal intrinsic factor and proteinuria. Both patients responded well to vitamin B12 therapy, with a normalisation of serum B12 levels and FBC results. The proteinuria is persisting post treatment in these twins with no evidence of kidney damage; this is often seen in patients with this syndrome due to the common defective transport protein.

A50. SETTING UP ANATOMICAL PATHOLOGY IN EAST TIMOR

BM Gormley

School of Human Life Sciences, University of Tasmania, Launceston, Tasmania

[email protected]; [email protected]

This presentation will describe the initial setting up of the Anatomical Pathology laboratory at the Dili Hospital in East Timor.

Prior to the establishment of the laboratory, specimens requiring histopathological diagnosis were transported from East Timor to Australia by visiting surgeons and other medical personnel and reported on by volunteer pathologists in Australia. The turnaround time for the reporting of these specimens was quite lengthy, so this group, together with The Royal Australian College of Surgeons (RACS) began organizing for the setting up of such a laboratory at the hospital laboratory in the Dili Hospital.

Early in 2003, because of my previous experience in establishing a similar laboratory in Surabaya in Indonesia I was approached to see if I would be interested in doing the same in East Timor on a voluntary basis. Through the auspices of the Australian Business Volunteers (ABV) I accepted.

I will discuss the following.• Preparation of lists of the equipment and

consumables required based on the range of stains to be performed.

• Requests for donations of equipment and consumables from laboratories in Australia (Perth, Adelaide, Launceston)

• Provision of some of the consumables such as formalin, absolute ethanol, xylene and commercially prepared stains such as Haematoxylin and Eosin, Van Gieson, Masson Trichrome, Periodic Acid Schiff, Gram Stain and Ziehl-Neelsen stains.

• Transportation of donated equipment and consumables to Perth for shipment to East Timor.

• My arrival in Dili and the problems associated with the non arrival of the equipment.

I returned to Australia without actually setting up the laboratory but before returning I wrote method manuals and organized what I could in the area allocated for the laboratory.

Eventually when the equipment did arrive from Perth another volunteer Medical Scientist (from Ballarat) was sent to do the setting up of the laboratory.

The Anatomical Pathology laboratory in East Timor is now producing slides that are reported on by a resident


pathologist from Cuba. The turnaround time for reporting has been significantly reduced.A51. NOVEL QA PROGRAMS - PROFICIENCY TESTING FOR SECURITY SENSITIVE BIOLOGICAL AGENTS

J Gray,1 W Rawlinson2 1RCPA BioSecurity QAP, RCPA QAP, Sydney, NSW 2Director of Virology, SEALS Microbiology, Prince of Wales Hospital, Sydney, NSW

[email protected]

IntroductionThe RCPA BioSecurity QAP has been established

by a request from the Department of Health and Ageing to provide a proficiency testing program for Security Sensitive Biological Agents (SSBAs). Commencing in 2009 the focus has been on the preparation of surveys for Bacillus anthracis. This bacterium has been used in bioterrorism incidents and is an organism that laboratories may not encounter in the normal course of their work. The surveys are available to laboratories within Australia that have facilities for handling SSBAs.

Program purpose is to:• Confirm or rule out B.anthracis• Characterise the different strains of B.anthracis

to assist forensic investigations• Establish antibiotic susceptibility of B.anthracis

to assist in establishing treatments Performing these functions quickly and accurately

would result in a significant reduction in loss of life.Methods

Complies with ISO/IEC 17043:2010 Conformity assessment - General requirements for proficiency testing.

Specimens are cultures (pure or mixed), blood, cerebral spinal fluid, swabs, white powders, environmental specimens, virtual microscopic images or genetic material.Results

Five surveys have been sent in 2009/2010. The first surveys indicated that participants were not

always aware of the unique characteristics of B.anthracis e.g. morphology and tenacity of colonies and they varied in their ability to deliver accurate results for those tests that they knew were indicative of B.anthracis e.g. motility, haemolysis and penicillin sensitivities.

In performing these surveys the participants have become increasingly consistent and confident in their ability to confirm or rule out B.anthracis. Conclusions

This controversial program has been accepted by participants and has developed a sound reputation within the biosecurity community.

A52. RCPA QAP TARGET SETTING WITH NIST MATERIAL: PERFORMANCE WITH RETINOL, α-TOCOPHEROL AND β-CAROTENE

RF Greaves, KE Hoad, GA Woollard, TA Walmsley, S Briscoe, LA Johnson, WD Carter, JP Gill.

The AACB Vitamins Working Party

http://www.aacb.asn.au/web/Scientific_&_Regulatory_Affairs/Working_Parties/Vitamins/

[email protected]

IntroductionSince 1999, the RCPA Quality Assurance Program

(QAP) has conducted an assessment of analytical performance for retinol, α-tocopherol and β-carotene. Previous target setting exercises have been carried out with National Institute of Standards and Technology (NIST) standard reference material (SRM) 968c, provided at two levels; with targets successfully set for retinol but not α-tocopherol or β-carotene. In 2009 NIST released a new, single level, SRM 968d. Here we describe the outcome of the 2010 target setting exercise with NIST SRM 968d.Methods

Laboratories participating in this QAP utilise reverse phase HPLC with spectrophotometric detection. Target setting is conducted using a standardised procedure where selected laboratories are supplied with material for the forthcoming cycle along with the SRM, in this case NIST SRM 968d. The QAP target values are set using the SRM as calibrator.Results

Assigned values for NIST SRM 968d are: total retinol 1.09±0.17µmol/L; α-tocopherol 13.77±1.28µmol/L; β-carotene 0.145±0.013µmol/L. The linear regression analysis of the NIST SRM 968d target values against all results returned by laboratories in cycle 22 of the RCPA Vitamin QAP are: retinol y=1.0032x–0.0099, r2=0.9987; α-tocopherol y=0.8020x+1.5772, r2=0.9964; β-carotene y=0.8031x–0.1065, r2=0.9914. Discussion

Target setting was successful for retinol, but unsuccessful for α-tocopherol and β-carotene. The concentration of β-carotene in NIST SRM 968d is too low. α-Tocopherol is assessed in the NIST material by HPLC with fluorometric detection, which is different to the detection method of QAP participants. Furthermore, the allowable error reported by NIST (≈10%) approximates the total allowable limits for the QAP.Conclusions

NIST SRM 968d is not usable as a primary calibrator for α-tocopherol and β-carotene.


53. NEW CLSI SWEAT TESTING GUIDELINES

RF Greaves

School of Medical Sciences, RMIT University, Bundoora Vic 3083

[email protected] collection of sweat by pilocarpine iontophoresis,

followed by electrolyte analysis for the diagnosis of Cystic Fibrosis, is based on the technique developed by Lewis Gibson and Robert Cooke in 1959. Associated literature reports highlight both false positive and false negative results. Whilst a small proportion of these are associated with simultaneous pathologies the majority have been attributed to preventable collection and analytical issues. This has provided the impetus for the development of guidelines to improve standards.

The Clinical and Laboratory Standards Institute (CLSI) published such a guideline in 1994 and then a second edition in 2000. In 2003 a UK multi-disciplinary group produced an extensive evidence based guideline. Using this UK guideline as a reference, the AACB Sweat Test Working Party (STWP) developed “Australian guidelines for the performance of the sweat test for the diagnosis of Cystic Fibrosis” in 2005. Together these three sets of guidelines have served to improve performance.

In late 2009 the third edition of the CLSI guideline was published; “Sweat Testing: Sample Collection and Quantitative Chloride Analysis; Approved Guidelines – Third Edition.” Some important new features are the inclusion of additional information relating to the preferred site of collection, applied iontophoresis current, specimen stability and storage, age related reference intervals, and increased emphasis reinforcing chloride as the diagnostic analyte.

The production of the CLSI guideline 3rd edition improves alignment of the three sets of guidelines. The Australian (AACB) sweat testing guideline is based on the UK guideline. The CLSI guideline should however continue to be used as an additional resource. Ideally the development of a freely available CLSI-UK-AACB combined guideline will be a future joint initiative.A54. SWEAT TESTING: SITE, STAFF TRAINING AND COMPETENCY ASSESSMENTS

RF Greaves

School of Medical Sciences, RMIT University, Bundoora Vic 3083 Australia

[email protected] Fibrosis (CF) is a serious life-limiting disease.

The reporting of false negative, and false positive, sweat chloride results can have detrimental consequences. Total intra-individual variation (CVt) for sweat chloride has been demonstrated to be as high as ≈30% in the non-CF population. The collection of sweat is a significant contributor to CVt. To minimize pre-analytical error,

rigorous attention is required to maintain high levels of control over the collection process.

The performance of sweat testing is operator dependent. Stimulation and collection of sweat should only be performed on either the inner forearm (preferred site) or standardised alternative sites such as the inner thigh. The site selected is based on eccrine sweat gland density, safety considerations and the electrode surface sitting flat on the skin. Each trained collector should perform at least 10 collections per annum and ideally >95% of their collections should provide sufficient sweat based on the prescribed average sweat rate of one gram per meter squared per minute over a total sweat collection time of 25+/-5 minutes. Thorough training of collection staff is important to ensure optimization of these components.

Internal and external quality control procedures are valuable for analytical competency but do not test the ability of the operator to collect the sweat accurately. The area of sweat testing most susceptible to incorrect performance, operator competency, remains effectively uncontrolled. The Australian Sweat Test Guidelines support the repeat testing of a volunteer at regular intervals as a control. This approach provides the best assessment of staff competency, controls the overall sweat testing process and allows for the laboratory to assess their CVt.A55. LC-MS/MS: WHERE TO FROM HERE?

SKG Grebe,1,2 RJ Singh1

1Division of Clinical Biochemistry and Immunology, Department of Laboratory Medicine and Pathology;2Division of Endocrinology, Department of Medicine, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota 55905, USA

During the last decade LC-MS/MS has expanded from drug/toxicology testing and newborn screening into measurement of other low-molecular targets, which often tax the performance limits of current LC-MS/MS technology. In particular, steroid hormones and related compounds might circulate at very low concentrations in some patients and are often poor ionizers. The resultant low detection-signals can be further obscured by matrix interferences or by the presence of structurally similar precursors and metabolites. The consequent analytical challenges are compounded by the recent dramatic increases in sex-steroid and vitamin D testing.

The challenge for the next years will be to reconcile the requirement for better detection sensitivity and specificity with this simultaneous need for increased sample throughput. While LC-multiplexing and analyte, or patient-sample, multiplexing can be used to improve sample throughput to ~1,000,000 samples per year per LC-MS/MS instrument, improved sample clean up and better instrumentation are necessary to improve analytical sensitivity and specificity. MS systems with better mass


accuracy and -resolution are good candidates for the latter.

These instruments are also potentially better suited to expand clinical quantitative MS into the realm of peptides and proteins, a field that is moving from basic science/discovery into translational and, most recently, clinical applications. The focus of clinical peptide/protein MS has at first been to show proof of principle of quantitative and specific detection of defined protein/peptide targets. More recently, this work has been translated into clinical assays, with the initial focus being the establishment of reference methods. In addition, early clinical applications focus on targets which (i) are difficult or impossible to measure specifically and accurately with immunoassay, (ii) are subject to frequent interferences in immunoassays, or (iii) exist as isoforms or metabolites that are impossible or difficult to distinguish from each other by immunoassay.A56. THYROID TUMOUR MARKERS – THE OLD AND THE NEW

SKG Grebe,1,2 KW Cradic,1 A Algeciras-Schimnich,1 HV Reddi,2 B McIver2

1Division of Clinical Biochemistry and Immunology, Department of Laboratory Medicine and Pathology;2Division of Endocrinology, Department of Medicine, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota 55905, USA

Incidence rates of differentiated thyroid carcinoma are increasing in most countries. Since thyroid cancer is associated with low mortality and long survival, this has led to a dramatic increase in living thyroid cancer patients. Given current trends, thyroid cancer will be third most common diagnosis in living cancer patients/survivors in the USA within the next 5-6 years, behind breast and prostate cancer and ahead of colon cancer. Since tumour recurrence affects about 1/3 of patients at some stage of their illness, this creates a huge and growing need for follow-up testing.

Because of its organ-specificity, serum thyroglobulin (Tg) has long been the key thyroid cancer tumour marker. Recent improvements in Tg assay sensitivity have largely obviated the need for stimulated Tg measurements, while Tg testing in body fluids and biopsy needle washes has improved definitive diagnosis of suspected recurrences. However, Tg measurements are hampered in 15-20% of patients by the presence of anti-Tg autoantibodies (TgAB). In addition, if current trends of increasing incidence and falling mortality continue, a growing subset of future patients might neither receive total thyroidectomy, nor radioiodine remnant ablation. Consequently, serum Tg measurements will become less useful for detecting recurrence, as Tg is organ-specific, but not tumour-specific.

Identification of strategies to overcome TgAB interferences and to identify other thyroid tumour markers will therefore become increasingly important in the future. We have shown recently proof of principle for the latter in a prospective multi-year study of measurement of circulating BRAFT1799A in the follow up of papillary thyroid cancer patients. We detected BRAFT1799A in the blood of 20 of 173 patients, and its presence correlated with persistent/recurrent disease. We are now expanding this approach to other known molecular thyroid cancer markers and are investigating the diagnostic potential of circulating micro-RNA based markers.A58. BLOOD GROUP ANTIGENS AND THE IMMUNE RESPONSE

REB Green

Discipline of Laboratory Medicine, School of Medical Sciences, RMIT University, Bundoora, Vic 3083

[email protected] group antigens are represented by a wide

range of biochemical structures that are not all solely associated with red cells – the cells we normally think of as carrying our blood groups. Some of the blood groups are referred to as histo-blood groups to indicate their wide spread nature on many different cell types throughout the body. Others, including some of the histo-blood group antigens are associated with bacteria as well as being present as soluble antigens that can be adsorbed on to cell surfaces.

Besides their heterogeneity in biochemistry and distribution they are also differ in their immunogenicity. The multiple epitopes that constitute one antigen also differ in their immunogenicity. This is particularly evident in the Rh D antigen.

Antibodies to blood group antigens may be allo or autoantibodies, and on occasions patients may have a mixture of both. Interesting the development of alloantibodies may also cause the production of autoantibodies. It is not known precisely how and why this occurs. However mechanisms that have been postulated to account for the phenomenon include epitope spreading and T helper cell presentation of immunogenic peptides.

This presentation will review the development of allo and autoantibodies to blood group antigens and offer explanations for some of the serological anomalies encountered in the blood bank.


A59. AN UPDATE ON THE NATURE OF THE STORAGE LESION IN RED CELL AND PLATELET PRODUCTS

REB Green

Discipline of Laboratory Medicine, School of Medical Sciences, RMIT University, Bundoora, Vic 3083

[email protected] solutions to prolong the post transfusion

survival time and functional activity of red cells and platelets have evolved over the years to the point where it is now possible to store them under appropriate conditions for up to 42 and 5 days respectively before they must be discarded. The preservative solutions and storage conditions do not stop metabolic processes taking place within the cells, or of cells dying, but they do slow them down. It has been known for many years that the products of on-going metabolism and of cell death result in changes to the cells and of the milieu in which they are suspended. These changes result in what is called the storage lesion.

It has been known for some time that certain patients and clinical conditions are compromised by transfusion of products near their expiry date eg. neonates, liver and renal disease patients, due to the accumulated changes occurring in stored red cells and that they should be transfused with ‘fresher’ products. In recent years the debate around fresh versus old blood has been extended to other patient populations and has restimulated an interest in a better understanding of the diverse changes that occur in stored red cell and platelet products.

Increasing attention is being paid to the generation of a diverse range of cytokines and enzymes along with the products of cell death during the storage of red cells and platelets. This presentation will review the process by which these changes occur and the impact that products of the changes may have on transfused patients.A60. DNA SEQUENCING: FUTURE DEVELOPMENTS

DM Groth

Curtin Health Innovation Research Institute (CHIRI), School of Biomedical Sciences, Curtin University, Perth, WA

[email protected] the original, dideoxynucleotide sequencing

method was first described by Sanger in 1977, DNA sequencing has evolved slowly. However, the pace of evolution in DNA sequencing in the last decade has accelerated. The human genome sequencing project was commenced in 1990 with the final sequence completed 13 years later in 2003 at an estimated cost of $2.7 billion. Considerable improvements in robotics, optics, bioinformatics, computers (both with respect to processing speed and memory capacity) and instrumentation has

now allowed sequencing to be within reach of being a cheap and reliable method capable of whole genome analysis. Furthermore, the development of powerful nanotechnologies has the real potential to enhance miniaturisation, further resulting in increased efficiencies of the instrumentation used for sequencing with a solid state sequencer being now theoretically possible. The development of these next generation sequencing technologies and their uses will be discussed and potential and perceived deficiencies in these technologies will be explored.A61. “WOMEN’S BUSINESS”: FERTILITY, INFERTILITY AND LABORATORY INTERPRETATION OF FEMALE REPRODUCTIVE HORMONES

N Hadlow

Biochemistry Department, Western Diagnostic Pathology, Perth, WA 6154

[email protected]

Introduction Interpreting female reproductive hormones is often

a challenge for medical practitioners and the laboratory can provide valuable assistance.Outline

This presentation covers fertility and infertility in young women. The definition, prevalence and causes of infertility are discussed. The pattern of female hormones in a normal menstrual cycle and assessment of ovarian reserve is covered. Practical tips and example results will also be given to assist the laboratory scientist in assessment of hormone profiles.

It is important to ascertain whether a woman is having regular menstruation or not before determining appropriate laboratory testing. An explanation of ovulation tracking and examples of tracking results are given.

Irregular menstruation is a common symptom and can occur in a wide range of disorders including polycystic ovarian syndrome, hypothalamic amenorrhoea, thyroid dysfunction, pituitary disease, premature ovarian failure and late onset congenital adrenal hyperplasia. Brief examples of these different conditions and hormone profiles are given in a case presentation style. The importance of further investigation of elevated testosterone results is noted. It is also important to remember that the commonest cause of amenorrhoea in young women is pregnancy.Conclusion

This presentation gives an overview of female reproductive hormones. The talk is designed for the laboratory scientist interpreting female hormone results such that they understand the significance of abnormal results and can support clinicians in appropriate test selection.


A62. PATHOLOGY QUEENSLAND STATEWIDE POINT OF CARE TESTING

ONLINE TRAINING PROGRAM: INITIAL EVALUATION

V Hale, C Martin, A Francis

Pathology Queensland Statewide Point of Care Testing, Central Laboratory RBWH, Herston, Qld 4006

[email protected]

IntroductionSince early 2001, Pathology Queensland —

Statewide Point of Care Testing has grown into, reportedly, the largest network in the world extending from Mungindi on the NSW border to Thursday Island and Doomadgee. It also supports other successful initiatives such as Acute in Home Care programs. Due to the expansion in point of care testing there was an inability to provide standardised timely and responsive training to Queensland Health staff in remote health facilities. Adhoc training in the use of the iSTAT caused poor methodology compliance, resulting in reduced efficiency and increased costs in diagnostic results for rural and remote sites that have no onsite pathology facility.Methods

Using an external vendor and available systems, an online training program was implemented. A database was used to automatically register operators after an assessment. Assessments are valid for 12 months and management for the program is through a helpdesk type of arrangement at the central laboratory. Post training evaluations are used to submit feedback and modify the program.Results

Since release of the online training program we have >3500 operators trained. There was a 41% response rate for evaluations. The central data statistics show a reduction in cartridge wastage and our statistics show that post online training there is improved patient identification compliance of 2.5%.Conclusions

It was found that improved confidence by point of care operators resulted in better patient identification compliance and reduced testing errors resulting in more effective patient management. Online training appropriately constructed and implemented can provide the training needs for rural and remote staff, particularly when other options are limited.

A63. LABORATORY MEDICINE SUPPORT OF PAIN MANAGEMENT: BEYOND URINE DRUG TESTING

CA Hammett-Stabler

Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA 27599

[email protected] is an important component of life. In an acute

setting, it serves protective, even beneficial purposes — alerting us to trauma or disease — resolving when the injury or pathology heals. Unfortunately, >50 million patients within the USA are estimated to be experiencing pain persisting beyond the healing period. Pain of this nature is considered to be one type of chronic pain.

Chronic pain is a complex phenomenon that may also develop de novo, without any evidence of a precipitating event. Its presence frequently exerts a negative impact on a patient's overall health and quality of life as current treatment is less than optimal and often extends over the course of weeks to months. Moreover, the costs incurred by the health care system, workplace, and society are significant.

Relying on medications that have a high potential for misuse, pain management clinics have rapidly become the major clients of our toxicology services. Their use of urine drug testing as a means to determine compliance, as well as detecting misuse of prescriptive and illicit drugs by their patients, provides numerous opportunities for additional analytic and consultative services. For example, confirmation of both positive and negative screening results is warranted in many instances, particularly for those tests representing classes of drugs, i.e., the opiates and benzodiazepines. Unexpected and inappropriate urine drug tests results may be explained by additional serum drug concentrations and, occasionally, pharmacogenetic testing. This presentation will provide insight into some of the issues pain clinics face in the course of patient care, the commonly used medications, as well as the services we can provide.A64. A PROSPECTIVE STUDY OF PAPPA, BMI AND ETHNICITY AND MATERNOFETAL OUTCOMES

X Han, M McShane, Y Chan, Z Hussain, K Chen, C White

Endocrinology Laboratory, SEALS, Randwick, NSW 2031

[email protected]

IntroductionFirst trimester screening (FTS) markers of aneuploidy

have been associated with other adverse pregnancy outcomes. Pregnancy-associated plasma protein A (PAPPA) levels have been linked to small or large for gestational age babies, gestational diabetes and preterm


deliveries. Maternal BMI and ethnicity are also reported to be associated with gestational diabetes, hypertension and macrosomia. We examined the relationship between maternal BMI, ethnicity and serum PAPPA levels as the first step to investigate the potential combined predictive values of these markers.Methods

Serum was collected from women presenting for routine FTS in our laboratory. PAPPA was measured using Immulite assay and multiples of the medians (MoMs) were calculated using the PRISCA software. Height, weight, BMI and ethnicity were recorded for each patient. Fetal outcomes data is being obtained from the Obstetrix database.Results

Of 1450 pregnancies, 1241 and 209 were Caucasian and Asian respectively. BMI was significantly higher in Caucasian women (23.61 ± 0.11 vs 22.43 ± 0.27; p<0.001). The significant differences in PAPPA levels between Caucasian and Asian women (1.92 ± 0.04 vs 2.39 ± 0.11; p<0.001) resolved when PAPPA MoMs were corrected for weight and ethnicity. The median PAPPA MoMs of the same Caucasian population (1.03) were not significantly different (p=0.552) to the Asian population (1.01). The median for the weight corrected PAPPA MoMs for the total 1450 pregnancies was 1.02; the median PAPPA MoMs for BMI <20.0 was 1.05 (n=203) and for BMI>30.0 was 1.04 (n=96).Conclusions

If weight and ethnic corrections of PAPPA MoMs have any predictive value for adverse pregnancy outcomes it will be separate and independent of BMI. The utility of PAPPA and BMI in predicting maternofetal outcomes is being further investigated. A65 EXTERNAL QUALITY ASSURANCE PROGRAM: NUCLEIC ACID DETECTION

E Haremza

Royal College of Pathologists of Australasia Microbiology Quality Assurance Program, Royal North Shore Hospital, St Leonards, NSW 2065

[email protected] acid detection methods are very important

tools in rapid diagnosis and management of many infectious diseases. Microbiology Quality Assurance Program has been facilitating an external quality assurance program for nucleic acid detection since 2001. The main role of these programs is to evaluate laboratories performance. More than 130 surveys were sent out between 2001-2010.

The RCPA Microbiology QAP offers samples for nucleic acid amplification of Bordetella pettussis, Neisseria meningitidis, Mycobacterium tuberculosis, M. avium complex, Chlamydia trachomatis/N.gonorrhoeae, CMV, Enterovirus, HSV, VZV and mecA /nuc genes. Currently

there are a total of 96 participants enrolled in one or more modules; 67 inAustralia and the remainder overseas. Wherever possible pathogens are suspended in natural human material such as plasma, or urine butwhere this is not possible a human sample is simulated. Typically a despatch consists of six samples with specimens sent out as freeze dried preparations. Samples are accompanied by a questionnaire which is set out in the format of a request form with participants being asked to report their findings.

Participants are asked to provide details of methods used in deriving their result and are provided with a performance assessment report where results are marked as 'Correct', 'Incorrect', 'Not assessed' or 'Not assessable'. As molecular diagnostic methods continue to develop, their role in the diagnosis of infectious diseases will become more prominent. The challenge for RCPA Microbiology QAP is to develop and introduce -new- programs relevant to laboratory accreditation requirements.A66. EXTERNAL QUALITY ASSURANCE PROGRAM: VIRTUAL MICROSCOPY EDUCATIONAL TOOL

E Haremza

Royal College of Pathologists of Australasia Microbiology Quality Assurance Program, Royal North Shore Hospital, St Leonards, NSW 2065

[email protected] RCPA Microbiology QAP is committed to

undertake and promote educational activities. One such service is the use of Aperio ScanScopes® to convert glass slides to high resolution digital images and these are now being successfully used by Anatomical Pathology, Cytology and Haematology QAR. Microbiology QAP has been exploring the possibility of using this service. Six slides have been scanned so far. Two represent a parasitology specimen, another represents a sputum specimen spiked with AFB and three smears of various clinical specimens containing pus cells, Gram positive cocci and/or Gram negative rods. The parasitology slide was not satisfactory. It was very difficult to find parasites amongst the faecal matter. The parasites looked "very flat" and a bit squashed. We need to prepare more slides and scan them before we can say that VM is useful for the Parasitology module. The Scanned Gram stains were much better showing satisfactory details of pus cells and the Gram positive /negative organisms were clearly visible. Microbiology QAP provides smears for Gram stains in the STAT program. This program is intended for small laboratories which perform only critical microscopy before referring the specimen to the parent laboratory for culture. Results from the participants show the rate of failure between 10% and 20% due to under-decolorisation or over-decolorisation. RCPA Microbiology QAP should continue to provide participants with smears for Gram staining, only then we can assess their staining and microscope technique. The


slides for acid-fast staining of sputum were difficult to assess. In conclusion VM could be used as an educational tool supplementing smears for staining.A67. THE REGULATION OF IN-HOUSE IVD MEDICAL DEVICES UNDER THE NEW REGULATORY FRAMEWORK FOR IVDS

C Harwood, P Kaylock, G Gardner

IVD Framework Development Taskforce, Office of Devices, Blood andTissues, Therapeutic GoodsAdministration, Symonston, ACT 2609

[email protected] vitro diagnostic medical devices (IVDs) are, in

general, pathology tests and related instrumentation used to carry out testing on human samples, where the results are intended to assist in clinical diagnosis or in making decisions concerning clinical management.

A new regulatory framework implemented on July 1 2010 ensures that all IVDs will undergo a level of regulatory scrutiny that is commensurate with the risks associated with their use. The framework adopts the philosophies and recommendations of the Global Harmonisation Task Force (GHTF) for IVDs, ensuring requirements are internationally aligned.

IVDs are classified into four classes using a risk based approach where Class 4 IVDs pose a high public health risk and Class 1 IVDs pose no public health risk or low personal risk. The framework regulates both commercial and in-house IVDs. In-house IVD medical devices are IVDs used within a laboratory or laboratory network that are:

• developed from first principles; or• developed or modified from a published source;

or• developed or modified from any other source;

or• used for a purpose other than the intended

purpose assigned by themanufacturerLaboratories manufacturing Class 1 to 3 in-house

tests will be required to notify the TGA of the types of IVDs manufactured in each laboratory for inclusion on a data base. Such laboratories will be required to hold NATA accreditation and comply with the National Pathology Accreditation Advisory Committee (NPAAC) requirements for the development and use of in-house IVDs. Laboratories manufacturing Class 4 in-house IVDs will be subject to the same level of regulatory control as commercial Class 4 manufacturers.

A68. SECURITY SENSITIVE BIOLOGICAL AGENTS (SSBA)

F Haverkort

Scientist in Charge BioSecurity PathWest Laboratory Medicine WA QEIIMC

[email protected] weeks of the disastrous events of September

11, 2001 in America, anthrax letters were sent through the mail system that killed 5 people and seriously injuring 17. Both occurrences highlighted several things for the American authorities: they were attacks on civilians, attacks on home soil and they caused mass casualties and mass disruption. It also focused attention on America’s vulnerability to terrorism, naïveté over the use of biological weapons, and their level of un-preparedness to deal with it. These latter elements similarly focused Australia’s attention and galvanized the government to take action. In 2002, the Council of Australian Governments (COAG) agreed to a national review of the regulation, reporting and security surrounding the storage, sale and handling of hazardous materials, with the aim of minimising the risk of these materials being used for unauthorised purposes. The COAG review consisted of four parts covering: ammonium nitrate; radiological material; hazardous chemicals and harmful biological agents. This falls under the National Chemical, Biological, Radiological and Nuclear (CBRN) Security Strategy.

COAG endorsed the review of harmful biological agents and recommendations in April 2007. The SSBA Regulatory Scheme commenced on 31 January 2009 with the regulation of Tier 1 SSBAs and was fully implemented on 31 January 2010 with the regulation of Tier 2 SSBAs.

PathWest Laboratory Medicine WA provides a routine and specialist diagnostic pathology service across more than 2.5 million square kilometres, achieving this through a network of over 50 branch laboratories and collection centres and four major metropolitan laboratories. SSBA are regularly encountered in the course of normal operations. This presentation will describe how PathWest has integrated the requirements of the SSBA Regulations into its standard operational practices.A69. IMMUNOCHEMISTRY IN CYTOLOGY

M Havlat

St John of God Pathology, WA 6008 and University of Notre Dame, Fremantle 6160 WA

[email protected] t r y can complement

cytomorphological diagnostic criteria to help refine diagnoses, particularly when a number of diseases are present. In this presentation, the rational use of immunocytochemistry in cytopathological diagnosis will be explored. The importance of closely integrating


cytopathology and immunocytochemistry with clinical and imagining findings to help guide correct treatment will be stressed.A70. MERCY SHIPS, WEST AFRICA: ONE FIRST WORLD SCIENTIST’S EXPERIENCE DELIVERING HEALTHCARE IN THE THIRD WORLD

N Heal

Supervising Scientist, Laverty Pathology, Armidale, NSW ; Volunteer Medical Scientist, Oak Foundation Hospital, Mercy Ships, West Africa

[email protected] delivery in the third world is a jigsaw

of challenges, improvisation and rewarding experiences. Mercy Ships has operated the world’s largest non-governmental hospital ship providing free healthcare to the forgotten poor in West Africa since 1978.

Of the over 480 volunteers onboard, 3 medical scientists operate a close to first world equivalent, multidisciplinary laboratory, delivering services that facilitate the thousands of life changing surgeries performed annually.

Drawing from experiences gained whilst volunteering on the M/V Africa Mercy in Benin in 2009 and Togo in 2010 this presentation will be an informative photographic journey through the hospital ship, the laboratory, the conditions that plague patients and the social aspects of third world laboratory practice.

Were you trained after the time of bucket chemistry? You may be surprised how transferrable your modern day, first world, laboratory skills are in the fight to bring hope and healing to the world’s poor.A71. SNAKE VENOM DETECTION QAP: RESULTS OF A PILOT STUDY

NR Herrmann

RCPA Transfusion QAP, 44 Musk Ave. Kelvin Grove, Brisbane 4059

[email protected]

IntroductionInterest from within the industry and accreditation

bodies concerning the absence of data on the accuracy of results produced by operators of the CSL SVDK (Snake Venom Detection Kit) prompted the RCPA Transfusion QAP to investigate the technical aspects of establishing a suitable external quality assurance program. The aim of the program would be to assess kit performance as well as provide on-going operator training and assessment for a test that may be performed infrequently in many facilities. Methods

A letter was sent to targeted institutions throughout Australia informing interested personnel of the possibility of a snake venom detection QAP commencing in 2011.

111 respondents were interested in participating in a survey and 106 indicated that they would be willing to participate in the pilot. The test sample for the pilot was a standard dacron microbiology swab dipped in a weak solution of brown snake venom that was provided by CSL. A total of 82 pilot participants returned results for analysis. Participants were asked to identify the immunotype together with providing other information such as type of wash solution, reaction strength and timing of test reaction. Participants were also asked to comment on the clinical interpretation.Results

All participants correctly identified the test swab as brown immunotype. One participant failed to get a reaction but commented that it was used as a training exercise with an expired kit.Conclusions

The test was well performed by the pilot group with all participants correctly identifying the test venom as brown immunotype. A72. TRANSLATING CELL THERAPY TO THE CLINIC: TRIALS OF MESENCHYMAL STROMAL (STEM) CELLS IN AUSTRALIA

R Herrmann, 1,2,3 K Shaw1 and M Sturm1

1Cell & Tissue Therapies Western Australia; 2Haematologist, Department of Haematology, Royal Perth Hospital, Perth 3Clin. Professor, School of Pathology and Laboratory Medicine, University of Western Australia

Mesenchymal stromal cells (MSCs) can be isolated and expanded, then be utilised for a variety of therapeutic applications including inflammatory, cardiovascular, autoimmune and orthopaedic diseases. MSC were first discovered in bone marrow by their adherence to plastic in tissue culture. They self renew and can differentiate into cells of mesodermal lineage including bone, cartilage, tendon, muscle, fat and neuronal cells.

MSC are important cells regulating immunity in the body because they respond to inflammatory cytokines, becoming activated and expressing anti-inflammatory cytokines and other factors such as Indoleamine 2,3-dioxygenase (IDO). This results in suppression of cytotoxic T lymphocyte activity, suppression of B cell antibody production. They express low levels of HLA class I and no class II surface molecules and are immuno-privileged and escape detection by natural killer cells. MSCs also possess regenerative and reparative properties and have been employed in areas such as repair of myocardium after ischaemic injury.

Since 2007 we have been conducting a phase I study of MSCs in steroid refractory graft-versus-host-disease (GVHD) after allogeneic bone marrow transplantation. MSCs were cultured from bone marrow from HLA-identical or related “third party” normal donors. Initially,


patients were treated with 2 x 106 MSC / kg intravenously twice weekly for four weeks and subsequently modified to once weekly for two weeks. To date 102 infusions have been administered with no adverse safety effects. Of the ten patients evaluable with acute GVHD there were seven complete responses and four deaths, three due to sepsis and one to a haemorrhagic stroke. There have been no recurrences of haematological malignancy. Of the seven chronic GVHD patients, two have had CR and two PR, with four deaths due to ongoing progression of chronic GVHD. We are proceeding to a phase II study of GVHD.

Other MSC therapy trials are being developed. Ethics approval has been obtained at Royal Perth Hospital for a multi-centre Australian study in biologic-refractory Crohn’s disease and for a study in collaboration with Prince Charles Hospital in Brisbane for progressive obliterative bronchiolitis after lung transplantation. Further studies are being instigated in renal transplantation, initially to see if MSC growth from patients with end stage renal failure is normal and will support immunomodulatory activity.

Other potential applications for MSC therapy appear to exist and the issues will be discussed.A73. A REVIEW OF THE B’S AND C

K Hoad, R Greaves, W Carter, G Woollard, T Walmsley, S Briscoe, C Salonikas

The AACB Vitamins Working Party, The Australasian Association of Clinical Biochemists, Mt Lawley, WA, 6929

http://www.aacb.asn.au/web/Scientific_&_Regulatory_Affairs/Working_Parties/Vitamins/

[email protected]

IntroductionIn 2008 and 2010 the Royal College of Pathologists

(RCPA) Quality Assurance Program (QAP) introduced two additional programs for vitamins B1 (thiamine diphosphate, TDP) and B6 (pyridoxal phosphate) and then vitamin C. A review of results submitted for the vitamin B1/B6 program revealed a wide dispersion, particularly for TDP. This led to the circulation of a questionnaire to participants. The pilot vitamin C program was introduced for the first cycle of 2010. Here we provide an update of these programs.Methods

Both sub-programs are conducted in the established protocol widely adopted for programs in the QAP. Each cycle contains 6 linearly related samples in duplicate. Medians of results are used as the expected values. The acceptable ranges are determined by clinically based Allowable Limits of Performance.Results

In the first cycle of 2010 results for TDP (11 participants) demonstrated a CV of up to 46% between and 37.6% within laboratories. For pyridoxal phosphate

(5 participants) the variation is up to 28% between laboratories. Results for Vitamin C (13 participants) appear to be linearly related with a wide dispersion, as expected for the first cycle.Conclusions

These new vitamins programs offer a vital service that is of an international standard. The wide variation of results between laboratories is currently being addressed by the working party with a view to better understanding the source of variation and to assist in limiting it. The vitamin C was successful. While not large, it is a niche program that provides an international service and will continue as a full program from the second half of 2010.A74. THE AUSTRALIAN SNAKEBITE PROJECT: THE IMPORTANCE OF LABORATORY INVESTIGATION IN SNAKEBITE COAGULOPATHY

GK Isbister

Discipline of Clinical Pharmacology, University of Newcastle;

Department of Clinical Toxicology and Pharmacology, Calvary Mater, Newcastle, NSW

Australian snake envenoming causes both procoagulant coagulopathy - venom induced consumption coagulopathy (VICC) – and anticoagulant coagulopathy. Uncommonly thrombotic microangiopathy develops following VICC. Laboratory haematology is therefore a core part of the management of snake envenoming syndromes. VICC is common and results from the activation of the coagulation pathway by prothrombin activators in venoms of brown snakes (Pseudonaja spp.), taipan (Oxyuranus spp.) and the tiger snake group. VICC is often referred to as disseminated intravascular coagulation (DIC) because of the elevated D-dimer, prolonged prothrombin time and low fibrinogen. However, VICC differs and is not associated with other important features of DIC. VICC is characterised by unrecordable international normalised ratio and activated partial thromboplastin times (aPTT) within 2 hours of the bite, due to depletion of fibrinogen, factor V and VIII. Spurious results can occur with the first blood collection and misinterpretation of these results is problematic. This is compounded by the fact that most cases occur in rural and regional hospital after hours where haematology or coagulopathy laboratory support is limited. Unusual laboratory investigations with snakebite should be reviewed by a haematology scientist or discussed with an expert in snake envenoming.

Recent work suggests that an anticoagulant coagulopathy is common with black snake (Pseudechis spp.) envenoming and is not confined to mulga snakes. A coagulopathy occurs in over two-thirds of red-bellied black snake envenomed cases. Comprehensive clotting studies and factor levels have shown that the amount of phospholipids in the assay reagents affects the result and


high phospholipid containing aPTT reagents may produce normal results despite an anticoagulant coagulopathy.

Thrombotic microangiopathy is increasingly recognised following VICC and requires a coordinated approach between clinical and laboratory staff in the early recognition of the syndrome. Blood films and lactate dehydrogenase should become mandatory in patients with VICC. More specialised investigations are required in confirmed cases. A75. ASSESSMENT AND MANAGEMENT OF AGE OF RED CELLS AT THE TIME OF TRANSFUSION IN A REGIONAL CENTRE: AN ONGOING

STUDY

Maureen Jacobsen

lmmunohaematology, ACP, Lismore, Pathology North, Lismore, NSW 2480

Maureen.jacobsen@ncahs,health.nsw.gov.au

IntroductionCurrently, in Australia, the shelf life of banked

red cells is 42 days. Following many studies there are calls for a re-evaluation of shelf life and that red cells should be classified as outdated earlier than the current recommendations. This study was conducted to determine the age of the red cells at the time of transfusion, if it compared to the published studies and any measures that could be introduced to transfuse fresher red cells.Methods

An audit was conducted to determine the age of the red cells at the time of transfusion. As the red cell inventory is computerised, data was downloaded, the age at transfusion was divided into sets of five days, tabulated as a percentage of the total transfused and graphed for the years 2006, 2007 and 2008. Compared to published studies, inventory management changes introduced, re-audit and findings compared.Results

In 2006 to 2008, a 15% decrease in red cell transfusions was confirmed. This was comparable to a study that showed a 17% reduction in blood usage from 2005 to 2008. The majority of red cells were transfused at 21 to 30 days post collection with 71% greater than 21 days. Stock levels of red cells were reduced; all stock and crossmatched red cells were hold in pathology. Re audit showed the majority of red cells were now 21 to 25 days with 56% over 21 days.Conclusions

This is an ongoing study but results to date demonstrate with small changes in inventory management, age of red cells at the time of transfusion can be reduced.

A76. DELTA TROPONIN: INFLUENCE OF PRE-ANALYTICAL FACTORS

GRD Jones

Department of Chemical Pathology, St Vincent’s Hospital, Sydney

[email protected]

IntroductionA rise and/or fall in troponin concentration (delta

troponin) is a recognised tool to assist in separating acute myocardial infarction (AMI) from other causes of troponin elevation. The factors which contribute to background variation are generally considered to be biological and analytical variation. In this study we investigate the effect of some pre-analytical factors on delta troponin.Methods

The SydPath database was searched for samples with troponin and albumin results collected in the Emergency Department within 8 hours of each other on the same patient. Changes in albumin concentration were investigated as a marker of changes in sample hydration due to pre-analytical factors.Results

Over 5 years a total of 15,639 samples with both troponin and albumin from the ED were identified. Of these only 900 pairs fulfilled the complete selection criteria. The median albumin on the first sample was 41 g/L. For samples separated by between 4 and 12 hours there was a median fall in albumin concentration of 9% (10th and 90th centiles +4% and -24%). The extent of the fall increased with the time between collections up to 4 hours and then remained stable.Conclusions

The fall in albumin concentration is likely to reflect a combination of artefactual haemoconcentration of the first sample due to prolonged use of the tourniquet, such as commonly occurs in our institution when an intravenous cannula is inserted, and intravascular fluid increase in the second sample due to recumbency or iv fluid administration. The study is limited by the small number of data points and lack of systematic data collection. The effect described may be relevant when assessing values for delta troponin.A77. CRITICAL DIFFERENCE CALCULATIONS: ANALYTE CONCENTRATION IS IMPORTANT

GRD Jones


[email protected]

IntroductionThe Critical Difference (CD) is the smallest

difference between two results which is likely to indicate a true change in the patient. Current calculations use the initial result as the best estimate of the patient’s


homeostatic set point, with an equal chance that a following result will be higher or lower due to random changes. However when the initial result is above the population mean, it is most likely to be a high result from a patient with a set point closer to the population mean. Population and result distributions are used to estimate the patient mean and this approach is confirmed with patient data.Methods

For a given initial result, the patient set point was estimated by combining the probability distributions of the result (initial result as centre; CVtot as SD, CVtot=√(CVa2+CVi2)) and the population (population mean as center; CVg as the SD). The CD calculated as +/- 2.77 x CVtot from the estimate of the patient set point. This theoretical approach was modelled in Excel and validated using data from pathology data mining as previously described (Jones Clin Biochem Rev 2007, S28).Results

The model showed that the estimated patient set point was always closer to the population mean than the initial result. The CD is smaller moving away from the population center than when moving towards. The model provided a good prediction of results seen for analytes with a Gaussian distribution. Conclusions

The approach described here shows that it is more probable for a second result on a patient to be closer to the population mean than further away. CD calculations should be developed to take this effect into account.A78. COMPLEMENTARY THERAPIES FOR CANCER PATIENTS: THE SOLARISCARE EXPERIENCE

D Joske,1,2 A Petterson,2 M Phillips,3 K Poland2

1Haematology Department, Sir Charles Gairdner Hospital, Nedlands, WA2SolarisCare Foundation, Nedlands, WA3Western Australian Institute for Medical Research, Nedlands, WA]

[email protected]

IntroductionSolarisCare Cancer Support Centre (originally

Brownes Dairy Cancer Support Centre) opened at Sir Charles Gairdner Hospital in September 2001 with the purpose of providing support, information and complementary therapy (CT) sessions for individuals with cancer and their carers. SolarisCare provides innovative community-based support services through its volunteers, both meet and greet and complementary therapists. Methods

The Centre has over 120 visitors weekly, half will attend CT sessions. Inpatients can also access sessions.

Patients completed a symptom distress scale (SDS) and a quality of life (QoL) scale immediately before and after the first, third and sixth sessions. Results reported here are for 1244 patients treated between February 2002 and November 2007.Results

Of 1244 patients, 77% (n=952) were female and the mean age was 55 (range 19-85 years). Outpatients accounted for 81.7% of patients (n=970) and 32% (n=846) received mainstream cancer care at another hospital. In total, 2724 CT sessions were performed. These are categorised into: touch based therapies e.g. reflexology (51%); energy-based e.g. reiki (39%); mind-based e.g. meditation (7%) and supportive counselling (3%). Over a course of 6 CT sessions, individual SDS improved for fatigue, nausea and pain, bowels, breathing, sleep and appetite. The improvement in overall SDS (calculated from mean of individual scores) was statistically significant over time (p<0.0001). Mean QoL also showed significant improvement (p<0.001). Due to marked attrition over time (1303 first sessions, 977 third sessions and 444 sixth sessions) analysis was made for “missingness” using a multi-variate random-effects model, which confirmed the statistical significance of the results.Conclusions

Data presented demonstrates that offering complementary therapies in a teaching hospital through a community-based cancer support centre has a positive impact upon QoL and can reduce symptom distress in cancer patients. A79. THE USE OF MOLECULAR DIAGNOSTICS IN THE CLINICAL MICROBIOLOGY LABORATORY

ID Kay

Department of Microbiology and Infectious Diseases, PathWest WA Royal Perth Hospital, Perth

Traditional clinical microbiology relies on staining, culture and biochemical or immunological identification of organisms. After sample collection, the organism needs to be transported carefully to the laboratory to ensure viability. The introduction of diagnostic molecular technologies in clinical microbiology laboratories offers the potential for the rapid detection and quantification of pathogens. The organism does not need to be viable, so transport of specimens is easier to achieve. Real-time PCR is an enhancement which allows for rapid amplification and detection with the added benefit of quantitation. This type of PCR has been utilised at Royal Perth Hospital to develop a S. pneumoniae assay which can detect and quantitate this organism from whole blood in less than two hours. This has the potential to provide valuable diagnostic information to clinicians in assessing patients attending the ED. Recently commercial companies have released “stat” molecular assays which do not require the


specialised skills of molecular trained Medical Scientists. These systems have targeted MRSA, VRE, C. difficile, respiratory viruses and can be performed in approximately one hour.

Automation, upstream and downstream from specimen collection has had a significant impact on human resources. Front end robotics can remove much of the manual processing of specimens and allow a redistribution of valuable human resources. This talk will present types of automation which are used at Royal Perth Hospital.A80. OVERTURNING CURRENT REFERENCE INTERVALS: “TOWARDS A NATIONAL STANDARD”

G Koerbin

ACT Pathology, Canberra, ACT

IntroductionThe appropriateness of using the reference

intervals supplied by diagnostic reagent and equipment manufacturers for clinical decision making in Australia is questionable. The manufacturers are predominantly North American, quote small sample populations do not include health status data and sometimes draw those populations from hospital-based groups. The Aussie Normals Study aims to establish reference intervals for haematological, biochemical and immunological metrics for healthy Australians using community sampling.Method

In this onging study, blood is collected from volunteers into tubes containing no anticoagulant, ACD, EDTA, and lithium heparin. 116 biomarkers including LFT, iron studies, electrolytes, TFT’s, lipids, cancer, cardiovascular and glycaemia markers, immunoglobulins, complement and acute phase proteins, rheumatic markers, vitamin D and bone markers, endocrinology and reproductive hormones, FBC, T and B cell markers are analysed with additional biomarkers added as they become available. Ethics has been approved by ANU, UNSW, ACT and AEC HREC’s Results

Results generated include age-related data sets from young adults to geriatric subsets, which will provide the basis of appropriate reference intervals and assist us in identifying novel gender specific differences in some analytes and other unique information. We have identified novel associations between phenotype and analytes such as BMI and complement (C3 and C4). Conclusions

There is a substantial gap between theory and practice with respect to the application of reference intervals and closing that gap, overturning current reference intervals, moving us towards a national standard is not easy. The data generated by the Aussie Normals project will be used to determine appropriate reference

intervals for the Australian population and as a validation source for existing Bhattacharya data. To assess analyser bias a cohort of Aussie Normals samples will be analysed on variety of platforms.A81. MOLECULAR DIAGNOSIS OF NEUROMUSCULAR DISORDERS: PAST, PRESENT AND FUTURE

N Laing,1,2

1Centre for Medical Research, University of Western Australia, Western Australian Institute for Medical Research; QEII Medical Centre, Nedlands, WA 60092Neurogenetic Laboratory, Department of Anatomical Pathology, Royal Perth Hospital, WA

[email protected] disorders, diseases of the nervous

system and/or muscle, include devastating adult diseases such as Alzheimer’s, and motor neuron disease, but also infant diseases causing paralysis at birth. In 1987, molecular diagnosis for neuromuscular disorders was based on the only gene identified, the gene for Duchenne muscular dystrophy. Now >260 genes are known and molecular diagnosis could be provided for all. However, molecular diagnosis is difficult because neuromuscular disorders involve many of the largest human genes (eg titin) and because genetic heterogeneity (multiple genes causing the same disease) is high. Molecular diagnosis for neuromuscular disorders is currently performed one gene at a time and is thus expensive and time consuming. New technologies offer the possibility to analyse multiple genes in parallel: copy number variation chips to detect deletions and duplications, gene capture and new generation sequencing to analyse multiple genes for small-scale mutations. It is now possible to sequence the entire exome or whole genome for a reasonable price. The importance of identifying the disease-causing mutation in a patient is that it allows accurate diagnosis, determination of inheritance and prenatal diagnosis. Prenatal diagnosis in turn allows disease prevention, saving millions of dollars in health budget. Another aim of researching the genetic cause of diseases was to develop treatments. However, many of the treatments are very expensive, for example enzyme replacement therapy at >$500,000 pa. If the patient achieves a normal lifespan through treatment, the lifetime cost could be >$35m. This is not affordable. What is perhaps needed is prevention rather than cure. Many disorders are recessive. New technologies, for example genome sequencing when it is less than $1,000, may permit population screening to detect carriers before they find out they are carriers by having affected children. Maximising the possible benefit from genetic information, could take society to interesting places.


A82. LABORATORY INVESTIGATION OF HYPOTENSIVE TRANSFUSION REACTIONS

A Le Viellez

Transfusion Medicine, Haematology Department, PathWest Laboratory Medicine, Royal Perth Hospital, WA

[email protected]

IntroductionHypotensive and/or pulmonary oedema transfusion

reactions include Transfusion Related Acute Lung Injury (TRALI), Anaphylaxis, Transfusion Associated Sepsis (TAS), Isolated Hypotension. The differential diagnosis for TRALI in a reaction requires exclusion of Transfusion Associated Circulatory Overload (TACO). The diagnosis of isolated hypotension during transfusion requires exclusion of all other complications. Initial clinical reporting of transfusion reactions is often confusing and conflicting due to the rarity of these events.Discussion

A comprehensive transfusion reaction investigation tool that includes extensive patient clinical history and a laboratory testing algorithm assists in categorising and assessing probability of the blood product as cause. The laboratory investigation may include:

TRALI: neutrophil crossmatch donor plasma vs. patient neutrophils; anti-HLA class I/II antibodies and anti-HNA antibodies in donor/patient, and HLA and/or HNA genotyping or phenotyping of the patient. Serum albumin, total neutrophil and leucocyte counts, pre, onset and post reaction may be useful.

Anaphylactic: Patient IgA serum level and anti-IgA antibody pre-transfusion; serum mast cell tryptase at time of reaction and pre or 48 hours post reaction.

TAS: blood culture of patient, gram stain and culture of blood product and related products. Conclusions

Rapid identification of the cause of a non-haemolytic transfusion reaction is useful for determining patient requirements for further transfusions, and for isolating blood components and products that have potential to cause further harm to patients. The categorisation of these reactions is often complex. Adverse reactions may be categorised clinically but the ready availability of laboratory tests provide useful information to determine probability and likelihood of the implicated blood component(s) as the causative agent.

A83. THE CONTRIBUTION OF INFORMATICS TO THE LABORATORY: NEHTA AND THE E-HEALTH PROCESS

M Legg

Principal, Michael Legg & Associates, Consultants in Information and Organisational Systems

Professorial Fellow, Health Informatics Research Centre, University of Wollongong, NSW

With the new Australian Government formed, the budget to start implementing the National E-Health Strategy agreed by Health Ministers in December 2008 is established. While little detail is available yet, it is clear from the work done previously, that it is very important that, like the Strategy, the implementation plan needs to be widely supported through engagement with those experienced in e-health.

Pathology has had electronic health records in routine use in Australia for some forty years and is now one of the most ubiquitous providers and electronic distributors of health information. It ought to be an important player in any national e-health implementation.

The National E-Health Strategy makes special note that a barrier to implementation may be the availability of the specialised human resources required. These people include:

• Clinicians who understand these technologies and can apply them to clinical practice,

• Information technology professionals with in-depth knowledge of both the business and clinical needs of the health system,

• Health information management professionals with knowledge of e-health technologies,

• Planners who know how to utilize electronic health information systems to address system management issues, and

• Specialists in process re-engineering and change management

• Electronic health information systems will also create a greater need for privacy controls, standardised terminologies, and more extensive coding and classification systems.

There is currently a serious risk that skills and labour shortages in health informatics and health information management will:

• Constrain the successful implementation of e-health in Australia

• Hamper the implementation of health system performance reporting and activity based funding

• Limit Australia's progress in research and development in bio-medicine especially translational medicine


These shortages exist in many other countries with which Australia compares itself. Canada, for example, which has in many respects overtaken Australia with its investment of around $C2 billion in e-health initiatives since 2001, have found that skills and labour shortages are a major barrier to their progress. A recent workforce study showed that on a population-adjusted basis they have 85% more health informaticians and health information managers (HI & HIMs) than we have in Australia and yet they report current vacancy rates in excess of 10% in 6 of the 27 HI & HIM occupational groups. The Canadian modelling further predicts that an increase as large as 26% may be required by 2014, which translates to a hiring requirement of 38% of their current numbers (or 12,330 workers). The US, by comparison, has 50,000 new workers as their target over the next 5 years. The Canadian study also identified a further requirement to broaden the skills for 27% of their existing HI & HIM workforce rising to as high as 78% of the projected workforce by 2014.

In Australia, most universities offer some form of education in health informatics but the intake has been declining and courses have been closing or changing from undergraduate to post-graduate ones. This is so despite anecdotal evidence of high vacancy rates and remuneration. The market is not working. Australian governments must now address the skills and labour shortages in health informatics and health information management and fast-track the further resourcing and implementation of the National E-Health Strategy as a matter of urgency. If this does not happen, the major health reforms now underway will risk major delay or failure.A84. FUNCTIONAL BRAIN IMAGING IN ALZHEIMER’S DISEASE

NP Lenzo

Oceanic Medical Imaging Hollywood PET-CT Centre, Nedlands, WA; Department of Nuclear Medicine, Fremantle Hospital, Fremantle, WA; McCusker Foundation for Alzheimer’s Disease Research, Nedlands, WA

[email protected]’s disease (AD) is a burgeoning epidemic

throughout the world particularly in aging Western world nations such as Australia. It is estimated that by 2050 in Australia over 1 million people will be suffering from dementia. The pathognomonic marker of AD is the deposition of beta-amyloid within the brain with subsequent neurotoxicity and neuronal cell death. A major problem in the medical management of AD is early and accurate diagnosis. It is possible to derive a clinical diagnosis, but only after there has already been significant degeneration of the brain. The diagnosis of AD historically has been made with the use of neuropsychological testing, assessment of functional ability and monitoring changes

over time. Anatomical imaging modalities such as CT and MRI have by and large been utilised to exclude other pathologies rather than accurately diagnosing AD. With new potential treatments it is critical to diagnose AD early, accurately and preferably non-invasively. Functional imaging techniques appear to be able to not only give insights into the alteration in brain function that occurs over time with AD but now with potential specific imaging markers for AD for the first time we are able to define groups of patients at risk of developing AD well before the development of clinical symptoms. Three major functional imaging techniques have been utilised to assess brain function and more recently pathogenesis in AD. These include brain perfusion single photon emission computed tomography/positron emission tomography (SPECT/PET) which utilise tracers that map brain perfusion, 18-fluorodeoxyglucose (FDG) PET which measures glucose metabolism of the brain and C-11 Pittsburgh protein B (PIB) which measures beta-amyloid deposition in the brain. Brain perfusion agents and FDG PET appear useful in differentiating dementia types by the pattern of perfusion or metabolism demonstrated. Loss of perfusion and metabolism however indicates neuronal loss of function and likely neuronal death. C-11 PIB allows accurate assessment of cerebral amyloid burden and appears to predict the development of the clinical syndrome of AD. These techniques are allowing earlier diagnosis and neuronal function assessment. They will be important tools in assessing treatment response until other simpler biomarkers are developed.A80. ENDOCRINE CAUSES OF HYPERTENSION

EM Lim

Department of Biochemistry, PathWest Laboratory Medicine QEII; Department of Endocrinology & Diabetes, Sir Charles Gairdner Hospital. Nedlands WA 6009

[email protected] is common and is a major contributor

to vascular morbidity and mortality. Endocrine hypertension, where hormonal derangements cause significant elevation of blood pressure, accounts for 3% of secondary forms of hypertension. The most common causes of endocrine hypertension are excessive production of mineralocorticoids, for example in primary hyperaldosteronism, catecholamines in phaeochromocytoma or glucocorticoids in Cushing’s syndrome. The likelihood of a secondary cause of hypertension is increased when patients are in a younger age group, have hypertension which is refractory to treatment or a family history of an endocrinopathy.

Identification of an endocrine cause of hypertension is critically important as appropriate management often leads to partial or complete normalisation of blood pressure. Biochemical confirmation is usually required for diagnosis, as demonstrated in primary hyperaldosteronism,


Cushing’s syndrome, phaeochromocytoma or the 11- and 17-hydroxylase deficiency disorders of cortisol/aldosterone biosynthesis. The lecture will give a critical overview of commonly available biochemical investigations used in diagnosing endocrine hypertension and their limitations, as well as the role of genetic testing for certain familial diseases. Current endocrine society guidelines and recommendations in relation to screening strategies will also be discussed. A86. PLASMA NUCLEIC ACIDS AS A PLATFORM FOR MOLECULAR DIAGNOSIS

YMD Lo

Li Ka Shing Institute of Health Sciences and Department of Chemical Pathology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, China

[email protected] the past decade, there has been much interest

in the biology and diagnostic applications of cell-free nucleic acids in plasma. Research in this area started with the demonstration of tumour-derived DNA and RNA molecules in the plasma of cancer patients. My group has a longstanding interest in using this approach for the detection and monitoring of cancer common in China, including nasopharyngeal carcinoma and lung cancer. My interest has since expanded into other species of circulating nucleic acids and has led to the discovery of cell-free fetal DNA and RNA in the plasma of pregnant women. The latter has allowed the non-invasive prenatal diagnosis of a number of fetal genetic diseases and traits (e.g. RhD blood group) from maternal blood. Progress in this area has been accelerated with the development of a number of powerful analytical tools. Recent examples include microfluidics digital PCR and next-generation DNA sequencing. The impact of these developments to the future practice of molecular diagnostics will be discussed.A87. CAN HbA1c BE USED FOR SCREENING AND DIAGNOSIS OF GESTATIONAL DIABETES MELLITUS?

ZX Lu,1,2 KA Sikaris,1 EM Briganti3

1Melbourne Pathology, Collingwood, Vic 30662Department of Medicine, Monash University, Clayton, Vic 3168 3Epworth Hospital, Richmond, Vic 3121

[email protected]

IntroductionHbA1c is recommended for screening/diagnosis

of diabetes in non-pregnant adults in the US. Here, we aimed to examine whether HbA1c can be used for screening/diagnosis of gestational diabetes mellitus (GDM), classified using both the current and the new international criteria.

MethodsData from pregnant women (n=96) who had a

75g-OGTT and an HbA1c (Bio-Rad Variant-II Turbo analyser) performed within 2-weeks of OGTT were reviewed. GDM was classified using the current criteria (FPG≥5.5 or GLU-2h ≥8.0 mmol/L) and the new criteria (FPG≥5.5; or GLU-1h ≥10.0; or GLU-2h ≥8.5 mmol/L). Prevalence of GDM with either criterion was calculated for each defined HbA1c group. Results

In this group, 53 (55%) had GDM based on the current criteria and 52 (54%) with the new criteria. People with GDM had significantly higher HbA1c than those without (GDM-current: 5.69 (mean) ±0.60% (mean±SD) vs 5.32±0.38%, respectively, p<0.01; GDM-new: 5.74±0.58% vs 5.37±0.38%, respectively, p<0.01). Prevalence of GDM by HbA1c is listed below:

HbA1c Prevalence of GDM, n (%)

% n Current Criteria New Criteria

≤5.0 14 3 (21%) 0 (0%)

5.1 7 0 (0%) 0 (0%)

5.2 5 0 (0%) 0 (0%)

5.3 10 7 (70%) 6 (60%)

5.4 14 7 (50%) 6 (43%)

5.5 10 10 (100%) 10 (100%)

5.6-6.0 22 17 (77%) 22 (100%)

>6.0 14 14 (100%) 14 (100%)

There is a significant difference in the mean HbA1c from those with or without GDM. Using the new criteria, GDM is unlikely when HbA1c is ≤5.2% but is highly probable when HbA1c is ≥5.5%. Conclusions

This preliminary study, although based on small sample size, suggests that HbA1c may have a clear potential for screening/diagnosis of GDM. Further studies are needed to explore this issue including linking HbA1c to pregnancy outcomes and the future development of diabetes in the mother.A88. SHOULD THE FIRST LINE TEST FOR FOLATE DEFICIENCY BE SERUM FOLATE OR RED CELL FOLATE?

ZX Lu,1,2,3 J Calleja,1 K Sikaris,1 G Streitberg,2

J Newman,2 J Doery2,3 1Melbourne Pathology 2Dept of Pathology; Monash Medical Centre 3Dept of Medicine, Monash University; Clayton, Vic 3168

[email protected]

IntroductionFolate is primarily ordered to investigate macrocytic

anaemia. The prevalence of folate deficiency (FD) has declined substantially in Australia since volunteer folate


fortification from 1995 and is expected to decline further with mandatory fortification introduced in 2009. Folate can be measured in red cells (RCF) or serum (SF). RCF is routinely measured in Australia while SF is used in the UK. We examined FD prevalence and the concordance of RCF and SF in identifying FD in community and hospital settings. Methods

Community setting: FD Prevalence was calculated using 104,080 consecutive RCF results from Melbourne Pathology. Concordance was assessed with paired RCF & SF (n=215). Reference intervals (RI) (Roche E170) were: RCF 800–3000 and SF 6–45 nmol/L.

Hospital setting: FD prevalence was determined on 100 serial adult admissions to Monash Medical Centre. Concordance of RCF & SF was evaluated in separate 114 patients. RI (Beckman DXI800) were >380 and >6.8 nmol/L, respectively. Results

Community setting: FD prevalence was 0.2%. The RCF & SF gave concordant results in classifying people with or without FD except in one patient.

Hospital setting: Prevalence of FD was 1%. Of the pairs results, all had normal RCF but 4 had slightly low SF. Conclusions

The prevalence of FD is now extremely low in both community and hospital populations as compared to the 8.5% prior to folate fortification. RCF assays are more costly, labour intensive and have much higher imprecision (RCPA/QAP data) than SF assays. Furthermore, RCF results can be misleading at high haematocrit levels probably due to incomplete in vitro haemolysis prior to analysis. In view of low prevalence of FD, the good concordance of RCF and SF and the analytical issues, we propose that SF be the first-line screening test for FD and reserve RCF for confirmation only. A89. NGAL IN THE ASSESSMENT OF ACUTE HEART FAILURE

Stephen Macdonald

Emergency Physician; Clinical Research Fellow, Centre for Clinical Research in Emergency Medicine, Royal Perth Hospital, Perth, WA

Emergency Medicine Specialist, Armadale-Kelmscott Hospital, WA

Patients presenting to the ED with acute cardiac failure comprise a heterogeneous group. Clinical assessment of intravascular volume status can be difficult, and therapies such as diuretics, for example, may exacerbate renal injury. Serum creatinine is a poor marker for early renal dysfunction. The ability to identify patients at risk for worsening renal insult at an early stage would enable more individualised therapy in the acute setting. The purpose of this trial is to assess whether NGAL level

at presentation in patients with ADCF 1) is elevated compared to controls and 2) predicts deterioration of renal function during hospital stay.A90. CLINICAL DIAGNOSIS OF CYSTIC FIBROSIS

R Mackay.

Department Clinical Biochemistry, Canterbury Health Laboratories, Christchurch, New Zealand

[email protected] clinical aspects and diagnosis of classical cystic

fibrosis are sufficiently well known that it is enough to say that it is an autosomal recessive syndrome of suppurative endobronchitis often with sinusitis, more or less pancreatic insufficiency, and many other manifestations and late complications. It is due to absence or malfunction of an epithelial chloride channel called Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) from more than 1500 documented mutations in the CFTR gene.

Recently, patients with incomplete phenotypes, and others with intermediate sweat test values but only one documented disease-causing mutation, have been labelled as having “CFTR-related disorder” and “CFTR-related metabolic syndrome” respectively. The use of such terms, while not universally accepted, at least emphasise that this is a spectrum disorder, as is becoming clear with most genetic disorders.

With widespread newborn screening especially in the developed west, the overwhelming number of patients are diagnosed pre-symptomatically. However we are now seeing an increasing awareness of intermediate and adult presentations of the disease which is presenting new challenges in testing and in interpretation of results. Sweat testing, the subject of this workshop, is well documented in children in particular but has only recently been applied to adults in a systematic way.

The analysis of the electrolytes themselves, often at low concentrations, is clearly important but would not justify an AACB working party. What makes the sweat test special is the method of collection of the sweat. Quite clearly, variations between laboratories in this collection cannot but be reflected in the precision of the results, and these variations have been well documented in the literature. It is therefore the intention of the working party to standardise the sweat test to the extent that it is necessary. Local and international publications have clearly documented this procedure.


A91. COMPARATIVE ANALYSIS OF THE ALERE TRIAGE TROPONIN I TEST AND THE ABBOTT ARCHITECT i2000SR STAT TROPONIN-I ASSAY

C Mandelt

Medical Scientist, PathWest, Royal Perth Hospital; Special Chemistry Section, Core Clinical Pathology and Biochemistry Department, Royal Perth Hospital, Perth, WA

95 samples received in the laboratory from the Emergency Department or other wards within the hospital and that had a troponin-I request were assayed in parallel using the Triage meter. These results were then compared taking into consideration the recommended cut values for both assays.A92. PROTEINURIA ALBUMINURIA WORKING GROUP

HD Martin

Healthscope Pathology, Wayville, South Australia

[email protected] kidney disease (CKD) is an important

health issue with some 2 million Australians estimated to be affected. Early detection requires input from both clinicians and laboratorians. The effectiveness of the implementation of eGFR in Australasian laboratories was in part due to the co-operative activities of professional Nephrology and Clinical Biochemistry bodies. In September 2009 a working group convened, seeking to achieve similar uniform practice in screening for proteinuria, the hallmark of CKD. The Proteinuria Albuminuria working group (PAWG) has members from Australasian Association of Clinical Biochemists (AACB), Australian and New Zealand Society of Nephrology (ANZSN), Kidney Health Australia (KHA), the Royal College of Pathologists of Australasia (RCPA), the Royal Australian College of General Practitioners (RACGP) and the Australian Diabetes Association (ADA). The purpose of the group is to provide recommendations for the screening of proteinuria in the adult Australasian population to clinicians and laboratorians. A draft document has been produced that recommends urine albumin/creatinine ratio, ideally on a first morning void as the preferred sample to screen for proteinuria. Dipstick testing is not recommended, nor is urine protein/creatinine ratio. Current reporting practice amongst laboratories is far from uniform and there are a number of opportunities for improvement; for example the Group recommends the adoption of gender based reference intervals, use of S.I units and repeat testing to confirm positive results. Possible interpretative comments are also offered

A93. STANDARDISATION OF REPORTING IN ELECTROPHORESIS

HD Martin

Healthscope Pathology, Wayville, South Australia

[email protected] Electrophoresis of serum and urine is an essential

laboratory technique in the investigation of suspected myelodysplasias but there are few guidelines to inform specific reporting practices. Results from two surveys conducted by the AACB confirmed a wide variation in electrophoresis reporting practices between laboratories; such variation is undesirable because it may lead to clinical confusion.

A working party comprising members proposed by the professional bodies most involved in electrophoresis reporting: Australasian Association of Clinical Biochemists (AACB), The Australian Society for Clinical Immunology (ASCIA), the Haematology Society of Australia and New Zealand (HSANZ), and the Royal College of Pathologists of Australasia (RCPA) was therefore established to develop recommendations for laboratories. A draft consensus statement was developed and includes technical specifications and clinical comments.A94. HIGH RESOLUTION ANOSCOPY: ANAL WARTS, INTRAEPITHELIAL NEOPLASIA, HPV GENOTYPING AND CYTOLOGY.

J McCloskey,1 I Kay,2 V Williams,3 MA French,4

C Metcalf,5 J Flexman2

1Sexual Health, Royal Perth Hospital, WA; School of Biomedical Sciences, University of Western Australia 2Department of Microbiology and Infectious Diseases, RPH, School of Biomedical Sciences UWA3Western Australian Biomedical Research Institute, Curtin University of Technology, WA4Department of Clinical Immunology, RPH, School of Surgery and Pathology, UWA5Department of Anatomical Pathology, RPH, WA

The rates of anal cancer are rising, particularly among HIV positive men. High resolution anoscopy is a relatively new assessment procedure similar to coloposcopy in women, to assess disease in the anal canal. The procedure of high resolution anoscopy will be described and photographs of clinically abnormal findings will be shown. The results of a paired anal cytology histology study will be presented.

A histological database of anal/perianal warts has been established at Royal Perth Hospital and audited to establish rates of intraepithelial neoplasia (IN) in surgically excised wart material. High rates of IN have been found and this data will be reviewed. In addition the findings of a genotyping study comparing HIV positive men to HIV-negative men with perianal/anal warts will be presented.


High resolution anoscopy is a useful procedure to detect anal IN. The role of anal HPV genotyping remains to be established. Anal cytology is highly sensitive for the detection of abnormal squamous cells, however has a low specificity for predicting the grade of histological abnormality. A95. REPORTING OF SWEAT CHLORIDE RESULTS

MP Metz

SA Path at the WCH, North Adelaide, SA, Australia; Clinpath Laboratories, Kent Town, SA

[email protected]

[email protected] As our understanding of Cystic Fibrosis and its

manifestations grows, it is sensible that our understanding of sweat chloride reference intervals grows as well.

In classical disease, the traditional reference intervals of < 40 mmol/L- normal, 40-60 mmol/L- equivocal, and > 60 mmo/L- supporting a diagnosis of CF, work well. The more subtle disease associated with varying ages and mutations are best illuminated by the changes in reference intervals recently described showing a gradual increase in sweat chloride concentration throughout life.

Particularly in subtle disease, one must be aware of the non-CFTR mutation related causes of increase in sweat chloride including adrenal disorders and malnutrition.

While investigation of mutations in people with suggestive chloride values can be helpful, it is important to recognise that standard panels of mutations often do not include the mutations associated with difficult sweat chloride results.

In typical CF, reporting sweat chlorides is straightforward. In atypical CF, reporting sweat chlorides is challenging and calls for close communication between the laboratory and the clinician. A96. CHILDREN’S REFERENCE INTERVALS

MP Metz

SA Path at the WCH, North Adelaide, SA, Australia; Clinpath Laboratories, Kent Town, SA

[email protected], [email protected]

Suitable reference intervals are the keys to unlocking the benefits of results of laboratory testing. Even for common analytes, children’s reference intervals have been sorely lacking. There are a number of good reasons for this.

Over the last few years a number of projects around the world have been undertaken to help improve this state of affairs. The CALIPER project from Canada, Norip from Scandinavia, the American National Children’s study, and CHILDx from ARUP Laboratories are projects underway.

In addition to using projects designed to determine reference intervals, it is good to keep an eye open for unexpected but usable data.

Novel approaches to data manipulation have been developed to better describe reference intervals. TJ Coles’ smoothed percentiles (lmsChartmaker) are among useful tools for evaluating data.

For use today, the Mayo Medical Laboratories and Pediatric References Intervals, 6th Edition by SJ Soldin, et al are readily available offshore resources. Sonic Network reference intervals for children are new local resources.

Whole scale changes in our ability to provide useful information to enhance the care of children are becoming available to everyone involved in the care of children.A97. PARAPROTEINS: THE CLINICAL APPROACH

P Mollee

Haematology Department, Pathology Queensland, Princess Alexandra Hospital, Brisbane

The primary reason for performing serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP) is to detect monoclonal immunoglobulins associated with plasma cell dyscrasias and lymphoproliferative disorders. As any laboratory assay report needs to deliver clear information to the clinician to assist them in the management of their patients, an understanding of the clinical requirements of a protein electrophoresis report is essential. Clinicians are primarily interested in whether a paraprotein is present or not, and if present, how large it is. Given the role of protein electrophoresis in monitoring plasma cell dyscrasias (and current information technology), the ability to view a cumulative report is also essential. In cumulative reports each paraprotein description should be stable and consistent, particularly if there is more than one paraprotein. Reports must contain adequate information to enable assessment of disease response to therapy. Several recent publications have defined and highlighted the clinical importance of response criteria in the monoclonal gammopathies including partial response, very good partial response, near complete response and complete response. For example, the latter two response categories require performance of immunofixation electrophoresis on samples where a paraprotein was previously detected in order to demonstrate its absence. Other specific circumstances where the approach to SPEP reporting varies considerably and may be a source of confusion to clinicians include paraproteins migrating in the non-gamma regions, small abnormal bands appearing after haematopoietic stem cell transplantation and first presentations of small abnormal bands in patients without a known paraprotein. Commenting also needs to take into account the level of knowledge of the requesting clinicians and their patient demographics. For example, commenting


for general practitioners may differ from commenting for specialist physicians in tertiary level hospitals. Occasional samples can be more complex and require individualised commenting. A uniform approach to the reporting of serum and urine protein electrophoresis addressing these clinical requirements would be beneficial.A98. VITAMIN D: OPTIMUM LEVELS AND TREATMENT THRESHOLDS

HA Morris

Hanson Institute & Chemical Pathology, SA Pathology, Adelaide and School of Pharmacy and Medical Sciences, University of South Australia, Adelaide 5000 SA

[email protected] D contributes to the maintenance of

calcium, and phosphate homeostasis as well as exerting a wider range of biological activities including regulation of cellular differentiation and proliferation. The endocrine action of vitamin D acts through its renal metabolism, producing 1,25 dihydroxyvitamin D (1,25D) in the circulation for which the intestine is the major responsive organ controlling absorption of calcium and phosphate. Serum 25-hydroxyvitamin D (25D) levels below 20 nmol/L decrease the endocrine action of vitamin D resulting in hypocalcaemia, hypophosphataemia, secondary hyperparathyroidism and osteomalacia in bone. 1,25D is also synthesised in a wide range of tissues including bone cells where it is under investigation as an autocrine or paracrine agent. Vitamin D insufficiency in the elderly increases the risk of hip fracture due to osteoporosis. A major question is the cellular and molecular mechanisms by which depleted levels of vitamin D produce osteoporosis. Preclinical studies with low vitamin D diets demonstrate that serum 25D levels between 20 and 80 nmo/L result in trabecular and cortical bone loss without any evidence of osteomalacia. This bone loss is largely due to increased bone resorption. No relationship is evident between bone volume and either serum 1,25D or parathyroid hormone in these animals. 25D is metabolised to 1,25D by each of the major bone cell types which is essential for its anabolic bone cell activities particularly related to promotion of bone cell maturation. These preclinical data indicate that osteomalacia is resolved with serum 25D levels below 20 nmol/L while osteoporosis is resolved at serum 25D levels above 80 nmol/L. A99. USING MULTIPLE BIOMARKERS TO SAFELY AND RAPIDLY EXCLUDE AMIIN THE EMERGENCY DEPARTMENT

Y Nagree, MBBS MRACMA MBA FACEM

Emergency Specialist; Clinical Senior Lecturer Uni WA Fremantle Hospital, WA

Chest pain to the Emergency Department is a common problem accounting for up to 7% of attendances

and over 400,000 total ED attendances in Western Australia (WA) in 2008. The usual process involves the Rule-out of obvious causes including, but not limited to, STEMI, aortic dissection and pulmonary embolus however there are many undifferentiated patients. This study assessed the serial combined myoglobin, CK-MB, cTnl, +/- BNP over 2 hours with clinical risk assessment and ECG interpretation (TIMI and NH F/CSANZ risk group) and whether physicians can safely identify a low-risk group of questionable ACS patients suitable for early discharge and outpatient investigation.A100. PROVOKING LOCAL INFLAMMATION DRIVES TUMORS TO BECOME THEIR OWN PROTECTIVE VACCINE SITE

D Nelson

Curtin University, School of Biomedical Sciences, Perth, WA 6102

[email protected]

IntroductionThe aim of anti-cancer immunotherapies is to

generate an immune response that not only attacks and destroys all existing tumours, but also provides long-term protection against recurrence. This is rarely achieved. Our studies were designed to identify reasons for the failure of the immune system to eradicate cancer, and to design a treatment strategy that might overcome this failure. Methods

Murine models using lung cancer and mesothelioma tumour cell lines were used in these in vivo studies. A number of immune-modifying molecules were used as immunotherapies. The roles of key immune cells and molecules were identified using depleting or blocking monoclonal antibodies. Immunohistochemistry and PCR were used to monitor changes in the tumour microenvironment. Tumour challenge experiments were used to test for the generation of protective memory.Results

In agreement with others, we found that tumours use multiple mechanisms to avoid the immune system including tumour antigen loss and CD25+ suppressor cells. Several monotherapies induced tumour regression if tumours were small at the start of treatment. However, they failed at a precisely defined ‘cut-off’ tumor burden. Larger tumours required combination therapies that simultaneously targeted tumour blood vessels, as well as tumour-infiltrating CD8+ T cells and neutrophils. In this situation protective memory was also induced.Conclusions

We have conducted proof-of-principle studies showing that the tumour itself can be turned into a patient’s own anti-cancer vaccine site. In this situation, the tumour microenvironment changed from being resistant to immune killing to becoming highly susceptible to immune-mediated destruction. Furthermore, this


immune response was capable of a recall response in the same way a vaccine against, for example, whooping cough protects you from the disease. A101. HAEMATOLOGY REPORTS: AN OVERVIEW

S Neville

RCPA Haematology QAP, Northmead, NSW 2152

[email protected]

IntroductionWith the continued development of the Haematology

QAP Programs the reports issued to participants have also continued to evolve. A number of different styles and formats are used across various programs and it is important to present a periodic review of the features in the Haematology QAP reports.Methods

Presenting a concise review of the Haematology QAP report formats including examples of qualitative and quantitative styles and reports utilising filters. Reports specially designed for Diagnosis, such as Morphology and Haemoglobinopathy will be discussed as well as reports from the Automated Differential, Manual Differential and G6PD Programs. The importance of the correct information being held by the Haematology QAP database will be highlighted. In addition the current IT projects under development will be presented. The RCPA Quality Assurance Programs company is investing heavily in the continued development and upgrading of the current data analysis system with the focus to improve the functionality and experience for our participants. Improved web-based access and the availability of .pdf reports are just some examples of improvements soon to be made available to all participants.Conclusions

The format and diversity of reports issued by the Haematology QAP is sometimes perceived as overwhelmingly complex. Periodic review of the different styles is seen as an opportune way to ensure participants are able to fully interpret their reports and thereby derive the most benefit from the information supplied.

A102. IMPAIRED BUTYLCHOLINESTERASE FUNCTION DUE TO THE INTERACTION OF A NOVEL GENE VARIANT WITH THE K-VARIANT

C Newbound,1 M Kersten,1 C McCaulay,1

L Greenwood,1 D Ravine,1,2 J Beilby1 1Molecular Genetics, PathWest Laboratory Medicine Western Australia, QEIIMC, WA, Australia2School of Pathology and Laboratory Medicine, University of Western Australia, Nedlands, WA

[email protected]

IntroductionThe BCHE gene media te s synthes i s o f

butyrylcholinesterase (BChE) in the liver. While the precise physiological role is yet to be established, BChE is important in the metabolism of numerous natural and synthetic drugs (pesticides, acetylcholine, cocaine, mivacurium and succinylcholine). Impaired enzyme activity is usually of little consequence, but is associated with serious risk of prolonged apnoea following administration of the muscle relaxant suxamethonium.

Reduced BChE activity is strongly associated with the Atypical (Asp70Gly), FLUORIDE1 (Thr243Met), FLUORIDE2 (Gly390Val) and quantitative K- (Ala539Thr) gene variants. Compound heterozygotes for the Atypical and K- variants, exhibit lower activity than simple Atypical heterozygotes. We report a novel BCHE genotype in a 42 year old female with very low BChE activity.Methods

DNA sequencing of the BCHE gene locus, located on chromosome 3(3q26.1-26.2), was performed to identify rare gene variants.Results

A middle-aged female demonstrated consistently low BChE activity over 12 years (2.0kU/L [5.2-12.0kU/L]). Genotyping yielded compound heterozygosity for a novel missense mutation, Phe43Ile (NM_000055.2:c.211T>A;NP_000046.1:p.Phe71Ile), in combination with the K-variant. Further studies revealed a son, with borderline BChE activity (5.3 kU/L), heterozygous for Phe43Ile; and a daughter, with BChE of 6.0 kU/L, homozygous for the K-variant. Testing revealed that maternal variants were located on alternate alleles and that, in the heterozygous state, the novel variant exerted minimal influence on total enzyme activity. Conclusions

The novel Phe43Ile variant in the simple heterozygous state does not cause a significant reduction in BChE activity. However, when co-inherited with the K-variant, the Phe43Ile variant is associated with a marked reduction in enzyme activity.


A103. IN-VITRO STABILITY OF FETAL DNA IN MATERNAL BLOOD: THE IMPACT OF SAMPLE PROCESSING TIMEFRAMES ON A FETAL RHD GENOTYPING SERVICE

H O'Brien,1 GJ Gardener,2 CA Hyland,1

GM Millard,1 AE Tremellen,3 JA Hyett4,5

1Research and Business Development, Australian Red Cross Blood Service, Brisbane, Qld2Maternal Fetal Medicine, Mater Mothers' Hospital, Brisbane, Qld3Clinical Research Support Unit, Mater Medical Research Institute, Brisbane, Qld4RPA Women and Babies, Royal Prince Alfred Hospital, Sydney, NSW5Discipline of Obstetrics and Gynaecology, Central Clinical School, Faculty ofMedicine, University of Sydney, Sydney, NSW

[email protected]

IntroductionNon-invasive assessment of fetal RhD status involves

extraction and analysis of cell-free DNA from maternal plasma. While current literature suggests that fetal DNA is stable in whole blood for at least 24 hours, there is limited data on in-vitro stability. We report our experience in the detection of fetal DNA sequences in 10 first trimester pregnancies where whole blood specimens were processed 24, 48, 72 and 96 hours following collection.Methods

EDTA whole blood samples were collected from RhD negative subjects (mean gestation 14 weeks; range 11-16 weeks). Plasma was harvested and frozen 24, 48, 72 and 96 hours following phlebotomy. DNA was isolated and tested using qPCR assays validated for the assessment of fetal RHD.

Results No false negative or false positive results were obtained when predicting fetal RhD status. However, in 2 cases, samples processed 48 hours post-collection gave 'inconclusive' results according to our algorithm.Conclusions

Processing samples more than 24 hours following collection can compromise our ability to conclusively assess fetal RHD in late first trimester patients. In the event that we were to offer an effective test service to a geographically diverse Australian clientele, it will be necessary to define strict sample transportation timeframes until alternative pre-analytic sample collection systems have been validated.

A104. TECHNICAL DEVELOPMENTS AND THEIR DIAGNOSTIC SIGNIFICANCE

VJ Ojeda

Pathologist, St John of God Pathology, Bendat Cancer Centre, Subiaco, WA

Pathology services play a critical role in both primary and secondary healthcare. It has been estimated that pathology and pathologists are responsible for 70% of all diagnoses and 100% of all cancer diagnoses. The annual cost is about 1.8 billion dollars in Australia.

The question that is not often asked is how pathologists make such diagnoses? Tissue specimens are fixed, processed and stained with haematoxylin and eosin for histological assessment. In about 90% or more of all cases that is all what is needed. Tissues should be prepared and fixed properly. Fixation is the only stage of the process that cannot be corrected.

Therefore, all diagnoses or differential diagnoses are based on haematoxylin and eosin sections. Small proportions, perhaps less than 10% of all cases, require special classical stains and/or immunohistochemistry. From that small proportion, another small fraction would need electron microscopy and/or sophisticated molecular studies, which are extremely specific and costly. Therefore, we should not forget that the base for a good diagnosis is a proper preparation of the specimen, in particular fixation. The classical basic principles of Anatomical Pathology are far too often overlooked and poor fixed specimens are frequently processed in a hurry. The results predictably can be conflictive. The basic principles of preparation of specimens are of paramount importance in the pursuit of excellence in the practice of Anatomical Pathology diagnoses.A105. EXTERNAL QUALITY ASSURANCE: URINE DIPSTICK CHEMISTRY

L 0lliffe

Royal College of Pathologists of Australasia Microbiology Quality AssuranceProgram, Royal North Shore Hospital, St Leonards, NSW 2065

[email protected] dipstick tests can be used as a rapid method

of detecting or excluding urinary tract infections. The test is widely used due to its low cost and the limited technical training required. External quality assurance is required for accreditation, confidence of the user in accurately interpreting the result and reduction of user error. Microbiology QAP has 321 (213 Australian and 108 international) enrolled participants in the Urine Dipstick Chemistry program. The majority of labs enrolled are either microbiology laboratories or smaller STAT laboratories. Simulated urine is spiked with a combination of blood, nitrite, protein and glucose. The homogeneous sample is tested at approximately the same time across many locations, by different individuals


using many different kits and read either manually or by machine. Two lyophilised samples are sent four times per year. Participants are required to reconstitute the samples to 10mL, Pathology Quality Assurance Program in providing external proficiency testing of laboratories and pathologists.A106. GENETICS OF HEREDITARY HAEMOCHROMATOSIS

JK Olynyk

Department of Gastroenterology, Fremantle Hospital, Fremantle, WA

School of Medicine & Pharmacology, University of Western Australia; Western Australian Institute of Medical Research Curtin Health Innovation Research Institute

Profound advances in our knowledge of Hereditary Hemochromatosis (HH) have occurred during the last 150 years resulting in two distinct iron ages; the pre-HFE gene era and post-HFE gene era. During these periods, family studies, HLA association studies and ultimately HFE gene studies in various populations have informed us of the genotypic prevalence, as well as the clinical and biochemical penetrance of HH. We have learned that HH has a highly variable clinical penetrance in susceptible individuals of Northern European ancestry. Further, we now recognize that the natural history of HH is not as discrete as previously believed, as genetic and environmental modifiers of disease penetrance are increasingly identified as influencing the clinical expression of HH. The key genetic mutations which result in Hereditary Haemochromatosis include those affecting HFE, transferrin receptor 2, ferroportin, haemojuvelin and hepcidin. These primarily result in impaired sensing of iron status and production of hepcidin, the key regulator of iron absorption from the gastrointestinal tract and iron release from bone marrow macrophages.A107. THE FUTURE OF QUALITY CONTROL IN THE LABORATORY: NEW QC STRATEGIES

CA Parvin

Manager, Advanced Statistical Research, Quality Systems Division, Bio-Rad Laboratories, USA

There is increasing demand from regulators, the health care community, and patients themselves that all parts of the health care system should be constantly striving to minimize risk to the patient. This focus on patient risk combined with the many enhancements the modern laboratory has realized in the era of laboratory automation provide both the incentive and the opportunity for laboratories to rethink the ways they design, implement, and evaluate their internal quality control (QC) strategies. This talk will address how QC strategies can be designed to manage patient risk by limiting the number of incorrect patient results reported by the lab. The interrelationships between the power of a QC rule, the quality required of

a patient result, the analytical imprecision of a laboratory test, and the frequency of QC testing will be explored. Understanding these interrelationships makes it possible to optimize QC strategies while managing patient risk.A108. THE MERITS AND APPLICATION OF VIRTUAL MICROSCOPY IN ANATOMICAL PATHOLOGY

M Peck, E Little

RCPA Quality Assurance Programs Pty Ltd – Anatomical Pathology, Melbourne, Vic 3125

[email protected]

[email protected]

IntroductionThe Royal College of Pathologists of Australasia and

the RCPA Quality Assurance Program, with support from the Commonwealth Department of Health and Ageing, has introduced Virtual Microscope Technology into the practice of pathology. The RCPA Anatomical Pathology Quality Assurance Program, based in Melbourne, commenced using Virtual Microscopy in 2004 for the scanning of microscope slides. This presentation is intended as an overview, providing an insight into the merits of using this technology by the Program. Methods

Virtual microscopy has proven a valuable tool in diagnostic pathology, research, education, and of course external quality assurance. The technology creates digital images which can be magnified in a similar fashion to light microscopy. These image files can be compressed and reproduced on DVDs for distribution elsewhere for subsequent viewing. Associated software packages enable these images to be annotated as required. Results

Virtual Microscopy is now routinely used by the Anatomical Pathology Quality Assurance Program for all diagnostic pathology modules. It has enabled the provision of a broader range of cases (diagnoses) to pathologists, including biopsies which would otherwise have been impossible to include on a glass slide to all participants of a diagnostic survey due to insufficient tissue. Conclusions

An overview of the application and merits of Virtual Microscopy will be discussed; in particular those benefits achieved by the RCPA Anatomical Pathology Quality Assurance Program in providing external proficiency testing of laboratories and pathologists.


A109. KEY INCIDENT MONITORING AND MANAGEMENT SYSTEMS (KIMMS)

P Petinos,l Ken Sikaris2

Quality Manager and KIMMS Pilot Program Coordinator, RCPA QualityAssurance Programs Pty Ltd, Sydney NSW 2010

Chairman, KIMMS QA Program, RCPAQualityAssurance Programs Pty Ltd, Sydney NSW 2010

[email protected] Key Incident Monitoring & Management

Systems (KIMMS) project was initiated by the Quality Assurance Scientific and Education Committee

(QASEC) of the Royal College of Pathologists of Australasia. RCPA Quality Assurance Programs P/L (RCPA QAP) acquired the project from QASEC and the pilot was run in 2007-2008. KIMMS was introduced as a Quality Assurance Program in 2009. Pathology in Australia has been a leader in the introduction of accreditation and quality assurance for pathology laboratories to demonstrate competence and continual improvement. Recent studies in many countries however, have shown that the majority of adverse patient incidents occur in the non-analytical phase of the test-requestreport cycle. In order to minimise the risk of errors and incidents in pathology, the pre- and post-analytical phase of testing need to be measured and monitored.

KIMMS aims to monitor the pre- and post-analytical phase of the laboratory quality system thus extending measurement of quality to the entire quality system. The project is designed to provide pathology practices with the tools for continuous measurement and monitoring of key incident indicators.

The workshop will provide general information about the KIMMS QAP and will also include an interactive session for setting up your LIS to capture the KIMMS data. In addition, the workshop will include sessions on KIMMS in relation to regulatory requirements and discussion of the proposed Risk Matrix to be implemented in 2011. The KIMMS QAP offers all the advantages of a conventional analytical QAP, with participant confidentiality, data de-identification, performance reports and summary reports.

RCPA QAP thanks the Department of Health & Ageing for supporting this project.A110. BENCHMARKING IN PATHOLOGY QAP

S Pfeffer

RCPA QualityAssurance Programs Pty Ltd, Sydney, NSW

[email protected]

IntroductionThe Benchmarking in Pathology Program Project

commenced in 1996, with the aim of developing Key

Performance Indicators to assist pathology practices measure, compare, benchmark, and improve critical aspects of their cost performance. After the successful completion of two pilot phases the Project was upgraded from Pilot Project status within RCPA to the status of a full Quality Assurance Program within the RCPAQualityAssurance Programs Pty Ltd in 1999.Methods

Data collection covers the full financial year period. Two six-monthly or one twelve month data set can be submitted, via email, for processing and analysis. Sites can also submit "what if' data sets for processing to assist them in making managerial decisions within their organisation. The in-house developed computer system uses a wide variety of calculations to trickle higher level costs down to the end product of test cost.Results

After processing and analysis of the data submission has been completed the Benchmarking in Pathology QAP distributes several individual site reports back to the site within one week of receipt of the data. Peer group comparison reports are provided to laboratories at the completion of the first six months and the end of the financial year (End of Cycle report).Conclusions

The existing reporting system has matured over many years due to participant input and feedback, enabling participants to determine their cost performance, identify inefficiencies, possible areas for improvement or development and areas where cost containment strategies could be applied. Sites participating in the Program have found the reports very detailed and an excellent resource in gaining a better understanding of their cost structure and areas of cost consumption enabling them to achieve cost efficiencies without detriment to the quality of the service provided.A111. ENSURING QUALITY IN IMMUNOHISTOCHEMISTRY

M Platten

Pathwest, Histopathology, QEII Medical Centre, Nedlands, Perth, Western Australia

Michael.Platten @health.wa.gov.auHistopathology has remained relatively unchanged

for the past hundred years. In the past 40 years the immunohistochemical identification of various cellular proteins and micro-organisms using the antibody-antigen reaction, with chromagen labelling has taken the accuracy of disease diagnosis to a new level. The emergence of immunohistochemistry (IHC) has transformed the industry, by improving the diagnostic accuracy, guiding treatment and providing prognostic and predictive information. The burgeoning use of IHC, also places extra burden on the histopathology laboratory, to ensure that the techniques are carried out accurately, and


reproducibly, to avoid the possibility of false positive and negative results. The automation of these techniques has relieved laboratories of some of this burden, but it is often the non automated aspects of the procedures that cause the most problems. There are many pitfalls in the use and interpretation of IHC, with potential for error at all steps from the pre-analytical to the post-analytical stages of the process. Key to successful IHC includes proper fixation and processing, antigen retrieval and the choice of appropriate controls. Underpinning excellence in IHC is the necessity to have dedicated and experienced scientific staff and pathologists. It is an unreasonable expectation that inexperienced or part time staff can provide the same level of quality assurance and improvement as highly trained and dedicated IHC scientists. With the increasing routine use of IHC in pathology laboratories, the standard of practice now needs to meet the requirements of external bodies such as the RCPAQAP and NATA A112. POINT-OF-CARE TESTING: DISRUPTIVE TECHNOLOGIES AND IMPROVING HEALTH OUTCOMES

CP Price

Department of Clinical Biochemistry, University of Oxford, Oxford, United Kingdom

[email protected] technologies are described as “innovations

that create an entirely new market through the introduction of a new product or service”, or “innovations that improve a product or service in ways that the market does not expect, typically by lowering price or designing for a different set of consumers”. They have also been described as “innovations that challenge the status quo”. Whilst they may be generic descriptions they can equally be applied to health care insofar as they represent a means of changing the way that health care is delivered e.g. care closer to home (new market), being more patient centred (new customer) and reducing costs (lowering price).

Reviews of health care in recent years have found systems to be fragmented and wasteful, with poor delivery and constraints in the use of new technologies, including informatics. Solutions have focused on being more patient-centred, safe, efficient and effective. Care has increasingly gravitated to the hospital setting, which cannot always accommodate patient needs in remote areas, or the increasing burden of chronic disease in the population, as well as not always being appropriate for the needs of public health.

Laboratory medicine has evolved in much the same way, with early testing at the bedside moving to an increasingly centralised mode of delivery with increasing levels of automation. However this is at the expense of the needs of rapid turnaround of results to support a more patient centred approach - whether it be for acute clinical needs, enabling better dialogue between patient

and carer, or to improve the whole process (e.g. reducing length of stay).

Point-of-care testing addresses these shortcomings. The technologies being developed reflect the experience seen in other service areas e.g. telecommunications and computing, enabling testing to be performed by less skilled people, and ultimately the patient as the customer.A113. COMMISSIONING LABORATORY SERVICES ON THE BASIS OF EVIDENCE

CP Price

Department of Clinical Biochemistry, University of Oxford, Oxford, United Kingdom

[email protected] generic definition of commissioning is “a means

securing the services that most appropriately address the needs and wishes of the individual service user, making use of market intelligence and research, and planning accordingly”. In health care this means securing the best value for patients and payers, with the best possible health outcomes, the best possible health care experience, which is affordable.

There are generally considered to be four stages in commissioning a service (i) assessing the local health care needs – and the expected outcomes, (ii) specifying the services required - and identifying the resources required, (iii) securing the services required – and any clinical practice change and resource reallocation, and (iv) monitoring against the contract issued, and evaluating the outcomes against the expectations. There are similarities to the so-called evidence-based laboratory medicine cycle, of (a) identifying the clinical problem or need, (b) acquiring the evidence, (c) critically appraising the evidence, (d) applying the evidence, and (e) auditing the process. These attributes are also embodied in continuous quality improvement. Commissioning has generally been applied to care pathways, the implication being that all of the elements of the pathway operate effectively - a major challenge in a complex service such as health care.

The evidence of impact of laboratory medicine on health outcomes is poor, and inappropriate utilisation is acknowledged. A diagnostic test can be employed in a number of ways (screening, diagnosis, monitoring etc) and consequently should be evaluated and commissioned in the context of a “diagnostic pathway” rather than merely as a “test”, reversing the increasing commoditisation of laboratory services. Effective implementation of a test requires a change in clinical process and reallocation of resources; these aspects of service integration and transformation represent major challenges in health care if laboratory services are to be used effectively.


A114. ASSESSMENTOF THE CLINICAL UTILITY OF PROGESTERONE ANALYSIS IN SERUM, SALIVA AND URINE

D Purwanto,1,2,3 K Knight,3 A Read3

1Biochemistry Department, Medical Faculty, Sam Ratulangi University, Manado, Indonesia;2Laboratory Medicine, RMIT University, Bundoora, Vic 30833Biochemistry, Pathlab, Burwood, Vic 3125

[email protected]

IntroductionBlood has been the accepted routine specimen

worldwide for assessing the secretion rate of progesterone. Whether salivary and urine progesterone assays are similarly useful needs to be investigated, as these specimens are non-invasive and more convenient for frequent collections. In this study, blood, saliva and urine progesterone were compared to see whether they exhibit similar patterns during the menstrual cycle.Methods

Serum, urine and saliva samples were collected simultaneously from 12 premenopausal females, twice, two weeks apart, for the measurement of progesterone. Serum progesterone was assayed using Architect ci8200 Chemiluminescent Microparticle Immunoassay technology (Abbott Diagnostics). Salivary progesterone was analysed using the DRG progesterone ELISA kit. Urine pregnanediol (the main progesterone metabolite) was assayed using an Agilent 6890 Gas Chromatograph coupled to a 5973 Mass Selective Detector. Statistical analysis included the Wilcoxon sign rank test, Friedman test, paired Student t test, and McNemar test, performed with SPSS version 16.Results

The concentration of progesterone found in the follicular phase was: serum <0.30–2 nmol/L; saliva 70–150 pmol/L; and urine (pregnanediol) 0.02–0.26 µmol/mmol creatinine. Comparatively the concentration of progesterone in the luteal phase was: serum 4.8–26 nmol/L; saliva 250–780 pmol/L; and urine (pregnanediol) 0.4–1.1 µmol/mmol creatinine.

A strong correlation between serum, saliva and urinary progesterone levels was demonstrated. Statistically, there was no difference in the proportion of results interpreted as follicular phase (or similarly, luteal phase) between saliva or urine versus serum; all p values >0.05.Conclusions

Both saliva and urine are good alternative specimens to serum in assessing progesterone production and stage of the menstrual cycle.

A115. FROM OBSCURITY TO “SUPERBUG”: THE RISE OF CLOSTRIDIUM DIFFICILE

TV Riley

Microbiology & Immunology, The University of Western Australia and Division of Microbiology & Infectious Diseases, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Nedlands 6009, WA

Clostridium difficile is a known cause of diarrhoea in hospital patients exposed to antimicrobials in developed countries. Recently in North America and Europe a highly virulent strain of C. difficile (NAP1/PCR ribotype 027) has emerged. Rates of detection of C. difficile have risen dramatically and C. difficile infection (CDI) has become more severe. Acquisition of C. difficile is facilitated by its ability to form spores that remain viable for long periods. Toxigenic C. difficile usually produces two toxins, A and B, that are the major virulence factors. NAP1/PCR ribotype 027 produces 16 to 23 times more toxins, due to mutations in a regulatory gene tcdC, and an additional “binary” toxin. These strains are resistant to fluoroquinolones and excessive fluoroquinolone use appears to be driving recent outbreaks. There is no evidence that “epidemic” C. difficile has established in Australia although a single case has been reported recently in Perth, and a cluster of cases has occurred in Melbourne. C. difficile has also been found in both diarrhoeal and non-diarrhoeal pigs, horses, and cattle, suggesting a potential reservoir for human infection, and in 20-40% of meat products (beef, pork and turkey) in Canada and the USA, suggesting the possibility of food-borne transmission of C. difficile. Recently, there has been some overlap of animal and human ribotypes of C. difficile, particularly in some areas of The Netherlands where 22% of human isolates are ribotype 078, the pig strain. Ribotype 078 C. difficile is similar to ribotype 027 in terms of virulence and is now the 3rd most common C. difficile ribotype isolated in Europe. A116. SIZE AND SOURCES OF SWEAT CHLORIDE VARIABILITY

H Robins,1 R F Greaves,2 R J Mackay3

1ACT Pathology, ACT2The Royal Children’s Hospital, Vic3Canterbury Health Laboratories, Christchurch, NZ

IntroductionSweat testing is important in the diagnosis of

Cystic Fibrosis (CF). Sweat chloride results <40mmol/L are considered normal and >60 mmol/L suggestive of CF. The analytical imprecision of the test is quantifiable by internal and external quality assurance programs but the variation due to the collection procedure and the biological variation of the patient is not well defined.Methods

In a study of healthy adults sweat was collected on eight occasions in three subjects and on twelve occasions


in one subject over a 2 year period using the Wescor Macroduct collector system. A separate study assessed sweat conductivity weekly for 5 weeks in 15 healthy adult volunteers, 20 healthy infants and 20 known CF patients. A third study investigated test variability by comparing sweat electrolyte values from 2 sites collected simultaneously by the Gibson and Cooke method. Results

The simultaneous measurement study showed a coefficient of variation (CVt) between the 2 sites of 20.2% for chloride (n = 269). The CVt of the adult volunteer group ranged from 14.9 to 32.9%. This may have been higher due to temporal variation. The sweat conductivity study showed CVt of 18% for the healthy infant group. These uncertainties of measurement may lead to misclassification in diagnosis, with false positives up to 15% and false negatives up to 12%. Conclusion

These results indicate that great care must be taken in the interpretation of sweat chloride results. Defined cut-off values do not take account of the CF spectrum, which is likely to be continuous, nor the wide intra-individual variation. The diagnosis of CF must include a critical evaluation of the clinical presentation of the patient.A117. CURRENT TRENDS IN CORD BLOOD BANKING AND TRANSPLANTATION

R Rodwell

Queensland Cord Blood Bank At The Mater, Mater Pathology, Mater Health Services, South Brisbane QLD 4101

[email protected] Cord Blood (UCB) is now an accepted

substitute for bone marrow (particularly for patients lacking a HLA-matched bone marrow donor) for transplantation of patients with haematologic malignancies, immunodeficiencies, bone marrow failure, inherited metabolic disorders and haemoglobinopathies. Over 20,000 unrelated UCB transplants have been performed in children and adults since the first related UCB transplant was performed in 1988. A global network of Cord Blood Banks (CBBs) has evolved and there is an estimated 450,000 cord blood units (CBU) from altruistic donations in frozen repositories. Within Australia, there are three government-funded public CBBs (collectively known as AusCord) in Queensland, Sydney and Melbourne; each is licensed by the Therapeutic Goods Administration and accredited by the Foundation for the Accreditation for Cellular Therapy. A number of private CBBs collect UCB for potential autologous use. The advantages of UCB as a source of graft include ease of procurement, lack of risk to the mother and baby, minimal donor attrition, ready availability, low risk of latent viral infection, less stringent requirements for HLA matching and a decreased risk of graft-versus-host –disease. Key selection criteria for CBUs

and predictors of survival post-transplantation are the degree of HLA match and the total nucleated cell (TNC) dose per /kg recipient body weight. However, the limited number of Haematopoietic Stem Cells in UCB compared to bone marrow leads to delayed engraftment, prolonged hospitalization and increased risk of graft failure and early mortality. Various approaches have been examined to overcome these limitations including HSC expansion, double CBU graft, direct intra-bone transplant of UCB and the use of non-myeloablative UCB transplantation in older patients and those with co-morbidities. Factors shown to influence survival rate include the direction of HLA mismatch, donor exposure to non-inherited maternal HLA antigens, donor Killer-immunoglobulin receptor (KIR) ligand matching and ABO major incompatibility. The demand for CBUs with high TNC dose is selectively depleting the frozen reserves. The challenge for CBBs will be to enhance the representation of donors from ethnic minority groups and thus HLA diversity and to improve the quality of stored CBUs with respect to TNC dose.A118. NEONATAL HAEMATOLOGY

R Rodwell

Haematology Molecular Genetics Division, Mater Pathology and Queensland Cord Blood Bank At The Mater, Mater Health Services, South Brisbane, QLD 4101

[email protected] The diagnosis of haematologic abnormalities in

the neonatal period may be difficult as both WBC and RBC kinetics may be influenced by peripartum factors and the rapid physiologic changes associated with the transition from intra-uterine to extra-uterine life. The newborn infant has a naive immune system and is immunocompromised compared to adults and in the first days of life is more susceptible to infection than at any other time in life. Haematologic changes are commonly noted with infections but may also occur related to developmental processes, intra-partum factors, maternal/foetal interactions, less frequently with genetic disorders and rarely with leukaemia or bone marrow failure syndromes.

The seminar will include selected topics with illustrative case histories. The introduction to Neonatal Haematology will cover haemopoiesis in the foetus and the influence of perinatal factors and the maternal-foetal relationship, reference values, risk factors for infection, the haematologic changes associated with infection and their value in the early diagnosis of neonatal sepsis. A diagnostic approach to WBC disorders and RBC disorders in the neonate will be presented. These will be followed by a presentation on the diagnosis, significance and management of T Cryptantigen Activation and Polyagglunatibility in the neonate.


Understanding of the unique aspects of the peri-natal period and maternal/foetal interactions and the implications for the foetus and neonate in combination with a systematic approach assists in the diagnosis of haematologic problems in the neonate. A119. MOLECULAR MARKERS AND THEIR PROGNOSTIC SIGNFICANCE IN ACUTE MYELOID LEUKAEMIA WITH NORMAL CYTOGENETICS

G Romeo

Molecular Haematology Laboratory, PathWest Laboratory Medicine WA, Royal Perth Hospital, Perth, WA

[email protected] myeloid leukaemia (AML) represents a group

of heterogeneous haematopoietic stem cell malignancies, characterised by the accumulation of acquired genetic alterations in clonal myeloid blast cells that alter normal mechanisms of proliferation and differentiation. Detecting structural and numeric cytogenetic abnormalities is not only essential for disease diagnosis and sub classification but the karyotype also constitutes an important independent prognostic factor for the attainment of complete remission and overall survival and helps form the basis for the selection of therapy. In approximately 45% of de novo adult AML however, no detectable chromosomal abnormality can be found on standard cytogenetic analysis. This subgroup has highly variable outcomes and is usually classified to an intermediate-risk prognostic category with 5 year survival rates between 24 – 42%.

In the last decade, somatically acquired gene mutations as well as deregulated expression of genes that contribute to cell proliferation, myeloid differentiation and regulation of cell cycle and apoptosis have been the focus of molecular analysis in AML. The identification of these prognostic and predictive molecular markers in normal karyotype AML has increased our understanding of leukemogenesis and lead to molecular based risk assessment and treatment stratification, as well as novel risk adapted therapies thereby potentially optimising the treatment patients receive.

In this presentation, mutations in NPM1, FLT3, CEBPA and MLL genes; as well as alterations in the expression levels of WT1, BAALC and ERG and their significance in normal karyotype AML are reviewed. Our experience with the routine laboratory detection of NPM1 and FLT3 gene mutations, including a few patient case studies will also be presented.

A120. CHALLENGES FOR CYTOLOGY PROFICIENCY TESTING: ARE CYTOLOGISTS READY FOR VIRTUAL MICROSCOPY?

J Ross

RCPA Cytopathology QAP, Kelvin Grove, Brisbane, QLD 4059

[email protected] RCPA Cytopathology QAP encompasses both

gynaecological and non gynaecological cytology and provides testing material to more than 200 laboratories within Australia and overseas. Testing material comprises glass slide surveys, staining exercises and questionnaires on laboratory practice. Laboratories may enrol in any or all of four cytology modules: conventional gynaecological, liquid based gynaecological, general non-gynaecological and fine needle aspiration.

The provision of a program comprising solely of glass slides raises specific challenges for cytology proficiency testing. Gynaecological slides cannot be manufactured or purchased. Often the paucity of cellular material in non-gynaecological specimens means preparing sufficient slides is may not be possible. The Cytopathology QAP is entirely dependent on members of its advisory committee and other participants to donate suitable material for surveys. In recent years, the program has encountered some difficulty in obtaining enough high quality cases with sufficient slides to ensure the tinely distribution of both gynaecological and non gynaecological slide surveys.

The use of Virtual Microscopy in proficiency testing is not new but presents some specific challenges to cytology proficiency testing. In contrast to histological sections or haematological smears, the combination of a high degree of depth of focus and the presence of hyperchromatic crowded epithelial cells in cytology preparations can make digitizing the whole slide difficult. The challenge to reliably create a virtual proficiency test for Cytopathology that closely mirrors the actual work environment will be discussed as well as alternative strategies currently being considered for the use of virtual microscopy in the Cytopathology QAP.


A121. A BIOCHEMICAL MARKER MODEL PREDICTS LIVER FIBROSIS IN VIRAL HEPATITIS B AND C AND FATTY LIVER DISEASE

R Rossi,1 LA Adams,2 M Bulsara,3 GP Jeffrey2 1Biochemistry, PathWest Laboratory Medicine WA, Queen Elizabeth II Medical Centre, Nedlands, WA 69092Hepatology, Sir Charles Gairdner Hospital, Nedlands, WA 69093University of Notre Dame, Fremantle, WA 6959

IntroductionCommon liver diseases such as chronic viral hepatitis

types B (HBV) and C (HCV) and non-alcoholic fatty liver disease (NAFLD) often require staging of liver fibrosis to guide treatment decisions. Currently, staging involves an invasive liver biopsy. Hepascore is a model which uses four serum biochemical markers to calculate a composite score which is predictive of liver fibrosis. Methods

HBV (194 patients) and HCV (104 patients) were confirmed by virology testing and NAFLD (119 patients) by liver biopsy. All patients had liver biopsies staged for fibrosis and significant fibrosis was defined as stages F2 to F4. The prevalences of significant fibrosis were 42% in HBV and NAFLD patients and 57% in HCV patients. Serum taken at liver biopsy was analysed for bilirubin, γ-glutamyl-transferase, hyaluronic acid and α2-macroglobulin. Hepascore (range 0.0–1.0) was calculated and a 0.50 cut-off applied as follows: scores ≥0.50 indicated significant fibrosis was present and scores <0.50 indicated significant fibrosis was absent. Results

In both HCV and NAFLD patients, a Hepascore ≥0.50 had a positive predictive value of 88% for significant fibrosis. Hepascores <0.50 were less accurate for excluding fibrosis; the negative predictive values were 65% for HCV and 75% for NAFLD. In HBV patients, Hepascores <0.50 excluded fibrosis with a negative predictive value of 83%, whereas the positive predictive value of a score ≥0.50 was 68%. Conclusions

Hepascore had a very good positive predictive value for predicting the presence of significant hepatic fibrosis in NAFLD and HCV patients. In HBV patients it was more effective for the exclusion of fibrosis. A122. THE ROLE OF PATHOLOGY IN ASSISTING PATIENT CLINICAL MANAGEMENT

C Saunders

Winthrop Professor, School of Surgery, QEII Medical Centre, Perth WA 6009

Conventional histopathology continues to provide the mainstay of prognostic information which guides the clinical management of cancer. Patient characteristics and

service availability, however, play an often surprisingly large role in treatment decisions.

Recent advances in molecular pathology are now opening exciting new diagnostic and treatment avenues.

This paper will explore new molecular pathological insights into breast cancer and how these are beginning to reach “the bedside”. This has already led to significant improvements in survival for a small minority of patients with breast cancer, has opened the door to new treatments which may be significant for a majority of patients with breast cancer, but come with high costs which may not be possible for our community to pay.

New ways to investigate these treatments will be discussed, which rely implicitly a multidisciplinary approach to research and treatment including pathology and surgery.A123. NOTCH1 ACTIVATING MUTATIONS ARE CORRELATED WITH

INCREASED SENSITIVITY TO 6-MERCAPTOPURINE IN T-CELL ACUTE

LYMPHOBLASTIC LEUKAEMIA CELL LINES

AD Schoof,1,4 J Ford,1 JD Jago,2,3 CH Cole,4,5 AH Beesley,1 NG Gottardo,1,5 UR Kees1

1Division of Children's Leukaemia and Cancer Research, Telethon Institute for Child Health Research and Centre for Child Health Research, The Universityof Western Australia, Perth, WA2School of Biomedical Sciences, Curtin University of Technology, Perth, WA3Western Australian Biomedical Research Institute, Curtin Health Innovation Research Institute, Curtin University of Technology, Perth, WA4School of Paediatrics and Child Health, The University of Western Australia,Perth, WA5Department of Paediatric Oncology/Haematology, Princess MargaretHospital for Children, Perth, WA

[email protected]

IntroductionAcute lymphoblastic leukaemia (ALL) is the most

common cancer in children, with T-cell ALL (T-ALL) occurring in about 15% of cases. Using current protocols 5-year event free survival rates of over 70% have been achieved. However, many of the patients that relapse become resistant to the current chemotherapeutic drugs and a cure remains hard to achieve. NOTCHI, a critical developmental gene, has been implicated in T-cell leukaemogenesis with over 52% of T-ALL patient specimens containing NOTCHI activating mutations. This project examined whether NOTCHI mutations affected the drug sensitivity profiles of the T-ALL cell lines.


MethodsThe drug resistance profiles for standard

chemotherapeutic agents used in the clinic to treat T-ALL were previously measured using a cell survival assay (BJC 2006, 95:1537). For the detection of NOTCH1 activating mutations, DNA was extracted from 12 cell lines. Exons of NOTCH1 known to harbour mutations were amplified using polymerase chain reaction, and sequenced. Differences in the drug resistance between NOTCHI mutated and wild-type cells were assessed using a hierarchical statistical model.Results

Activating mutations of the NOTCHI gene were identified in 7 of 12 cell lines (58%). Correlation of these results with the drug resistance profiles revealed that cell lines with NOTCHI activating mutations were significantly more susceptible to 6-mercaptopurine than cell lines without NOTCHI activating mutations (P=0.015).Conclusions

These results have potentially important implications for the development of improved risk stratification and individualised treatment strategies based on the underlying biology of patient's leukaemic blasts.A124. ANALYITCAL ISSUES: NEW VENTURES IN 2010

S Scott

RCPA Chemical Pathology Quality Assurance Programs, Adelaide SA 5000

[email protected] RCPA Chemical Pathology QAP is continually

developing and improving the current programs being offered and investigating the possibility of offering new programs to participants. The QAP aims to keep the participants informed and involved in this process.

This session will discuss three new initiatives of the RCPA Chemical Pathology QAP in 2010. Firstly a detailed overview of the On-site Urine Toxicology Screening Program for qualitative screening of drugs of abuse will be undertaken. This program is being offered to laboratories and onsite screening devices and includes 6 drugs of abuse. A summary of the results to date and the report interpretation will be included. A second new program for 2010, Total Bile Acids, will be reviewed and the issues that have arisen in 2010 will be discussed. This year also saw the inclusion of Vitamin C in the Vitamins Program which will be summarised.

A125. ANALYTICAL ISSUES: QAP REPORT INTERPRETATION

S Scott

RCPA Chemical Pathology Quality Assurance Programs, Adelaide SA 5000

[email protected] session will provide an overview of the RCPA

Chemical Pathology QAP reporting system, discussing report interpretation for effective review of the QAP reports by participants. This session will specifically cover the Interim and End-of-Cycle Reports and time permitting the KPI Report Interpretation. The aim of this summary is to provide a greater understanding of the information available in the reports for peer review and laboratory performance so that effective troubleshooting can be undertaken by laboratories if and when required.A126. PoCT MODELS FOR RURAL AND REMOTE AUSTRALASIA

MDS Shephard

Community Point-of-Care Services, Flinders University Rural Clinical School, Bedford Park, SA 5042

[email protected]

IntroductionPoint-of-care testing (PoCT) provides a practical

option for the provision of pathology services in rural and remote communities, as tests are conducted on-site on a small blood sample, results are available in less than 15 minutes, and clinical management can be initiated ‘on the spot’. Methods

The Community Point-of-Care Services unit at Flinders University has introduced innovative education, training and competency, quality management and support service frameworks to underpin and implement a range of PoCT models using a variety of different devices for the prevention and management of chronic and acute diseases in Indigenous and non-Indigenous rural and remote community settings across Australasia. These include the QAAMS Program (involving 115 Aboriginal medical services), the Diabetes Management Along the Mallee Track Program (at the rural town of Ouyen, Victoria), the Northern Territory i-STAT POCT Program (involving 33 remote health services), the KEY Study (with Kidney Health Australia) and the Ngati Porou Hauora Warfarin Management Program (in 6 Maori health services, New Zealand). Results

Analytical quality has consistently met profession based analytical goals and/or state of the art laboratory performance across these models. Clinical effectiveness has been proven using case studies, statistically significant improvements in clinical outcome measures (eg glycaemic


control, time in target range, changes in clinical categories), stabilisation of acute conditions and reduction in medical retrievals. Community satisfaction with PoCT has been validated using qualitative surveys of device operators and patients. Partnerships with Governments, professional organisations and community health services have been pivotal to success and sustainability.Conclusions

There is a strong evidence base that PoCT has facilitated community engagement, enhanced service delivery, and improved patient outcomes in rural and remote Australasia.A127. TWIN SPECIFIC MEDIANS IN FIRST TRIMESTER PREGANCIES

R Sinnadurai, JM Morris, V Tasevski

Fetal Maternal Medicine, (PaLMS) Royal North Shore Hospital, St Leonards, NSW 2065

[email protected]

IntroductionFirst trimester screening involves measuring nuchal

translucency (ultrasound), free beta human chorionic gonadotropin (Free βhCG) and pregnancy-associated plasma protein A (PAPP-A). Biochemical data is corrected for gestation and weight to produce Multiple of Median (MoM) using specific populations. The aims of this study were (a) determine twin specific medians and compare them to singleton pregnancies and (b) determine how twin specific medians in this population compared to published data.Methods

In the period 25/10/2005 to 30/12/2009, 283 twin pregnancies and 45913 singleton pregnancies were measured for Free βhCG and PAPP-A using immunoassay (Siemens Immulite 2000). Gestation medians were calculated and compared at each week (10–14) for twin and singletons pregnancies. This data was used to derive the twin specific regression equations and then MoMs calculated. This MoM data was then compared to published studies. Results

Serum concentrations of Free βhCG and PAPP-A were higher in twin compared to singleton pregnancies. Median Free βhCG concentrations were 87.0, 77.6, 69.6 and 64.6 in twin and 52.6, 45.1, 38.2 and 32.3 IU/L in singleton pregnancies at 10, 11,12 and 13 weeks whilst median PAPP-A concentrations were 1.90, 2.65, 3.82 and 7.64 in twin and 0.86, 1.33, 1.93, 2.82 IU/L in singleton pregnancies at 10,11, 12 and 13 weeks respectively. MoMs calculated for both markers using the derived equations correlated well compared to published studies using different twin populations.

ConclusionsFree βhCG and PAPP-A concentrations in twins

were higher compared to singletons pregnancies. Derived equation Free βhCG and PAPP-A MoM data correlated well with published studies. Twin specific regression equations developed in our population will be used for future calculations of individual MoM data.A128. POINT OF CARE TESTING IN MICROBIOLOGY: ACCESSIBILITY AND QUALITY?

DW Smith Division of Microbiology and Infectious Diseases,

PathWest Laboratory Medicine WA; School of Biomedical, Biomolecular, and Chemical Sciences; and School of Pathology and Laboratory Medicine, University of Western Australia; Division of Health Sciences, Curtin University of Technology

Point of care (POC) testing has attracted growing interest, particularly where early results may assist in patient, infection control and/or public health management of infectious diseases or in settings without access to other tests. POC tests are currently available for detection of a number of viral antibodies or antigens, including HIV, dengue, rotavirus, influenza and RSV. POC test for dengue antibody and antigen, rotavirus antigen tests and influenza antigen tests have found applications, especially for laboratories lacking access to PCR tests. HIV antibody detection using POC assays has proven useful overseas to extend testing in groups that are unlikely to access conventional tests. However, with few exceptions, these do not perform as well as laboratory-based tests, and this must be taken into account in the application of the tests and the interpretation of results. Also, if performed outside an accredited laboratory quality management system, then there is more concern about the accuracy of the results. Nevertheless, they will become an increasing part of medical practice, and it is important that laboratories participate in the appropriate use of these assays.A129. LYMPHOMA PATHOLOGY: THE ROLE OF THE HISTOPATHOLOGY LABORATORY.

D Spagnolo

PathWest Laboratory Medicine WA, Nedlands, Western Australia

[email protected] lymphomas, while not having the high

public profile of the more common malignancies such as breast, prostate and colorectal carcinomas, nevertheless are the 5th most common malignancy in our community and are a cause of significant morbidity and mortality. Commensurate with the explosion in knowledge in the fields of lymphocyte ontogeny and biology, there has been in the last quarter century a paradigm shift in the approach to lymphoma diagnosis and classification. Lymphomas are


clinically, biologically and pathologically heterogeneous. At least 45 different lymphoma (disease) entities are recognised in the most recent WHO classification scheme (2008), with further multiple subtypes of some categories. Lymphomas are now defined by a combination of their clinical, histopathological, immunophenotypic, cytogenetic and molecular features. While the approach to diagnosis has by necessity become a multiparametric one involving several diagnostic modalities and laboratories, the histopathology laboratory retains its key, pivotal role in diagnosis. Accurate diagnosis begins with the appropriate handling of fresh diagnostic tissue or fluid samples by the pathologist and scientist in the Anatomical Pathology laboratory. Decisions are made on how best to triage material to other key laboratories to perform ancillary studies, based on the amount of tissue or fluid available. Despite the sophisticated technological and biological advances made in the field of lymphoma diagnosis, the production of a high quality haematoxylin and eosin stained section remains the "gold standard" in diagnosis, and takes precedence over all other diagnostic modalities that may be used to arrive at an accurate diagnosis. Highly skilled scientists dedicated to producing excellent sections are key in the diagnostic process. As important are the skilled scientists in the immunohistochemistry, flow cytometry, cytogenetics and molecular laboratories involved in clonality assays. Collectively, this pathologist/scientist partnership is an indispensable unit to meet the exacting standards and mimimal datasets required for diagnosis and reporting now mandated by peak national bodies such as the RCPA. A130. UPDATE ON HEPATITS C

DJ Speers

Head, Department of Microbiology, PathWest Laboratory Medicine, Nedlands

Infectious Diseases Physician, Sir Charles Gairdner Hospital

Clinical Senior Lecturer, School of Medicine and Pharmacology, University of Western Australia

Hepatitis C is one of the global chronic diseases that afflicts developed and third world countries alike. Thousands of new cases are diagnosed in Australia each year and the majority become carriers, of which some will develop chronic liver disease. Hepatitis C is now the commonest indication for liver transplantation in Australia. The lack of symptoms from infection until chronic liver disease ensues makes laboratory diagnosis critical for timely counselling and treatment. With a combination of under-utilisation of diagnostic testing and current therapies only being available to a selected group of hepatitis C sufferers the hepatitis C epidemic will continue into the future.

Topics to be discussed will be the epidemiology, clinical history, diagnosis and treatments for hepatitis C.A131. DIAGNOSIS OF INSIGHT AND JUDGMENT IN DEMENTIA

S Starkstein,1 Simone Brockman,1 David Bruce,2

1School of Psychiatry, University of Western Australia, WA 69592School of Medicine, University of Western Australia, WA 6959

[email protected]

IntroductionThe loss of decision-making capacity is an inevitable

consequence of Alzheimer’s disease (AD), and many patients have poor insight into their functional limitations and behavioural changes. The lack of a reliable and valid instrument to assess deficits of insight and judgment is one of the main problems in the routine clinical care of AD patients. We have designed the Structured Interview for Insight and Judgment in Dementia (SIJID) for the overall assessment of insight and judgment in AD. We herewith present the main clinical correlates of the instrument.Methods

A consecutive series of 94 patients with a diagnosis of AD assessed at the Memory Clinic at Fremantle Hospital and their respective caregivers participated in the study. All patients were assessed with the SIJID, a semi-structured interview that consists of three modules. Module A assesses insight and included questions about current physical, intellectual, emotional, and behavioural problems. Module B assesses judgment and includes questions about performance on basic and instrumental activities of daily living. Finally, Module C assess competency and includes the Dangerous Behaviours Checklist.Results

The SIJID showed high reliability and internal consistency. Based on the SIJID algorithm, 21% of the 94 patients met criteria for no risk, 54% for minor risk, 6% for major risk, and 19% for extreme risk. The frequency of anosognosia for patients with no or minor risk was 17% as compared to 47% for patients with major or extreme risk (p<0.05). Poor insight was significantly associated with more hours of supervision, and higher scores on both the Caregiver Strain Index and the Zarit Burden Scale for caregivers.Conclusions

Our study demonstrates that the SIJID is a reliable and valid instrument to measure deficits of insight and judgment in AD. It also provides important information related to risk for patients and strain and burden in caregivers.


A132. POLYCYSTIC OVARY SYNDROME

BGA Stuckey

Keogh Institute for Medical Research, Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital; School of Medicine and Pharmacology, University of Western Australia, Nedlands, WA

Polycystic ovary syndrome (PCOS) is the most common form of endocrine disorder in premenopausal women. Reported prevalence of PCOS among women of reproductive age varies according to the mode of diagnosis and is estimated to be between 5 and 18%. The diagnostic hallmarks are hyperandrogenism and ovulatory dysfunction leading to hirsutism, acne, male pattern alopecia and infertility. The diagnostic criteria for PCOS are broadly inclusive and there are undoubtedly subsets of PCOS with different pathophysiology. However, insulin resistance and subsequent hyperinsulinaemia are thought to be central to the pathophysiology in the majority of PCOS with high circulating insulin amplifying ovarian androgen production via insulin receptors on theca cells and increases bioavailable testosterone by suppression of SHBG. There is a high prevalence of obesity, dyslipidaemia, glucose intolerance and diabetes in women with PCOS and women with PCOS have a higher prevalence of the metabolic syndrome compared with age-matched population, implying increased cardiovascular risk. No longterm studies, using accepted diagnostic criteria, have been done to confirm this prediction.

Nevertheless, there have been many studies in PCOS - biochemical, functional and structural - identifying an increased prevalence of conventional and non-conventional cardiovascular risk markers, impaired endothelial and vascular function and structural changes in arterial walls compared with controls. Lifestyle modification, weight control and exercise and insulin sensitisers have been demonstrated to ameliorate hyperandrogenism and menstrual irregularity. More importantly, these interventions are likely to reduce the cardiometabolic consequences of the syndrome. A133. MESENCHYMAL STROMAL CELLS: AN EMERGING CELL THERAPY FOR APPLICATION IN THE TRANSPLANT AND IMMUNE DISORDER SETTING

M Sturm, K Shaw, J Fogarty, R Herrmann

Cell & Tissue Therapies WA (CTTWA), Royal Perth Hospital, Perth, WA 6000

[email protected]

IntroductionAn exciting advancement in the treatment of immune

based disorders is the cellular therapy, mesenchymal stromal cells (MSC). These cells can be isolated from various tissues, including bone marrow, have an extensive proliferative capacity, are capable of differentiating down multiple lineages into different tissue types and

are considered to play a role in tissue regeneration and repair. MSC also have immunosuppressive and immunoregulatory capabilities, making possible the manipulation of immune responses in various clinical conditions. MSC are not naturally immunogenic, do not stimulate alloreactivity and escape lysis by T cells and NK cells, hence, are universal donor cells and can be used for transplantation without a major risk of rejection. Our centre has several clinical trials underway, assessing the safety and efficacy of MSC therapy in clinical conditions of immune dysregulation.Methods

The three MSC trials, approved by Hospital Ethics Committees and registered with the Australian Clinical Trials Registry, are a Phase I trial in steroid refractory graft-versus host disease (GVHD) associated with allogeneic haemopoietic stem cell transplantation, a Phase I trial in obliterative bronchiolitis associated with lung transplantation and a Phase I/II trial in steroid refractory Crohn’s disease. MSC are manufactured in CTTWA under GMP. Cells are culture expanded from the bone marrow of healthy donors. Approximately 2.0 x 106 MSC/kg patient weight are administered according to trial protocols or given as required.Results

To date, 19 patients have been accrued to GVHD study, 2 to the OB study and 3 to the Crohn’s study. More than 110 infusions have taken place with no adverse safety effects noted. All GVHD patients, both acute and chronic, have responded to MSC infusion with a partial or complete response of clinical symptoms. An improved overall survival has been demonstrated for patients with acute GVHD. Accruement for the other trials is in early phase and of those enrolled, treatment is still in progress or clinical responses are being evaluated.Conclusions

The safety of MSC administration and efficacy in ameliorating clinical symptoms of GVHD has been demonstrated. Outcomes for the other two clinical conditions are keenly anticipated. MSC are a potential therapy in clinical settings for which limited treatment options are available.A134. GUIDELINES FOR LUPUS ANTICOAGULANT TESTING

J Thom

Haematology Department, Royal Perth Hospital, Perth WA 6000

First described in 1952, lupus anticoagulants (LA) are a heterogeneous group of antibodies directed against phospholipids bound to proteins such as β2GP-1 or prothrombin. Although they prolong in vitro coagulation screening tests they are paradoxically associated with a varying degree of thrombotic risk. However they are


often an incidental laboratory finding of no clinical significance.

Accurate and sensitive laboratory diagnosis is important for two main reasons. Firstly to differentiate lupus anticoagulant from other inhibitors such as heparin and specific coagulation factor inhibitors. Secondly the clinical consequences can be severe, including venous and arterial thrombosis and recurrent pregnancy loss.

In the laboratory investigation of LA it is important to quantitate anti-phospholipid antibodies by ELISA as well as demonstrate circulating antibody using clotting tests. It is also necessary to show failure of a normal plasma mix to correct the clotting defect and the ability of excess phospholipid to overcome it. Over the years there has been a proliferation of tests, debate about their relative sensitivity and specificity, and confusion over how to interpret a panel of tests some of which may be positive and some negative.

The release of ISTH guidelines in 1995 helped enormously to introduce some standardisation. These guidelines were updated last year. This presentation will review LA testing, examine the latest guidelines, consider those patients with conflicting results and explore the tension between the theoretical ideal and day to day laboratory practice.A135. PRENATAL RHESUS D DETECTION AND GENDER DETERMINATION USING CELL FREE FETAL DNA IN MATERNAL CIRCULATION.

R Vanhaeften,1 G Romeo,1 J Dickinson,2 T Warner,2 E Edkins,1 M Higgins,1 A le Viellez,1 J Ivey,1

P Cannell1

1PathWest Laboratory Medicine;2King Edward Memorial Hospital.

[email protected]

IntroductionThe presence of cell free fetal DNA (CFF DNA) in

the maternal circulation was first reported by Dennis Lo and colleagues in 1997. It has since become an important target for prenatal genetic diagnostics, avoiding invasive amniocentesis or chorionic villus sampling and the associated risk of miscarriage. Detection of a paternally inherited Rhesus D (RhD) gene was among the first reported uses and is now routinely implemented in the UK and Europe. Its prime benefit is identification of pregnancies at risk of Haemolytic Disease of the Fetus and Newborn (HDFN). Gender determination using Y chromosome PCR targets is useful both to confirm the presence of fetal DNA and determine inheritance risk in sex-linked genetic disorders. Methods

Twelve millilitres of EDTA blood was collected from 29 RhD negative pregnant women ranging from 10-19 weeks gestation, with a median of 12 weeks. DNA was extracted from 2mL plasma using the Qiagen QIAamp

Circulating Nucleic Acid (CNA) kit. Six Taqman PCR assays were performed for exons 4, 5, and 7 of the RhD gene, the SRY gene for gender determination, and the RASSF1A and B-actin genes to confirm the presence of fetal DNA.Results

The baby’s gender was available in 29 of 29 cases (15 male, 14 female) and blood group in 27 of 29 cases (15 RhD positive, 12 RhD negative). RhD and gender genotypes were performed blinded to phenotype and were 100% concordant. Fetal DNA was detectable in all samples by RASSF1A PCR. The QIAamp CNA kit showed a greater than 5 fold recovery of fetal DNA than a modified QIAamp blood DNA mini kit protocol, even accounting for the higher starting volume.Conclusions

Prenatal RhD status and gender determination was 100% accurate using our method. The technique is relatively expensive and labour intensive but will be a useful tool for identifying high-risk pregnancies.A136. DEVELOPMENTS IN OSTEOPOROSIS

S Vasikaran

PathWest Laboratory Medicine, Royal Perth Hospital, Perth, WA 6000

[email protected] is a major clinical problem in

Australia and worldwide, and its prevalence is increasing exponentially. Fracture is the important clinical outcome of osteoporosis; the lifetime risk of sustaining an osteoporotic fracture for a 50 year old Australian woman is >40%. While Bone density measurement is used for diagnosing osteoporosis, age and other risk factors also significantly impact on, and are used in, fracture risk calculation in individual patients. The 10 year absolute fracture risk calculation in individual patients, incorporating all identified risk factors, is a useful tool for targeting those at high risk of developing osteoporotic fractures in order to make cost effective treatment decisions.

The availability of several bone turnover markers in urine and in serum has led to different markers being used in different studies. There is currently inadequate data on any bone turnover marker for their inclusion in fracture risk calculation; however, they are useful in monitoring therapy. There is a need for an internationally agreed reference bone marker each for bone formation and for bone resorption for use in clinical trials. This would help accumulate adequate data on the designated reference bone markers in prospective studies for them to be then included in fracture risk calculation algorithms. IFCC is working towards this goal.

Apart from the established antiresorptive agents such as bisphosphonates which are widely used for treatment of osteoporosis, the recent availability of anabolic agents such


as injected PTH analogue (Teriparatide) has broadened choice in treatment. In addition, the elucidation of molecular pathways that control bone remodelling and influence bone loss has led to development of novel treatments that selectively target those pathways with precision, and these agents are now becoming available for effective use in treatment of osteoporosis.A137. CORTISOL: ACTH RATIO IN DIAGNOSIS OF PRIMARY HYPOADRENALISM

S Vasikaran,2 MKV Lee,1 D Prentice1 1Department of Medicine,2 PathWest Laboratory Medicine, Royal Perth Hospital, Perth, WA 6000

[email protected]

IntroductionThe short Synacthen© test (SST) is used for assessing

the integrity of the hypothalamic-pituitary-adrenal axis. Measuring basal serum cortisol and adrenocorticotrophin hormone (ACTH) simultaneously and using the cortisol:ACTH ratio as a screening test may be a more convenient alternative to performing a SST. Our aim was to assess the reliability of the cortisol:ACTH ratio for screening for primary hypoadrenalism.Methods

We performed a retrospective review of patients who had a SST together with a simultaneous baseline ACTH performed from April 2006 to July 2009. Their baseline cortisol:ACTH ratio was calculated and their final diagnosis was determined by examining their clinical notes. We also retrospectively reviewed the pre-treatment cortisol:ACTH ratio of 10 patients with known primary hypoadrenalism to validate its reliability.Results

Eighty-five patients were included. Five patients had primary hypoadrenalism, 26 patients had secondary hypoadrenalism and 54 patients had normal adrenal function. All the patients with primary hypoadrenalism had a cortisol:ACTH ratio <25. All 54 patients with normal adrenal function had a cortisol:ACTH ratio >25. Of the 26 patients with secondary hypoadrenalism 17 had a Cortisol:ACTH ratio >25 and nine had a ratio <25. Therefore, a cortisol:ACTH ratio <25 had a 100% sensitivity and 89% specificity for the diagnosis of primary hypoadrenalism in this population. All 10 patients with known primary hypoadrenalism also had a pre-treatment cortisol:ACTH ratio <25.Conclusions

Cortisol:ACTH ratio >25 reliably excluded primary hypoadrenalism in our study population. Cortisol:ACTH ratio <25 very likely indicates primary hypoadrenalism although secondary hypoadrenalism can not be excluded. Larger studies are needed to confirm whether cortisol:ACTH ratio is sufficiently reliable to replace SST for the diagnosis of primary hypoadrenalism.

A138. THE USE OF POINT CARE TECHNOLOGY WHAT IT MEANS TO THE PATIENT.

M Walters

Anticoagulation Clinical Nurse Consultant, Sir Charles Gardiner Hospital, Nedland, Perth, WA

[email protected] Technology has meant changes in the way health

care in delivered. One of the areas of growth has been in the use of Point of care technology to aid in the management of patient care.

The talk will describe the reasons why POC INR testing has been well received by patients. This talk will focus on the patient perspective of POC testing in relationship to INR monitoring and warfarin dosing.

POC INR machines provide another aspect to patient care delivery. A139. TUBERCULOSIS

JA Waring

Medical Director, Western Australian TB Control Program, Perth Chest Clinic, 17 Murray St, Perth WA 6000.

Tuberculosis (TB) remains a major and increasing health problem globally. TB is well controlled in Australia, but Australia’s region, and the countries from which we receive an increasing proportion of our migrants, have the highest TB burden and risk. Ten year targets for improved TB control were established in 2005 as a United Nations’ Millennium Goal. Halfway through some limited progress has been made.

A key strategy is to improved case finding by the development of faster and more sensitive diagnostic tests. TB culture techniques have improved, but are not routinely available in many TB endemic areas. Nucleic acid amplification tests are useful in species confirmation, but remain an unrealised area of promise as a primary TB test. Many different immunologically based blood tests have not proved useful in active TB diagnosis.

There have been essentially no new TB drugs for 40 years. While existing drug regimens are highly effective in the majority of cases, development of new agents to shorten or simplify the treatment course is needed. Strict case management remains the cornerstone of successful TB treatment and protection against worsening drug resistance.

BCG is one of the oldest vaccines, but has a limited role in global TB control. There are at least 6 new TB vaccine candidates that have completed at least phase 1 clinical trials, and these may offer a new option in TB control in the next 5-10 years.


A140. CEREBRAL MALARIA

R Wells

Core Haematology Pathology Queensland Central Laboratory, Royal Brisbane and Women’s Hospital, Herston, QLD

IntroductionThis presentation will provide an overview of

cerebral malaria and two case studies that demonstrate the severity of this infection. Cerebral malaria is the best known severe manifestation of one of the five species of Plasmodium that infect humans – P. falciparum. It mainly affects children aged 2 to 6 years in Africa and adults in south-east Asia and leads to altered consciousness, seizures, coma and death. Method

The first case study is of an aid worker, who had returned from Tanzania with a prior history of contracting malaria there five weeks earlier. She had not taken her full course of treatment and consequently presented with cerebral malaria. She survived but had a long stay in hospital with many complications. The second case is a PNG national who contracted malaria who did not have access to treatment and consequently succumbed to the infection.Conclusions

Cerebral malaria is universally fatal if untreated and is associated with 20% mortality even in treated patients. The risk factors for CM include age, pregnancy, poor nutritional status, genetic susceptibility, transmission intensity, and splenectomy. Non-immune adults are also more susceptible.A141. IMMUNOLOGY QAP AND THE PARAPROTEIN MODULE

L Wheatland

RCPA QAP Immunology, Flinders Medical Centre, Bedford Park, SA 5042

[email protected] RCPA Immunology QAP program provides

accredited external quality assurance in Clinical Immunology to laboratories by providing patient specimens with clinical notes and a wide range of analytes relevant to participants. This presentation will focus on the Paraprotein Module which provides testing for Monoclonal specificities in both urine and serum samples, and serum free light chain testing in serum samples. Feedback from participants on any aspect of the QAP will be welcome.

A142. A HEALTHIER FUTURE FOR ALL AUSTRALIANS”: INTEGRATING LABORATORY MEDICINE INTO THE VISION

V Williams

Western Australian Biomedical Research Institute (School of Biomedical Sciences), within the Curtin Health Innovation Research Institute, Curtin University of Technology. GPO Box U1987 Perth, WA

[email protected] Strategies to address the future health of Australians

and the sustainability of the health professional work force have been the subject of recent Government funded reports. These reports acknowledge the current and future shortfall in the number of active workers in professional groups required to address increasing health service demand. Incentives to address recruitment, training and retention of health workers, in particular medical practitioners, nurses and other registered allied professional groups have been activated or proposed. To ensure the success of the health service reforms the same attention should extend to allied health professionals who are not bound by registration legislation and whose activities are essential to the quality of health care in Australia. Pathology testing underpins Australians’ healthcare being the way most diagnoses are confirmed and being integral to the safe management of most diseases. Recent research into the composition of the Pathology workforce has confirmed that the demand for medical scientists will exceed supply in the near future. Drivers for the undersupply of medical scientists are a combination of demographic, technological and regulatory processes. Pathology is the most highly regulated of the health professions however the pressure from these processes may change the position of the traditional laboratory. Innovations such as point of care testing, emerging applications in molecular pathology and convergence of diagnostic technologies will impact on traditional diagnostic testing but are unlikely to reduce demand for laboratory scientists. Purposeful and innovative action must be taken now by government, industry, the profession and secondary and tertiary education facilities to address the impending crisis.


A143. GOVERNMENT FUNDING OF PATHOLOGY SERVICES: A ROLE FOR EVIDENCE?

C Willis,1 A Watt,1,2 M Metz,3

A Elshaug,1,2 J Hiller1,2

1School of Population Health and Clinical Practice, University of Adelaide2Adelaide Health Technology Assessment3ClinPath Laboratories, Adelaide

[email protected]

IntroductionNewly introduced Federal initiatives, including the

MBS Quality Review Framework and Review of Funding Arrangements for Pathology Services, have highlighted the government’s intention to make explicit the role of ‘evidence’ in funding decisions of new and existing MBS items. This project explores how this policy context might impact existing pathology services such as vitamin B12 and folate tests. In accordance with the review frameworks, the diagnostic accuracy of these services will form a critical component of MBS assessment. Therefore, this study aimed to investigate the evidence base of the diagnostic accuracy of serum B12, serum folate and red cell folate tests through a systematic literature review.Methods

Based on a protocol, a standardised search strategy was applied to six databases. Primary studies and systematic reviews that met inclusion criteria were selected. Included studies underwent appropriate quality assessment and data extraction.Results

The search identified 57 articles comparing (any of ) serum B12, serum folate and red cell folate tests with a reference standard(s). Results demonstrated highly variable diagnostic accuracy for serum B12 and serum folate, and a limited evidence base for red cell folate tests. Extensive heterogeneity existed, particularly in test methods, threshold values, clinical indications and study quality. The discriminatory power of these tests is often low across various subgroups. Conclusions

Estimates of the diagnostic accuracy of serum B12, serum folate and red cell folate tests suggest these services could be candidates for assessment in the context of the Federal Quality Assessment framework. This work demonstrates the nuanced approach required for evaluating diagnostic tests in the context of public reimbursement.

A144. THE ROLE OF HLA AND KILLER CELL IMMUNOGLOBULIN-LIKE RECEPTORS (KIR) IN ALLOGENEIC NK CELL-BASED THERAPY FOR AML

C Witt

Dept Clinical Immunology, PathWest, Royal Perth Hospital, Perth, 6000, Western Australia

[email protected] haematopoietic stem cell transplantation

has been used for many years to treat acute myeloid leukaemia (AML). A donor T cell-mediated graft-versus-leukaemia (GVL) effect is an important factor in the success of allogeneic transplants although graft-versus-host (GVHD) disease has always been an attendant risk. Recently it has been demonstrated that particular kinds of HLA mismatch between donor and recipient results in an NK cell-mediated GVL effect providing the donor also has the appropriate NK cell KIR receptor gene. Importantly, alloreactive NK cells do not mediate GVHD. This has resulted in attempts to use stem cell grafts and, more recently, donor NK cell infusions without a prior stem cell graft, to treat AML patients. This presentation discusses the principles behind NK cell alloreactivity, the HLA and KIR gene typing required for a laboratory supporting such activities and the results of recent trials.A145. ETHICAL AND LEGAL CONSIDERATIONS IN MOLECULAR TESTING

N Zeps 1,2,3

1 St John of God Pathology, Subiaco WA 6008 2Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA 6009 3School of Surgery and School of Pathology and Laboratory Medicine, The University of Western Australia, Crawley WA 6009

[email protected] Modern molecular diagnostic tests are becoming

increasingly important for defining phenotypic changes that assist with making differential diagnoses. However, they also have the potential to reveal genetic variations in a person that, if present in the germline, create particular ethical and legal concerns. Questions such as whether a person should have to give consent before such testing is done or whether there is an obligation to pass on relevant findings to family members have provided considerable challenges to pathology services and regulatory bodies. This presentation will provide, with specific examples, some practical guidance on how to negotiate the federal and state laws as well as ensuring compliance with ethical guidelines. In addition it will highlight some of the new issues likely to arise in the near future with the advent of high throughput gene analysis coming online, and how the existing regulatory frameworks could easily accommodate such advances.


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P55 Botros M, Lu ZX, Sikaris KA

P56 Cluse ZN, Fudge AN, O’Loughlin PD, Whiting MJ

P57 Conradie J, Hadlow N, Wardrop R

P58 Galligan JP, McWhinney BC, Briscoe SE, Pretorius CJ

P59 Giannopoulos P, Jones GRD

P60 Ho S, Maguire R, Bell D, Gillett M, Corsbie S

P61 Jenkins N, Black M, Pasco J, Schneider HG

AIMS AACB COMBINED SCIENTIFIC MEETING

Perth 2010 25-29 October

POSTER ABSTRACTS PRESENTER INDEX


P62 Jones GRD, Nguyen L

P63 Lee K Tan K, Williams P

P64 Lu ZX, Sikaris KA

P65 Ridgwell M, Wood CCG, Ward P

P66 Ward P,Ridgwell M, Wood CCG

P67 Sikaris KA, Lu ZX, Briganti EM

P68 Tan K, J Tran J, Williams P

P69 Taranto M et al

P70 Tran J, Ray J, Gao K, Williams P, James M

P71 Wardrop R, Hadlow N

P72 Wardrop R, Grasko J, Hadlow N

P73 Hadlow N, Wardrop R, Tanner M

P74 Hadlow N, Wardrop R, Merton L

P75 Hadlow N, Varis R, Wardrop R

P76 Coelho M, Wardrop R, Hoad K, Hadlow N

P77 Whiting MJ, Wood S, Ewers C

P78 Whiting MJ

P79 Williams R, Bell DA, Musk AA, Lambert R, Glendenning P

P80 Ward P, Ridgwell M, Wood CCG

P81 Barron J, Ng C, Aspin L, Robinson L, Smith G

P82 Flatman R

P83 Higgins T, Stewart D, Rose B, Dayton J, Holmes D, Peralta J

P84 Livesey J, Dolamore B

P85 Louey W, Lu ZX, Sikaris KA

P86 Louey W, Lu ZX, Sikaris KA

P87 Reid E, Badrick T

P88 Ukich AW

P89 Matthews S, Adeli K, Jacobs E

P90 Milburn J, Badrick T

P91 Al-Boraich A, Gilmore G, Thom J, Baker RI

P92 Yong S, Haworth E, DeRosa L

P93 Orellana D, Kershaw GW

P94 Sargisson O, Howell Z

P95 Shi M, Tsai LY, Chen JH

P96 Newbound C, Finlayson J, Ghassemifar R, Holmes P, Figliomeni L,Pell N,Kersten M, Jennens M,Greenwood L,Beilby J

P97 Roche G, Pett M, Smith C

P98 Saunders K, Kidd T

P99 Woods AE, Logan JM

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P1. OPIATE GCMS PATTERN IN CLINICAL LABORATORY

ZX Lu,1,2 B Smirk,1 H Nguyen,1 J Calleja,1

KA Sikaris1

1Melbourne Pathology, Collingwood, Vic 3066 2Department of Medicine, Monash University, Clayton, Vic 3168

IntroductionOpiates are a class of drugs comprising both

prescribed (codeine containing medications) and illicit agents (heroin). Gas chromatography-mass spectrometry (GCMS) for opiates in urine is commonly performed to confirm heroin use for work safety or legal purposes or to monitor compliance during/after drug rehabilitation. Thus incorrect interpretation of the results has serious consequences. GCMS is designed to detect metabolites of heroin, namely 6-monoacetylmorphine (6-MAM), codeine and morphine. Presence of 6-MAM is diagnostic for heroin use, however, the urine needs to be collected within hours of heroin use as 6-MAM has a short half-life. Here, we examined the pattern of codeine to morphine ratio (Cod/Morph-ratio) from the people who were taking either panadeine or heroin.Methods

Over two years, 796 GCMS for opiates were performed. Medication list was obtained from the chain of custody declaration form. Overall, 153 people were reported to be taking codeine-containing medications alone – the ‘Panadeine group’; 40 people had detectable 6-MAM – the ‘Heroin group’. The GCMS cut-off: 300 µg/L for morphine or codeine each. Results

The median (25th to 75th percentile) Cod/Morph-ratio and the median (25th to 75th percentile) morphine were calculated based on the codeine cut-offs for each group. Results are below

Codeine (µg/L) 1-99 100-299 300-999 ≥1000

Heroin groupCod/morph ratio

0.0 (0.0-0.1)

0.1 (0.1-0.4)

0.1 (0.1-0.2)

0.2 (0.2-0.4)

Morphine (µg/L)

352 (176-1830)

1703 (773-2579)

3621 (2834-4385)

9908 (4238-16970)

Panadeine groupCod/morph ratio

0.3 (0.1-0.9)

0.9 (0.6-2.1)

2.0 (1.0-3.5)

3.4 (1.8-6.1)

Morphine (µg/L)

150 (64-243)

141 (66-190)

357 (178-621)

809 (478-2359)

ConclusionsThe overall results usually show a clear separation.

In the heroin group, the ratio was usually very low (<0.5). When codeine was >300 µg/L, the morphine level was very high (above 2800 µg/L). In the panadeine group, the ratio was typically >0.9 with the corresponding morphine

level commonly <800 µg/L. When the codeine level was >300 µg/L, the ratio is commonly >2.0. P2. HbA1C SURVEY RESULTS FROM THE WESTERN AUSTRALIA AACB QC SUBCOMMITTEE

E Byrnes,1 M Taranto2 and members of the AACB (WA Branch) QC Subcommittee1Biochemistry, PathWest, QEII Medical Centre, Nedlands, WA, 60092Biochemistry, PathWest, Fremantle Hospital, Fremantle, WA 6160

[email protected]

IntroductionHbA1c is widely accepted as requiring further

international standardisation and calibrator traceability to provide consistency in long-term monitoring of diabetic control. In 2009 the Western Australia (WA) QC Subcommittee surveyed methods across public and private pathology providers in WA using pooled patient samples.Methods

Seven linearly related EDTA preserved pooled whole blood samples were distributed to nine participating laboratories for duplicate HbA1c assay. Three commercial QC samples and two samples containing Hb variants (HbS and HbE) were included. Methods were either immunoassay (IA) (Roche Cobas Integra 800, n=4; Siemens Advia 1650, n=1; Siemens DCA Vantage, n=1) or HPLC (Bio-Rad Variant 2, n=2; (Bio-Rad Variant 2, n=2; Primus Diagnostics Ultra 2, n=1).Results

All labs quote HbA1c ranges as: non-diabetic <6% (<42 mmol/mol), good control 6-7% (42-53 mmol/mol) and action required >8% (>64 mmol/mol). Inter-laboratory imprecision across all nine labs for the seven samples ranged from 4.9% to 9.2%. HbA1c on the patient pool sample with a mean of 7.75% (61 mmol/mol) gave an average HPLC result of 7.1% (54 mmol/mol) and an average IA result of 8.1% (65 mmol/mol). This difference was not consistent with the QC material results (mean difference <2%). Results were more discordant at higher HbA1c concentrations. HbA1c results for the Hb variant samples were also highly method dependent. Conclusions

HbA1c results in Western Australia fall into two distinct method dependent subgroups. This is reflected in the RCPA QAP scheme with immunoassay methods giving higher results than HPLC. An average 13% difference in results between methods is significant in long term monitoring of diabetic control. The improved standardisation of methods and calibrators should significantly reduce these differences.


P3. ESTIMATING GFR: CKD-EPI OR MDRD EQUATION?

J Chew-Harris,1 M Saleem,2 C Florkowski,3 C Sies,3 P George3

1Biochemistry Department, Medlab South Ltd, Christchurch, New Zealand2University of Queensland, Princess Alexandra Hospital, Woolloongabba, Qld 3Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand

[email protected]

IntroductionThe CKD Epidemiology Collaboration (CKD-EPI)

group recently published a new equation to overcome the limitation of the Modification of Diet in Renal Disease (MDRD) equation, which systematically underestimates glomerular filtration rates (GFRs) above 60 mL/min/1.73 m2. Our study was aimed to assess whether the new CKD-EPI equation performs better than the MDRD equation. Methods

102 samples were collected from adult patients undergoing gold-reference radionuclide GFR measurements. Plasma samples were analysed for creatinine using the modified Jaffe and enzymatic reactions, by Abbott Laboratories and Roche Diagnostics. The eGFR values for the 4 methods were then compared with radionuclide GFR with respect to bias, correlation and accuracy in predicting GFR. Results• CKD-EPI equation using the Roche Creatinase

method was the only equation that did not produce any significant bias for the overall population

• At GFR values >60 mL/min/1.73 m2, all MDRD equations produced significant underestimation, while the CKD-EPI equation by most methods did not produce any bias

• When comparing the two Jaffe reactions, both CKD-EPI and MDRD equations underestimated GFR and none were found to be significantly different in predicting values within 30% of GFR

• However, when using enzymatic reactions, CKD-EPI had higher proportions of results within 30% of GFR than the MDRD equation. This was found to be significant in the overall population, in GFR > 60 mL/min/1.73 m2 and in females (P<0.05).

ConclusionsCKD-EPI equation is more accurate when using

enzymatic reactions to measure plasma creatinine. Laboratories would need to change from the traditional Jaffe methods to enzymatic methods to fully benefit the use of the CKD-EPI equation.

P4. ESTIMATING GFR IN CHILDREN WITH CANCER

J Chew-Harris,1 M Saleem,2 C Florkowski,3 C Sies,3 P George3

1Biochemistry Department, Medlab South Ltd, Christchurch, New Zealand2University of Queensland, Princess Alexandra Hospital, Woolloongabba, Qld 3Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand

[email protected]

IntroductionIn children with cancer, an accurate method for

assessing glomerular filtration rate (GFR) is essential during treatment with nephrotoxic chemotherapeutic drugs. Determination of GFR is time-consuming and difficult to perform. Plasma creatinine is inaccurate due to low muscle mass in children, and potential assay interferences. We assess the potential utility of cystatin C as a renal marker in children with cancer, with comparisons to radio-isotope GFR and plasma creatinine.Method

Samples from paediatric patients undergoing radionuclide GFR assessments were collected. Plasma samples were analysed for cystatin C by two methods; nephelometry and turbidimetry (Siemens and Abbott), and creatinine by two enzymatic creatinine methods (Roche and Abbott). Calculations of bias, correlation coefficients and percentage estimates between cystatin C equations, creatinine equations were compared with measured GFR.Results

Mean radionuclide GFR was 128.62 (range = 19.79 to 248.78) mL/min/1.73m2. Preliminary results on 45 paediatric patients showed that cystatin C equation such as Filler et al, and creatinine equations by Counahan-Barratt and Leger et al did not produce any significant bias compared with radionuclide GFR. When comparing the proportion of results within 30% of GFR, the most accurate prediction equation was that of Zapitelli et al (82.2%), where both cystatin C and creatinine were used in conjunction to estimate GFR. When comparing cystatin C and creatinine methods, results by the Siemens method (nephelometry) and Roche Creatininase Plus method, both had higher proportion of patients within 30% of GFR.

Conclusions

Using plasma cystatin C in conjunction with creatinine to predict GFR may improve GFR prediction in the paediatric population. A larger sample size and more research are needed to warrant its use before adaptation into operational use.


P5. PHARMACOGENOMICS AND THIOPURINE METHYL TRANSFERASE (TPMT) DEFICIENCY IN WA

S Ching,1 C Newbound,1 J Beilby,1 D Joyce1,2

1Clinical Biochemistry, Molecular Biology, Clinical Pharmacology & Toxicology, PathWest Laboratory Medicine Western Australia, QEIIMC, WA2School of Medicine and Pharmacology, University of Western Australia, Nedlands, WA

[email protected]

IntroductionMeasurement of TPMT enzyme activity identifies

genetically-determined deficiencies that strongly influence the toxicity of thiopurine drugs. A lack of consensus on a TPMT reference method, reference intervals and cut-offs has led to varying criteria for TPMT deficiency. Introduction of this assay into Western Australian necessitated the comparison of TPMT results with genotype analysis.Methods

TPMT activity was determined in 209 people by a phase partition method, using 6- mercaptopurine as a substrate. Genotyping was conducted by initial screening of the TPMT gene for the common variants *2, *3A, *3B, *3C and *8. Multiplexed Ligase-Dependant Probe Analysis (MLPA) and direct sequencing of coding regions was performed in cases with low activity in the absence of those common variants.Results

The TPMT enzyme activity assay gave an intra- and inter-assay precision of 2.3% and 12.9% respectively. Correlation coefficient and least square regression of 100 TPMT samples assayed by two independent laboratories were r2=0.807 with a slope of 0.869±0.064 and y intercept of 0.049. There were 24 (11%) subjects found to have TPMT activities in the lower quartile of the population range (<0.57 nmol/gHb/min). Twelve of these subjects were heterozygous for a low activity allele and 12 subjects homozygous for normal activity alleles.Conclusions

TPMT activity measurement, followed by selective genotyping,allowed laboratory results to be usefully linked to guidelines on thiopurine drug dosing. Reporting rules, based on the predictive value of TPMT activity and genotype for adverse drug response, have been developed to assist clinicians with drug dosage choice.

P6. CAN EXERCISE UNMASK EARLY ALBUMINURIA IN SUBJECTS WITH DIABETES?

J Doery,1,2 B Dayanath,1 KH Koh,2 P Kerr2

1Biochemistry Unit, Pathology Department, Monash Medical Centre2Department of Medicine, Monash University, Clayton, Vic 3168

IntroductionSpot urine measurement of albumin is now the most

commonly accepted approach to assessing proteinuria. Exertion prior to the collection may potentially influence the result of spot urine albumin estimation. We evaluated the effect of exercise on albuminuria in subjects at various stages of diabetic nephropathy and healthy control volunteers.Methods

Thi r ty - f i ve d i abe t i c sub j ec t s (19 wi th normoalbuminuria (NA), 9 with microalbuminuria (MA) and 7 with overt proteinuria (OP)) and nine control subjects were assessed. A 1km treadmill walk was performed. Four Spot urine specimens were collected; first morning void, immediately prior to exercise, and 1 and 2 hours after of exercise. A random effect linear regression mixed model was used to assess the effect of exercise on the urine albumin to creatinine ratio (uACR). Results are presented separately for males and female diabetic subjects due to a significant exercise/gender interaction (p<0.05).Results

No significant effect of exercise on uACR was seen in control subjects. In NA diabetic males no effect of exercise was seen while in females uACR 1hr post exercise was significantly higher than the early morning sample (3.55 mg/mmol, 95% CI 0.27-6.83). uACR increased 1hour post exercise in MA subjects although the effect was more marked in females (87.8, -24.3-199.4) compared to males (6.7, 2.1-11.3). For both males and females with OP, uACR was significantly increased 1 hour post exercise (67.5, 22-113 and 21.6, 8.4-34.8 respectively). In all groups uACR at 2 hours post exercise was not significantly different to the early morning sample. Conclusions

Exercise increased uACR estimation in subjects with diabetes with a larger effect in females. Whether exercise unmasks early diabetic nephropathy in NA subjects requires further study.


P7. DEVELOPMENT OF AN IN VITRO PROTOCOL TO TEST FOR POTENTIAL BENEFIT OF INTRAVENOUS FAT EMULSION THERAPY FOR DRUG OVERDOSE CASES

M Dissanayake,1 JCG Doery1,2 A Graudins3

1Biochemistry Unit, Pathology Department, Monash Medical Centre2Department of Medicine, Monash University, Clayton, Vic 3168 3Southern Clinical School, Monash University, Clayton, Vic 3168 Australia.

[email protected]

IntroductionThere is evidence that intravenous fat emulsion

(IFE) may be helpful in amelioration of lipid soluble drug toxidromes. We describe here a procedure to determine which drugs may be amenable to IFE therapy.Method

Sodium valproate, a relatively water soluble drug and carbamazepine, a relatively water insoluble drug were selected to establish the protocol. Tablets were dissolved in water (valproate) or ethanol (carbamazepine). A serum sample was then ‘spiked’ to make a primary working solution. From this 4 different concentrations of the drug extending well beyond the upper therapeutic limit were prepared. Aliquots were treated with 2 different volumes of fat emulsion (20% and 33%) or saline. The lipid-free infranatant was separated by centrifugation and then further centrifuged at high speed in a Millipore Ultrafree-MC 10,000 MW cutoff filter unit to get the protein-free fraction of the drug. At each step the concentration of the drug was measured in Beckman CoulterDxC-800 autoanalyser. Results

Free sodium valproate was approximately 10% at therapeutic levels (<700 µmol/L) but increased dramatically (>70%) when valproate exceeded 2,000 µmol/L. However there was minimal partitioning of valproate into the lipid phase. Carbamazepine was approximately 80% protein bound but showed modest partitioning into the lipid phase. Total plasma carbamazepine was reduced by approximately 30% at all drug concentrations using the 33% lipid addition while the free fraction was reduced by approximately 25%.Conclusions

Our proposed method for determining total and free drug fraction after treatment with IFE was a simple and practical way to screen drugs that may be amenable to such detoxification treatment.

P8. RED CELL FOLATE REFERENCE INTERVALS USING ROCHE ‘FOLATE III’ ASSAY REAGENTS

C Farrell


[email protected]

IntroductionRe-formulated reagents for Roche folate assays

were introduced onto the Australian market in 2008. These ‘Folate III’ reagents were observed to exhibit a proportional positive bias of approximately 22% in patient results for red cell folate compared to the previous, ‘Folate II’, reagents. This study sought to re-establish reference intervals for red cell folate using ‘Folate III’ reagents on both the Roche E170 and e411 analysers.Methods

EDTA-anticoagulated whole blood and serum specimens were collected from 240 healthy volunteers and subjects presenting for outpatient blood collection over a 4 month period who met the following criteria: aged 18-65 years, not pregnant, not consuming vitamin supplements and had a measured plasma homocysteine concentration less than 15 µmol/L. Red cell and serum folate measurements were made on the Roche E170 and e411 analysers and central 95% reference intervals were calculated using non-parametric statistics are per CLSI document C28-A2. Reference intervals for red cell folate were established both with and without a correction factor for serum folate.Results

The reference intervals thus established were: E170 red cell folate uncorrected for serum folate 1135–3026 nmol/L; E170 red cell folate corrected for serum folate 1105–2808 nmol/L; e411 red cell folate uncorrected for serum folate 1423–3295 nmol/L; e411 red cell folate corrected for serum folate 1403–3219 nmol/L.Conclusions

These data re-establish reference intervals for Roche analysers using ‘Folate III’ reagents. Furthermore, they allow laboratories to employ red cell folate reference intervals appropriate to whether or not they utilise a correction factor for serum folate.P9. EFFECT OF CORRECTING FOR SERUM FOLATE WHEN CALCULATING RED CELL FOLATE

C Farrell


[email protected]

IntroductionRed cell folate concentration may be calculated

either with or without a correction factor for serum folate. The correction factor is used to account for the contribution of folate from serum to the whole blood


haemolysate prepared for red cell folate measurement. Among Australian laboratories there appears to be uncertainty as to the need for this correction factor, with 26% of laboratories considering a correction factor appropriate. This study sought to clarify the need for employing a correction factor. Methods

Data was collected from 15,485 patients requiring red cell folate determinations over a 15 month period. Red cell folate concentrations were calculated both with and without a serum folate correction factor. The difference incurred by not correcting for serum folate was assessed against the optimum criterion for bias based on biological variation. Also examined was the incidence of patient misclassification, that is the calculated red cell folate concentration falling within the reference interval only when the correction factor was omitted.Results

The mean difference due to not correcting for serum folate was 2.4%, easily meeting the optimum criterion for bias of 8.4%. In fact 99.7% of all individual differences fell within the criterion for optimal performance. Not correcting for serum folate resulted in 0.2% of patients being misclassified. This compares favourably to the 1.5% misclassification rate inherent to the definition of the optimum criterion for bias. Most significantly, among all patient results there was only a single instance where a difference of greater than 8.4% resulted in misclassification of the patient. Conclusions

These data support the calculation of red cell folate without the need for a correction factor for the concomitant serum folate.P10. CAUSES OF ELEVATED URINE IODINE

M Galdamez, M Baxter, P Moore, G Ward, D Kanowski

Biochemistry Dept, Sullivan Nicolaides Pathology, Taringa, Qld 4068

[email protected]

IntroductionUnusually high urine iodine concentrations have

been observed at our laboratory. Iodine levels as high as 24g/L have been measured (WHO guidelines: urine iodine >100 µg/L Not iodine deficient). This study tested possible sources of laboratory contamination as well as other potential sources of iodine e.g. seafood. Methods

The baseline iodine level was measured in a urine pool before the addition of contaminants. Potential contaminants were added separately to aliquots of the pool and the iodine level was measured. Iodine in seafood was investigated following the consumption of prawns. A urine sample was collected prior to prawn consumption as well

as a first morning urine sample after the prawns. Urine iodine was measured using an Agilent 7500ce ICPMS. Results

The urine iodine level increased following contamination of the urine pool with Multistix, potassium iodide and Betadine, but did not increase following pH strips. Following the consumption of both wild prawns and farmed prawns, the urine iodine level decreased. The urine iodine of a patient on amiodarone was 8000 µg/L. One patient with a urine iodine concentration of 8 g/L was found to have had x-rays involving iodine radiocontrast media prior to testing. Conclusions

Patient preparation is essential when collecting a sample for urine iodine. Collection of urine following Xray procedures involving radiocontrast media should be avoided. The patient must avoid contact of the urine sample with Betadine antiseptic. There is potential for laboratory errors in iodine estimation if the samples are contaminated with dipsticks or other reagents in the laboratory prior to analysis. The consumption of seafood and patients on amiodarone do not appear to be the cause of the unusually high urine iodine levels observed. P11. EXPERIENCE USING A WHOLE BLOOD SAMPLE FOR A HBA1C EXTERNAL QUALITY ASSURANCE PROGRAM

J Gill,1 K Barancek,1 PD Merrilees2

1RCPA Chemical Pathology Quality Assurance Programs, Adelaide 2Point of Care Diagnostics, Sydney

[email protected]

IntroductionThe RCPA Chemical Pathology Quality Assurance

Programs (RCPA QAP) provides a PoCT quality assurance program (QAP) for HbA1c testing on the Axis-Shield Afinion™ AS100 Analyser System. As this instrument requires the red blood cell membrane to be intact, the material being provided is patient whole blood samples.Method

Identification of suitable patients, sample collection, pre-screening, aliquoting, packing and transport to testing sites is carried out by Point of Care Diagnostics to the RCPA QAP specifications. Every four weeks two samples are distributed to participating sites. The sites analyse the samples and return the results to the RCPA QAP. An extra aliquot is sent to the European Reference Laboratory for Glycohaemoglobin to assign a reference value which is used as the target value. The acceptable range is determined from the HbA1c allowable limits of performance, ±0.5 for target values up to 10.0% or ±5% for target values >10%.


ResultsA total of 13 sites are submitting results. The target

values for the samples range from 5.1-12.1%. The mean deviation from the target values for 10 samples is 0.1% with a range of 0-0.4. The mean between run %CV is 3.8% with a range of 2.5-6.2. 93% of the results are within the acceptable range, 6% are in the review area and 1% are unacceptable.Conclusions

Providing a whole blood sample for the PoCT QAP participants presents a significant logistical challenge compared with providing a lyophilised sample. However, the advantage is that there are no matrix issues. The Afinion instrument has shown excellent accuracy and a suitable number of acceptable results for the point-of-care environment.P12. LESSONS FROM THE CORRELATION OF 24 HOUR AND SPOT URINE MEASUREMENTS

D Grace,1 J Calleja,1 KA Sikaris,1 ZX Lu1,2

1Melbourne Pathology, Collingwood, Vic 30662Department of Medicine, Monash University, Clayton, Vic 3168

[email protected]

IntroductionAssessment of proteinuria and albuminuria has

traditionally been done using 24 h urine rather than spot urine collections with the expectation that a longer collection period will be more informative. A number of expert bodies have now recommended spot urine, especially from first morning void, as a preferred specimen and with creatinine correction to standardise the urine concentration. This, however, has not been universally accepted by clinicians. We conducted a study examining the correlation between 24 h and spot urine for protein and albumin. Method

All the requests over three months for 24 h urine for albumin and/or protein excretion were searched for concurrent request for mid-stream (spot) urine for microscopy and culture. Three measurements were made on the paired specimens: creatinine (Roche Jaffe), albumin (Roche immuno-turbidimetry) and protein (Roche Benzethonium Chloride). The correlations were assessed non-parametrically using Spearman’s correlation.Results

After excluding infection using the spot urine, 121 paired 24 h and spot urine specimens were used in the analysis. There were highly significant correlations (all p<0.001) between albumin concentration in the spot urine and albumin concentration in the 24 h urine (r=0.88) or 24 h albumin excretion (r=0.84). The highest correlation, however, was found between the albumin/creatinine ratio in the spot and 24 h urine samples (r=0.93). Similarly,

there were highly significant correlations (all p<0.001) between the spot urine protein concentration and protein concentration in the 24 h urine (r=0.69) or the 24 h protein excretion (r=0.58). Again, the highest correlation was found between the protein/creatinine ratio in the spot and 24 h urine samples (r=0.85).Conclusions

The results confirm the high correlation of a spot albumin/creatinine ratio or protein/creatinine ratio with all albumin or protein measurements made in 24 h urine samples. This suggests that 24 h collections usually add little more information.P13. UNEXPECTEDLY HIGH WHOLE BLOOD CHLORIDE LEVELS IN A SEVERE BURNS PATIENT CAUSED BY WOUND TREATMENT WITH CERIUM NITRATE

L Ha,1,2 GA Woollard,2 W Chiu2 1Clinical Biochemistry Laboratory, Middlemore Hospital, Auckland, New Zealand2Department of Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand

[email protected]

IntroductionA teenage male suffered severe burns after a domestic

explosion accident in Tahiti. He was transferred two days later to the National Burn Centre at Middlemore Hospital, Auckland. Unphysiologically high levels of whole blood chloride were noted by Radiometer ABL 800 blood gas analyser. Paired plasma chlorides measured by Abbott Architect Ci 8200 autoanalyser were much lower. We suspected interference to the chloride electrode of ABL 800 and investigated for the possible interferent(s). Methods

Patient’s plasma nitrate, bromide and thiocyanate were measured by ion-paired reversed phase HPLC with low UV detection at 205 nm. Plasma iodide was measured by ICPMS. The in-vitro effect of nitrate on ABL 800 and Abbott Architect Ci 8200 chloride measurements was tested by spiking blank pooled plasma with increasing concentrations of sodium nitrate. Results

Patient’s whole blood chloride levels (ABL 800) were 170 mmol/L, 137 mmol/L, and 119 mmol/L (from post-burn day 3,4 and 5 respectively) with corresponding plasma nitrate at 6.7 mmol/L, 4.9 mmol/L and 1.1 mmol/L. (reference limit <0.08 mmol/L). The decrease in chloride paralleled the decrease in nitrate over the five days of observation. In-vitro spiking with 7 mmol/L nitrate gave an apparent plasma chloride level of 180 mmol/L from ABL 800. Thiocyanate was not detected and other potential interferents were normal with bromide 0.045 mmol/L and iodide fluctuating <150 nmol/L.


ConclusionsEndogenous nitrate levels this high are not achievable

by activation of NO synthase following inflammation. Enquiries with the Tahiti hospital confirmed that cerium nitrate (Flammacerium) had been applied topically to his burn wounds. No nitrate containing medications had been given in New Zealand throughout the admission till his death. We suggest systemic absorption of nitrate from cerium nitrate has caused the positive interference on chloride measurement on Radiometer ABL 800 blood gas analyser. P14. EVALUATION OF THE GEM® PREMIER 4000 FOR UREA AND CREATININE ANALYSIS

X Coll, C Rees, C Brownlie, R Spooner

Clinical Biochemistry, Glasgow Royal Infirmary, Glasgow, UK

IntroductionInstrumentation Laboratory is developing a

cartridge for the GEM Premier 4000 blood gas analyser for measurement of electrolytes, glucose, lactate, haematocrit, urea, creatinine and tCO2. Measurement of urea and creatinine in patient samples are compared to current laboratory methods.Methods

103 arterial blood gas samples obtained from ITU, Renal and Emergency wards were analysed on the GEM 4000, and plasma on a c8000 analyser (Abbott) using the Abbott urea method, the Abbott Jaffe and Roche enzymatic creatinine methods. Plasma was also analysed for urea and creatinine on the GEM 4000 to compare with blood.Results:

• GEM 4000 urea = 0.97 (Abbott plasma urea) + 1.00, with slight positive bias at low concentrations and slight negative bias at higher concentrations (>20 mmol/L).

• Blood urea = 1.01 (plasma urea) - 0.57, with greater variability at concentrations >20 mmol/L and majority of plasma measurements positively biased.

• GEM 4000 creatinine = 1.05 (enzymatic plasma creatinine) - 9.64

• GEM 4000 creatinine = 1.02 (Jaffe plasma creatinine) - 12.35, with random scatter for both methods.

• Blood creatinine = 1.06 (plasma creatinine) + 11.96, with positive bias for plasma measurement, increased at higher concentrations.

84/103 patients were classified into the same CKD stage group (after eGFR MDRD4 calculation) across each method. Negative interference by creatine on creatinine measurement was observed in a septic patient with

serum creatine = 1334 µmol/L by LC-MS/MS. Creatine interference is detected and flagged by the GEM 4000. Conclusions

Good correlation was observed between the IL GEM 4000 and current laboratory methods for analysis of urea and creatinine in blood and plasma. GEM Premier 4000 shows promise for measurement of urea and creatinine in laboratory and POCT environments. P15. TOTAL BILIRUBIN ASSAY ON GEM® PREMIER™ 4000

X Coll, PVA Pamidi,1 R van der Pal,2 R Sanders,3

K van der Brugge,3 W Elgers3 1Instrumentation Laboratory, Bedford, MA, USA 2Instrumentation Laboratory B.V., Breda, The Netherlands 3Vlietland Ziekenhuis, Schiedam, The Netherlands

IntroductionTotal bilirubin is traditionally measured from

plasma or serum samples on chemistry analysers. Recently, whole blood total bilirubin measured on blood gas and CO-Oximetry analysers is gaining attention due to the elimination of plasma/serum separation step and clinically equivalent performance to chemistry analysers. GEM Premier 4000 is a critical care analyser offering blood gas, electrolyte and metabolite measurements together with integrated CO-Oximetry. Whole blood or plasma total bilirubin measurement has been added to the menu of assays on GEM Premier 4000. Analytical performance of whole blood based GEM Premier 4000 total bilirubin measurement is compared to the plasma/serum assay on the Olympus AU680 chemistry analyser.Methods

Heparinised blood samples were collected from neonatal and adult patients in capillary or syringe for testing on the Instrumentation Laboratory GEM Premier 4000 and simultaneously in collection tubes (Li-heparin) for plasma testing on the Olympus AU680 chemistry analyser.Results

Total bilirubin levels from 11-617 µmol/L (0.6-36.1 mg/dL) were tested on both GEM and Olympus AU680 for method correlation. Total bilirubin measurements on GEM Premier 4000 showed good agreement to the measurements on Olympus AU680 (y = 1.05x – 6.7, R² = 0.987, n = 50).Conclusions

GEM Premier 4000 showed equivalent performance to plasma measurements on the Olympus AU680 chemistry analyser for assessing the total bilirubin levels in newborns and adults. In addition, elimination of a separation step and the smaller volume requirements for the neonatal sample makes the GEM Premier 4000


suitable for total bilirubin measurements in POCT settings.P16. ASSESSMENT OF PLASMA HAEMOGLOBIN LEVELS USING HAEMOGLOBIN INDEX ON THE VITROS 5,1 FS ANALYSER

E Haworth, C Tran, A Chiriano

Core Biochemistry, Laboratory Services, The Royal Children’s Hospital, Parkville, Vic 3052

[email protected]

IntroductionAssessment of low levels of plasma haemoglobin is a

recognised method for the assessment of acute in-vitro red blood cell damage. The practical value of the measurement is virtually limited to circumstances in which acute intravascular haemolysis is believed to have occurred, as in haemolytic transfusion reactions, or in evaluation of the degree of haemolysis occurring by mechanical damage in medical equipment. Because free plasma haemoglobin is quickly bound by haptoglobin and removed from the blood and any non-haptoglobin bound haemoglobin is promptly excreted in the urine, measurement of free haemoglobin in plasma is of no practical value in the diagnosis of chronic haemolytic disorders. Methods

Plasma from 97 patient samples collected in lithium heparin were correlated using an empirical polynomial (AII) method using a Beckman DU®70 Spectrophotometer and the Ortho Clinical Diagnostics Vitros 5,1 FS Chemistry Analyser’s spectrophotometer used for measuring haemolysis index.Results

Correlation of the two methods shows R2 = 0.98 where PlHb = 0.0097x – 0.04, where x is the haemoglobin index value derived form the spectro scan. A detailed two tailed t-test shows p = 0.0054.Conclusions

Analysis of plasma haemoglobin by spectrophotometry on the Vitros 5,1 FS shows a positive bias when compared to an empirical polynomial (AII) method using a Beckman DU®70 Spectrophotometer. Limitations of plasma haemoglobin analysis by spectrophotometry derived haemolysis index on the Vitros 5,1 FS do not allow for measurement of plasma haemoglobin levels <1.0 g/L.

P17. EVALUATION OF THE BIO-RAD VARIANT™ II TURBO HbA1c KIT - 2.0 (TURBO 2.0)

T Higgins, D Stewart, J Dayton

Clinical Chemistry Department, DynaLIFEDx, Edmonton, Alberta, T5J 5E2, Canada

[email protected]

IntroductionThe Bio-Rad TURBO 2.0 method is an HPLC

method capable of analysing a sample for HbA1c in 97 seconds. The method was compared with an established method (Bio-Rad VARIANT™ II HbA1c) for precision and potential interference from haemoglobin variants and carbamylated haemoglobin. Methods

The correlation study was performed by comparing 181 non-variant whole blood samples over a 5-day period by both methods. Fifty samples with eGFR <60 ml/sec were analysed by both methods and sent to a National Glycohemoglobin Standardization Program laboratory for analysis. Samples containing haemoglobin variants were analysed by both methods. Both intra- and interday precision studies were performed. Results

The interday precision at HbA1c levels of 5.8 and 9.7 % were 0.1 and 0.1 % respectively.

The intraday precision at HbA1c levels of 5.8 and 9.7 % were 0.7 and 0.4 % respectively.

The regression equation was %HbA1c “TURBO 2.0” = 0.9651 x %HbA1c “VARIANT II” + 0.3938 (n=181, r=0.9946, Sy/x=0.15).

For carbamylated haemoglobin samples, the regression equation was %HbA1c “VARIANT II” = 1.054 x %HbA1c “NGSP” +0.0853 (n=50, r= 0.9911, Sy/x =0.19) and %HbA1c “TURBO 2.0” = 1.0402 x %HbA1c “NGSP” + 0.1491 (n=50, r= 0.9901, Sy/x=0.19).

For haemoglobin variant samples, the regression equation of the combined variant haemoglobins E, D, S, and C was %HbA1c “TURBO 2.0” = 0.9498 x %HbA1c “VARIANT II” + 0.3518 (n=105, r=0.9564, Sy/x=0.33).Conclusions

The precision is comparable with other HPLC based HbA1c methods. The TURBO 2.0 correlates well with an established method and is not affected by carbamylated haemoglobin. The method identifies haemoglobin variants and the retention time. A presumptive identification of the haemoglobin variant can be made via the retention time.


P18. AGE RELATED REFERENCE RANGES FOR SERUM PROCOLLAGEN TYPE I N-TERMINAL PROPEPTIDE (P1NP) AND TYPE I COLLAGEN C- TELOPEPTIDE (CTx) IN THE AUSTRALIAN MALE POPULATION

N Jenkins,1 M Black,1 HG Schneider,1 E Paul,2

J Pasco3

1Clinical Biochemistry, Alfred Pathology Service, Melbourne2Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne3Geelong Osteoporosis Group, Barwon Health, Geelong

[email protected]

IntroductionThis study aims to establish serum reference ranges

for procollagen type I N propeptide (P1NP) and type I collagen C-telopeptide (CTx) in Australian men. Methods

Fasting sera from 1145 males (mean age 60 years; range 20-97 years) who participated in the Geelong Osteoporosis Study were analysed for CTx and P1NP using the automated Roche Modular Analytics E170 analyser.

None of the subjects had any medical condition known to affect bone metabolism.Results

The reference ranges took into account values for the geometric mean ±2 standard deviations as well as the 2.5th and 5th percentiles and the 95th and 97.5th percentiles.

The CTx reference range is divided into three age groups. For men aged 25 to 40 years, the range is 170–600 ng/L; 40 to 60 years, the range is 130-600 ng/L; and for men aged greater 60 years the range is 100-600 ng/L.

For P1NP the reference range is 15-80 µg/L for men aged between 25 to 70 years.

In men greater than 70 years of age values are usually higher possibly due to increased bone turnover.

We also found that high values are frequently seen for both CTx and P1NP in males aged younger than 25 years. This is probably due to bone growth that is not completely finalised.Conclusions

Values obtained from this large study provide sound age related reference ranges for serum P1NP and CTx in Australian men.

P19. HIGH SENSITIVITY TROPONIN T: ANALYTICAL AND CLINICAL VALIDATION

GRD Jones, M Roser, L Nguyen


[email protected]

IntroductionWe have evaluated the Roche Troponin T high-

sensitivity assay (TnT-hs) as a replacement for the Siemens Centaur Troponin I Ultra Assay (TnI-ultra). Methods

Measurements were made using the Siemens Centaur TnI-ultra and the Roche TnT-hs assays. Studies performed included: precision, method comparison, clinical comparison and effect of haemolysis.Results

Within and between-run CVs of the TnT-hs were below 5% at all levels tested. Method comparison with the Centaur analyser showed a poor correlation overall with TnT-hs results approximately 0.1 times the TnI results (both expressed in µg/L) across 3 orders of magnitude with a scatter of ratios between 0.02 and 2. 20% more patients with troponin requests from the Emergency Department were positive with TnT-hs compared with TnI-ultra, however the majority of these patients were admitted to the hospital with only the negative TnI value available for clinical assessment. A delta troponin >30% provided reasonable separation of stable from rising troponin concentrations with most low positive TnT-hs patients showing a stable pattern. ROC analysis suggested a TnT-hs value of 30 ng/L would have the same sensitivity and specificity as a TnI-ultra decision point of 0.06 µg/L. The effect of haemolysis was shown to vary between patients with an average fall in measured troponin of 10% per 100 mg/dL Hb (range 0–20% fall). Methods for reporting haemolysed samples are developed. Clinical consultation supported the use of ng/L rather than µg/L for reporting.Conclusions

Changing from the Centaur TnI to TnT-hs involves new units, decision points and numerical values. There will be a higher number of positive results, many of whom are clinically unwell but may have a normal delta troponin.


P20. PERFORMANCE OF URINARY BENCE JONES PROTEIN MEASUREMENT IN CLINICAL LABORATORIES

S Jovanovich,3 J Tate,1 H Martin,2 L Wheatland3 1Department of Chemical Pathology, Pathology Queensland, Royal Brisbane and Women’s Hospital, Herston, Qld 40292Biochemistry Department, Healthscope Pathology, SA 50343RCPA Immunology QAP, SA Pathology, Flinders Medical Centre, SA 5042

[email protected]

IntroductionQuantitation of Bence Jones protein (BJP) is used

to monitor the size of the population of malignant cells in an individual patient. BJP is quantitated by densitometric measurement of the band from the urine protein electrophoresis (UPEP) and urine BJP concentration is calculated as a percent of the urine total protein (UTP). RCPA Immunology QAP Urine Paraprotein Specimen 14-01 was analysed by 59 laboratories and BJP measurement assessed. Methods

UPEP methods included Helena, Sebia (Acid Violet stain), Sebia (Amido Black stain), Capillary Zone Electrophoresis (CZE), cellulose acetate, and inhouse. UTP methods were pyrogallol red-molybdate (PRM), benzethonium chloride (BTCl) and pyrocatechol violet-molybdate. Half of laboratories did not specify their UTP method.Results

Lambda BJP was the predominant band identified by immunofixation or immunosubtraction (56 of 59 laboratories). Mean (SD, range) for %BJP from UPEP was: All methods (N=49): 60 (19, 0.7-97); Helena (N=10): 62 (15, 43-82); Sebia (Acid Violet stain, N=11): 59 (22, 18-84); Sebia (Amido Black stain, N=15): 58 (12, 36-80). Mean (SD, range) for UTP in mg/L was: All methods (N=48): 1240 (410, 100-2000); PRM: 1530 (240, 1300-1900); BTCl: 1230 (300, 800-1600). Mean (SD, range) for BJP concentration in mg/L was 760 (280, 310-1540, N=39). Conclusions

Between-laboratory variation for BJP quantitation was approximately 5-fold. Factors that may contribute to this variation are: 1) lower UTP concentration by BTCl assay compared with PRM, and the lesser reactivity of tubular proteins, e.g. BJP; 2) differences in BJP dye-binding by different stains; and 3) use of concentrated versus unconcentrated urine with 2-fold variation for %BJP noted within individual UPEP methods. It is recommended to use the same methods to monitor BJP concentration in individual patients.

P21. GLUCOSE HOMEOSTASIS IN A HEALTHY PAEDIATRIC POPULATION

JL Kerrigan,1,2 EK Southcott,1,2 RD Telford,3

P Waring,3 ARA Lafferty,1,2 GJ Reynolds,1,2

PE Hickman,1,2 JM Potter1,2

1Australian National University Medical School, Acton, ACT 02002ACT Pathology, Canberra Hospital, Garran, ACT 26053Commonwealth Institute, Canberra, ACT 2603

[email protected]

IntroductionThis study aimed to assess glucose homeostasis in

a healthy paediatric population and observe changes between ages 8, 10 and 12 years.Methods

Using a population of 753 8y.o. in 2005 enrolled in the LOOK Study, a baseline analysis of glycated haemoglobin A1c (HbA1c), fasting serum glucose and insulin was performed with a calculation of Homeostasis Model assessment for insulin resistance (HOMA-IR). Measurements were repeated from the original population on 594 10y.o. in 2007 and on 501 12y.o. in 2009.Results

Significant changes were seen in fasting glucose levels between all age groups and between genders at ages 8 and 10 years, but not 12. A significant difference was also observed for HOMA-IR as both sexes grew older. Girls had a two fold increase compared with boys. At age 12 more girls had a HOMA-IR >2 than boys aged 12 or girls aged 10.Conclusions

By comparing serial changes in HOMA-IR and fasting glucose with the lack of any change in HbA1c we show that insulin sensitivity decreases from age 8 to 12 in boys and girls and the greater decrease in girls aged 12 may reflect the subtle physiological moderations associated with growth and more latterly puberty. P22. DIRECT SALIVARY CORTISOL EVALUATION ON BECKMAN ACCESS

C Kiggundu,1 S Greco,2 G Streitberg,1 JCG Doery1,3

1Biochemistry Unit, Southern Cross Pathology Australia, Monash Medical Centre, Clayton, Vic 31682Melbourne Pathology, Collingwood, Vic 30663Department of Medicine, Monash University, Clayton, Vic 3168

[email protected]

IntroductionSalivary measurements have the potential to provide

a convenient and non-invasive assessment of serum “free” cortisol. When assessed against strict criteria, midnight


salivary cortisol may be an effective screen for Cushing’s syndrome. Methods

Samples (n=33) were collected both morning and evening, by salivating into a 50ml spot urine container and then centrifuged at 2000 RPM for 10 minutes. The saliva was then divided into 2 aliquots and stored at -20’C until analysed. One set was analysed at Monash Medical Centre on the Beckman Access using a ‘Research only’ direct salivary cortisol method supplied by Beckman Coulter USA. This direct method, analysed saliva without extraction. The second set was analysed by Melbourne Pathology on an Immulite 2000 (Siemens Diagnostics) after extraction into ethylacetate and reconstitution into 1/10th volume normal saline. Results

Salivary cortisol values ranged from 1.46 to 36.65 nmol/L. There was a strong correlation between the two methods. The linear regression was Beckman = 0.8393xImmulite + 0.6136, r2 = 0.9749.Conclusions

The Beckman direct salivary cortisol assay is very simple and convenient to use and has the sensitivity to detect midnight cortisol in the normal range (<9) as well as in hypercortisolism (Cushings syndrome or acute stress). The potential to supplement or replace 24 hour urinary free cortisol for the diagnosis of Cushing’s disease is attractive but requires further validation. The method uses the serum/urine cortisol reagent kit available on board 24 hours a day. All three tests (serum, urine and saliva) can be calibrated at the same time, using the one kit, with one set of calibrators. One kit on board minimises wastage. Currently there is no EQA for salivary cortisol and this is clearly desirable. P23. WHAT IS THE BEST PREDICTOR OF THE ATHEROGENIC LDL SUB-CLASS PHENOTYPE ‘PATTERN B’?

R King,1 CM Florkowski,1,2 J Yeo,1 TA Walmsley,1

B Shand,2 RS Scott,2 PM George1

1Clinical Biochemistry, Canterbury Health Laboratories, Christchurch, New Zealand2Lipid and Diabetes Research Group, Christchurch Hospital, New Zealand

[email protected]

IntroductionA predominance of small-dense low density

lipoprotein (sdLDL) increases cardiovascular risk, and has been called the atherogenic lipoprotein phenotype ‘pattern B’. Gradient gel electrophoresis is considered a ‘gold standard’ method for identifying this phenotype, though it is impractical for routine laboratory practice. The LDL/Apolipoprotein-B ratio and recently introduced direct assays of sdLDL could potentially simplify LDL sub-fraction analysis and help recognise this atherogenic

phenotype. We aimed to compare a direct assay for sdLDL and the LDL/Apolipoprotein-B ratio with more accessible lipid parameters, fasting triglyceride and triglyceride/HDL ratio, to predict the presence of ‘pattern B’ phenotype. Methods

Blood samples were collected from 97 fasted subjects on up to three separate occasions. Total cholesterol, triglyceride, Apolipoprotein-B (Abbott Architect c8000) and sdLDL (sLDL-EX, Denka Seiken) were measured; LDL and HDL-cholesterol were determined after lipid ultracentrifugation. The predominant LDL particle size and phenotype were assigned by gradient gel electrophoresis.Results

‘Pattern B’ phenotype was identified in 36 % of samples. Peak particle size had a positive correlation with HDL-cholesterol, and a negative correlation with triglyceride and Apolipoprotein-B. Receiver operating curve (ROC) analysis showed triglycerides/HDL ratio and triglyceride alone to be the best predictors of ‘pattern B’ phenotype, area under the curve (AUC) 0.87 and 0.84 respectively. LDL/Apolipoprotein-B ratio and sdLDL gave significantly lower AUCs, 0.74 and 0.71 respectively (p<0.05). A raised sdLDL concentration had the highest specificity, 95 % and positive predictive value, 74 %, for predicting ‘pattern B’ phenotype, but low sensitivity, 43 %. The negative predictive values for sdLDL, triglyceride and triglyceride/HDL ratio were all similar at ~87 %.Conclusions

Direct measurement of sdLDL provided the most specific predictor of ‘pattern B’ phenotype with the highest positive predictive value; but triglyceride/HDL ratio or triglycerides alone, which are readily available in most laboratories, were the best predictors by ROC analysis. P24. IMPRECISION OF TUMOUR MARKERS ON THE BECKMAN DXI800

S Klingberg, T Brown

Chemical Pathology, Pathology Queensland, RBWH, Herston, Qld 4029

[email protected]

IntroductionPathology Queensland uses the Beckman Coulter

DxI800 platform for the quantification of the common tumour markers AFP, CEA, CA125, CA15.3, CA19.9, and PSA. The aim of this study was to compare the analytical imprecision (CVa) of these analytes against the desirable (DG) and optimal (OG) goals for imprecision, derived from biological variation (CVi), and the allowable limits of performance (ALP) as defined in the RCPA Tumour Markers Quality Assurance Program. From this data we will establish guidelines for result critical difference (CD) to facilitate better definition of delta check limits for these analytes.


MethodsCVa were calculated for each analyte from internal

quality control (IQC) data, collected over the last 5-8 months, and compared to corresponding DG (0.5CVi) and OG (0.25 CVi) and the RCPA ALP. Critical difference (CD) was calculated using the formula 2.77(CVi2 + CVa2)½.Results

All analytes showed similar CVa profiles across all levels of IQC. The mean and CVa (DG, ALP and CD in parentheses) for each biomarker, at IQC level nearest the clinically significant decision point, were as follows: AFP, 31.5 µg/L, 5.0% (6.0%, ±20%, 36%); CEA, 3.0 µg/L, 7.7% (6.4%, ±2 µg/L, 41%); CA125, 41.1 kU/L, 4.7% (12.4%, ±10 kU/L, 70%); CA15.3, 28.0 kU/L, 5.0% (3.1%, ±15%, 22%); CA19.9, 26.4 kU/L, 5.3% (8.0%, ±15%, 47%); PSA, 3.14 µg/L, 5.1% (9.1%, ±1.5 µg/L, 52%).Conclusions

Our data shows, that in our laboratory, all tumour markers perform well within the RCPA ALP; CEA and CA15.3 do not meet DG as defined by biological variation; and only CA125 performs at the OG. Empirically derived delta check limits of ±50% are inappropriate for CA125 and CA15.3 due to respectively high and low CVi.P25. QUALITY MANAGEMENT FRAMEWORK FOR INR POINT-OF-CARE TESTING IN THE NGATI POROU HAUORA WARFARIN MANAGEMENT PROGRAM

BC Mazzachi,1 MDS Shephard,1 A Shephard,1

C Johnson2

1Community Point-of-Care Services, Flinders University Rural Clinical School, Bedford Park, SA 50422Ngati Porou Hauora, Tokomaru Bay, New Zealand

[email protected]

IntroductionThrough a partnership between Ngati Porou

Hauora, Roche Diagnostics New Zealand and the Flinders University Community Point-of-Care Services unit, point-of-care pathology testing (POCT) for INR on the CoaguCheck XS is being conducted for warfarin management across a network of 6 remote Maori health centres along the East Cape region in the North Island of New Zealand. A quality management framework has been established to monitor the safety and analytical quality of INR testing. Methods

Clinic nurses were trained on-site in the theory and practice of INR POCT. A set of laminated posters provided a simple step-by-step guide for nurses on patient and quality testing. All nurses underwent a written and practical assessment to obtain a competency certificate as a qualified POCT operator in the program. Since 2008

nurses have conducted monthly quality control (QC) testing (Roche PT Control) and split patient sample testing (where a patient sample was tested by both POCT and the local laboratory).

Results

Between-site imprecision for INR QC testing across three reagent lot numbers averaged 6.6% in 2008 (n=43), 7.3% in 2009 (n=49) and 7.9% to May 2010 (n=15). This compares favourably with the average between-site imprecision of 8.0% observed for INR POC testing in the PoCT in General Practice Trial. For split patient sample testing, the mean difference between POCT and laboratory results were 0.23 (limits of agreement -0.42 to 0.88) (n=74).

Conclusions

INR testing on the CoaguCheck XS has been conducted safely and to an acceptable analytical standard. P26. HOW EQUIVOCAL IS A SWEAT CHLORIDE OF 40-60 mmol/L? AN AUDIT OF OVER 1,600 SERIAL ANALYSES

SF Moui,1 N Wijeratne,1 JCG Doery,1,2 ZH Lu1,2

1Biochemistry Unit, Pathology Department, Monash Medical Centre; 2Department of Medicine, Monash University, Clayton, Vic 3168

[email protected]

IntroductionAnalysis of sweat chloride remains the gold standard

for the diagnosis of cystic fibrosis (CF). Since about 1988 testing has been performed as follow up of the newborn heel prick IRT screening test, or in older symptomatic children and very occasionally for the investigation of male infertility. We have reviewed our data base of >1600 serial sweat analyses with a view to clarifying:

• the diagnostic significance of sweat [Cl] of 40–60 mmol/L.

• the reliability of ‘inadequate’ sweat collections i.e. <75 mg.

• the reproducibility of repeat sweat analyses.Methods

Sweat was collected by pilocarpine iontophoresis, chloride measured by microtitration method of Shales and Shales and sodium by flame photometry. Sweat chloride results of 40–60 were followed up to ascertain final clinical diagnosis. Concordancy with low sweat yields was based on results interpreted against the cutoffs; <40 normal and >60 CF.Results

Of all adequate sweat collections (>75mg) 3.6% had [Cl] between 40–60 i.e. equivocal. 104 patients had


repeat testing. Based on repeat testing, measurement of uncertainty of an adequate sweat analysis was estimated. However all yields >40 mg gave concordant results. The incidence of equivocal results based on initial indication for testing was: Failure to thrive and respiratory symptoms 2.1%, heterozygote 4.2%, family history CF 9.3%. The incidence of confirmed CF with [Cl] 40–60 will be discussed.Conclusions

Sweat testing is a skilled procedure which remains the gold standard for diagnosis of a serious lifelong and life threatening disease. Auditing results provides valuable insights to aid reporting and interpretation.P27. STABILITY OF FREE PSA IN SERUM AND EDTA PLASMA

L Nguyen, C Santorelli, GRD Jones

Department of Chemical Pathology, St Vincent’s Hospital, Sydney, NSW

[email protected]

IntroductionFree PSA (fPSA) is known to be an unstable analyte

which potentially creates problems when requested as an add-on test. We evaluated the stability of fPSA in serum and EDTA plasma when stored at 4°C for up to 7 days.Methods

10 paired serum with gel separator tubes and EDTA tubes were collected from patients with a total PSA between 0.2–10 µg/L. fPSA was measured on the day of collection (Day 1), Day 3 and Day 7 using the Roche free PSA assay on the Roche E170. Serum samples kept in the primary tube and whole blood EDTA aliquots were stored at 4°C in the same conditions as usual patient samples.Results

Baseline serum fPSA ranged between 0.087–1.53 µg/L with a mean EDTA plasma/serum ratio of 0.985 and linear regression equation: EDTA plasma= 1.0485x serum - 0.0089 (r2=0.9999). fPSA in serum decreased an average 11.7 ± 12.6% and 31.2 ± 19.1% by Day 3 and Day 7, respectively. fPSA in EDTA plasma decreased an average 2.8 ± 1.8% by Day 3 and 5.9 ± 7.6% (7/10 samples <10%) by Day 7.Conclusions

There was no difference in the baseline fPSA concentration obtained in serum and EDTA plasma. Roche claims a stability of 5 days in both tube types using recovery criteria of 90–110%. We found that only EDTA plasma fPSA is stable by Day 3 and would therefore be the preferred specimen for fPSA add-ons. While stable in most samples, fPSA measured in EDTA plasma at Day 7 should be interpreted with caution.

P28. HAEMOGLOBINOPATHY TESTING: A BIOCHEMISTRY PERSPECTIVE

J Pope,1 M Black,1 S Morgan2

1Clinical Biochemistry Unit, 2Haematology Unit, Alfred Pathology Service, The Alfred, Melbourne, Vic 3004

[email protected]

IntroductionHaemoglobinopathies and thalassaemias are

inherited conditions, occurring with increasing prevalence in Australia. Identification of haemoglobin (Hb) abnormalities is important in diagnosis of microcytic anaemias and in prenatal counselling of high risk pregnancies. Haemoglobinopathy testing at The Alfred was previously referred to another pathology provider. The Clinical Biochemistry Unit commenced in-house testing in 2009, using two techniques currently performed in our laboratory; HPLC screening using a Primus CLC385 and gel electrophoresis (acid and alkaline) using the Sebia Hydrasys system. These results in conjunction with haematology results and clinical information were used by a consultant haematologist for interpretation.Methods

EDTA whole blood was analysed for Hb A2, Hb F and for any Hb variants present, using 3 different methods; Primus CLC385 HPLC compared with Primus Ultra 2 HPLC (n=30) and compared with a Biorad Variant I HPLC (n = 71). Structural Hb variants were confirmed using the Sebia Hydrasys system.

We reviewed our internal QC (6 months), and the incidence of haemoglobinopathies diagnosed since in-house testing commenced.Results

• Passing-Bablok Hb A2 the Alfred = 1.0(Primus Ultra 2) - 0.1 (n=30) and the Alfred = 1.0(Biorad Variant I) – 0.30 (n=71).

• Less than 3 % of samples had Hb F levels >1 %, the LOQ.

• All Hb abnormal i t ies were correct ly identified.

• CVs of internal QCs for Hb F levels at 12.3% and 1.7% were 4.6% and 14.5%, respectively. CVs for Hb A2 levels at 4.8% and 2.0% were 3.0% and 4.9%, respectively.

• In 14 months we have performed 500+ tests, identifying 28 cases of Hb variants and thalassaemias.

ConclusionsWe have demonstrated that haemoglobinopathy

testing can be successfully performed by a Clinical Biochemistry Unit (with the appropriate expertise in both HPLC and gel electrophoresis), in collaboration with a consultant haematologist.


P29. JUST EVALUATION OF THE SEBIA MINICAP CAPILLARY ELECTROPHORESIS ANALYSER FOR HAEMOGLOBINOPATHY TESTING

S Just, L Ganly, P Manoiloff, R Freeman, M Crowther, J Robertson

Pathology Queensland, Royal Brisbane and Women's Hospital Campus,

Brisbane, Qld

IntroductionThe Sebia Minicap is a fully automated capillary

electrophoresis analyserwhich provides fast separation and good resolution for haemoglobinopathy testing. The purpose of this study was to evaluate the Minicap analysercompared to our current testing strategy of HPLC analysis on the Biorad Variant II analyser.Methods

Routine samples received for haemoglobinopathy testing were processed through the Sebia Minicap capillary electrophoresis and the Biorad Variant HPLC analysers.Results

A total of 333 patients were processed through both systems. Patients with beta thalassemia, Hb S, Hb E, Hb D Punjab and several other abnormal haemoglobin variants and normal individuals were tested. Stability of the sample was investigated to see if denatured Hb peaks interfered with analysis and to determine a maximum time frame between collection and testing. Carryover and reproducability studies were performed and there were no issues. Testing was performed on another 30 individuals with normal FBC indices and normal iron study results. Results showed that the HbA2 reference range for the Minicap analyser was comparable to that for the HPLC analyser.Conclusions

The Sebia Minicap capillary electrophoresis analyser is easy to use and allows detection of all of the normal haemoglobins (A, F and A2) and the major haemoglobin variants (S, C E and D). It provides quantitation of Hb H, HbConstant Spring, Hb Barts and Hb E which the Biorad Variant HPLC analyserdoes not quantitate. This instrument would allow streamlining of testing strategies for haemoglobinopathy diagnosis and minimal training for inexperienced staff due to its ease of use and software that provides preliminary diagnosis of detected variants.

P30. AACB WESTERN AUSTRALIAN QC SUBCOMMITTEE HDL-C SURVEY RESULTS

BM Rabey,1 and representatives of the AACB (WA branch) QC Subcommittee1Clinical Biochemistry, PathWest, QEII MC, Nedlands, WA 6009

[email protected]

IntroductionThe Western Australian branch of the AACB

QC subcommittee compared the performance of homogeneous high density lipoprotein cholesterol (HDL-C) methodologies across WA. The aim of the study was to determine if the matrix used for the RCPA QAP samples was affecting the HDL-C results using different methods. This was done by comparing HDL-C results for serum pools and 2010 End-of-Cycle RCPA QAP General Serum Chemistry results (EOC QAP).Methods

Five serum pools were analysed for direct HDL-C by fifteen laboratories using four methods (Siemens ADVIA 1650, n=1; Dade Behring Dimension RXL-MAX, n=1; OCD Vitros 250, n=10; Abbott Architect, n=4; Roche Integra, n=1). The samples were produced by linear dilution of high and low HDL-C pools at 0, 25, 50, 75 and 100 % dilutions. Results

The inter-laboratory precision (%CV) ranged from: 3.8 to 13.1% for HDL-C values of 0.85 to 2.26 mmol/L. At a mean HDL-C value of 1.21 mmol/L the CV was 7.9% with values from 1.05 to 1.33 mmol/L. The Architect and Integra assays produced the lowest results with a mean of 1.07 mmol/L and the other assays gave similar results with a mean of 1.26 mmol/L. Whereas, the Architect assay produced high results on the EOC QAP with a group mean of 1.73 mmol/L versus the target of 1.37 mmol/L; the group means for other assays ranged from 1.30 to 1.87 mmol/L.Conclusions

The HDL-C results from the EOC QAP compared to the patient serum pooled samples gave conflicting results despite most laboratories using the same cut-off values. It is likely that the QAP matrix and the HDL-C methods both contribute to these differences. P31. EVALUATION OF BILIRUBIN ANALYSIS ON THE GEM Premier 4000 BLOOD GAS ANALYSER

Heather Robins,1 G Koerbin,1 PE Hickman,1,2 A Hatzilias3

1ACT Pathology, ACT2ANU Medical School3Abacus ALS

IntroductionThe Gem Premier 4000 is a cartridge based blood

gas analyser which measures total bilirubin by multi-


wavelength spectrophotometry between 480 and 650nm using multi-variate regression. Sample size is 100ul. We evaluated this whole blood bilirubin and compared it with the Abbott Architect c8000 assay to assess its suitability for use in a Neonatal ICU.Methods

Heparinised whole blood samples from neonates and adults were analysed for bilirubin using the Gem Premier 4000. These samples were then centrifuged and the plasma analysed on the Architect c8000 using the Abbott diazonium salt method. Between run imprecision was determined for the whole blood assay. Results

Regression analysis produced the equation: y = 0.92x + 8.1, r = 0.99, n = 82 (range <10 to 650 µmol/L) when comparing whole blood samples (Gem Premier) and plasma (Abbott Architect C8000). Excellent correlation was demonstrated in the range 50–650 µmol/L, however significant differences were observed below 50 µmol/L. Precision studies showed a CV of 2.8% at a concentration of 333 µmol/L (SD = 9.47, n = 34) and 13.3% at a concentration of 73 µmol/L (SD = 9.73, n = 34). Conclusions

Monitoring of jaundice in the newborn is vital for the prevention of encephalopathy. Loss of accuracy is acknowledged by the manufacturer for whole blood bilirubin concentrations below 34 µmol/L due to high haemoglobin background. Inaccuracy at this concentration when monitoring jaundice in neonates is of limited clinical significance. The Gem Premier 4000 provides a rapid, small volume testing mode for measuring whole blood bilirubin and is suitable for monitoring clinically significant bilirubin concentrations in neonates.P32. A PRACTICAL HPLC METHOD FOR THE DETERMINATION OF ERYTHROCYTE THIOPURINE METHYLTRANSFERASE ACTIVITY

N Campbell, K Lunn, B McWhinney, D Morris

Department of Chemical Pathology, Pathology Queensland, Royal Brisbane and Women's Hospital, Qld 4029

[email protected]

IntroductionThiopurine methyltransferase (TPMT, E.C. 2.1.1.67)

is an enzyme implicated in the metabolism of thiopurine drugs, such as azathioprine, which is commonly used as an immunosuppressant. TPMT catalyses the methylation of the substrate 6-mercaptopurine (6MP) to produce the active metabolite 6-methylmercaptopurine (6MMP). Clinically, determination of TPMT activityguides dosage decisions, and is especially important in patients deficient in the enzyme. Our current radio-assay method has inherent limitations, wetherefore developed a

straightforward high performance liquidchromatography (HPLC) method.Methods

A Waters Alliance 2695 separations module and Waters Atlantis C18 column coupled with photodiode array detection was used for all chromatographic analyses. Haemolysates were mixed with buffer and 6MP substrate. A methyl donor (S-Adenosyl-L-methionine) was added to the test aliquot and not the blank. The aliquots were incubated at 37°C for 2 hours and the reaction terminated with perchloric acid. After centrifugation the supernatant was injected into the HPLC system to measure 6MMP concentration. The net 6MMP concentration was calculated by subtracting the blank from the test and the corresponding TPMT activity determined in U/g Hb.Results

Linear calibration curves were obtained using five levels of standards prepared from 6-mercaptopurine. Precision studies were done using 2 levels of in-house quality control material. The intra-day coefficient of variation (CV) gave <5% (n = 10) and the inter-day CV was <8% (n=20). Correlation using patient samples (n = 100) with the current radio-assay method gave R2 = 0.902, with regression formula y = 0.9113x + 0.0126. Conclusions

This method is a significant improvement on the current radio-assay method because it has introduced robust standardisation and simplified the sample preparation.P33. SIMULTANEOUS ANALYSIS OF POSACONAZOLE AND VORICONAZOLE IN SERUM USING HPLC.

AJ Wilce, BC McWhinney

HPLC Section, Department of Chemical Pathology, Pathology Queensland

Royal Brisbane and Women's Hospital, Qld 4029

[email protected]

IntroductionVoriconazole and posaconazole are used in the

treatment of opportunistic fungal infections. Currently, these two drugs are monitored using separate, High Performance Liquid Chromatography (HPLC) -based assays with differing chromatographic procedures. In order to gain efficiencies we have developed and validated a HPLC assay that simultaneously determines the concentrations of both agents in clinical samples.Methods

Plasma/serum (200 pL) was mixed with 10% (w/v) zinc sulphate and acetonitrile, containing an internal standard (IS, 2 mg/L diazepam) and microcentrifuged for 5 minutes. Analytes in the supernatant were separated isocratically and quantitated by UV absorbance using


a Waters Symmetry C8 column and a Waters 2690 Separation Module coupled to a Waters 996 PDA.Results

Blood levels (voriconazole range: 0-13.5 mg/L; posaconazole range 0-5.1mg/L) were determined in 20 patients using the combined method. There was strong statistical correlation between the combined method and the individual methods (voriconazole R2>0.99, y = 1.0058x + 0.1188; posaconazole R 2>0.97, y = 0.9172x + 0.0322). The coefficient of variation for three levels of controls was less than 6% for voriconazole (n = 24) and less than 5% for posaconazole (n =14). All analytes were well resolved and eluted within 10 minutes, an improvement of 4 minutes for voriconazole. Voriconazole was quantitated using the internal standard whereas previously no compound was used.Conclusions

We have developed a single HPLC assay that measures both voriconazole and posaconazole in biological samples. It correlates well with the individual methods and shows acceptable precision. Sample preparation has been simplified and the run time shortened. The new test increases laboratory efficiency and results in improved turn-around-time and patient care.P34. CAPILLARY ELECTROPHORESIS FOR HAEMOGLOBINOPATHIES AND THALASSAEMIAS

T Marzulli, K Harris, J Teo, A Lammi, M Snowdon, J Curtin

Haematology Department, The Children's Hospital at Westmead, NSW 2145

[email protected]

IntroductionThe investigation of haemoglobinopathies and

thalassaemias have seen the development of many methods of analysis, ranging from cellulose acetate through to capillary electrophoresis. We decided to evaluate a commercial capillary electrophoresis system for routine use in a paediatric context with a high proportion of haemoglobinopathy and thalassaemia investigations.Methods

We analysed patient samples using Sebia Minicap capillary electrophoresis and our routine High Performance Liquid Chromatography (HPLC) system. Those patients showing a haemoglobin (Hb) variant were additionally analysed by cellulose acetate and citrate agar electrophoreses.Results

Capillary electrophoresis % HbF values were lower compared with HPLC. HbA2 and HbA levels were comparable, as were the levels of common haemoglobin variants. Capillary electrophoresis was able to separate reliably HbE and Hb Lepore from HbA2 , whereas HPLC, cellulose acetate and citrate agar did not separate these.

Common variants such as Hb Constant Spring, HbH and HbS were distinct, distinguishable among themselves and from normal bands, by capillary electrophoresis.Conclusions

Capillary electrophoresis separation of HbE and Hb Lepore from HbA2 is an advantage, enabling clearer determination of thalassaemias based upon HbA, levels. Distinguishing between Hb Constant Spring and HbH by capillary electrophoresis, could potentially remove our need for alkaline electrophoresis in discerning these cases. Distinct HbS and HbA, capillary electrophoresis peaks, avoids the scenario of falsely elevated HbA 2 , when the HbS HPLC band tails into the HbA, area. In summary, capillary electrophoresis allows for a significant reduction in the number of alkaline and acid electrophoresis gels required, thereby reducing staff time and improving turn around times in the investigation and determination of haemoglobinopathies and thalassaemias.P35. ROCHE PARACETAMOL ASSAY – PRODUCING RESULTS ON HAEMOLYSED SAMPLES

MGE Roser, GRD Jones.

Division of Chemical Pathology, St Vincent’s Hospital, Sydney

[email protected]

IntroductionParacetamol (Acetaminophen) overdose is an

important presentation at emergency departments (ED). Samples from our ED are often haemolysed. Product Information for the Roche paracetamol assay indicates significant interference at haemoglobin concentration (H index) above 150 mg/dL. Our aim was to develop a method to allow release of results on haemolysed samples.Methods

Haemolysate was made from human red blood cells and added to 9 patient samples, 3 BioRad Liquichek™ Immunoassay Plus Controls and 2 aqueous standards. The paracetamol concentrations in the patient samples ranged from 0 to 84 mg/L, 7 to 100 mg/L in the controls, and were 105 and 524 mg/L in the aqueous standards. The H index ranged from 0–1000 mg/dL. The samples were analysed on a Roche P module for paracetamol and H index before and after adding the haemolysate.Results

A significant positive interference was seen on the haemolysed patient samples, which showed a constant linear relationship with the amount of haemoglobin. The haemoglobin effect can be described as 0.03 mg/L change in measured paracetamol per mg/dL haemoglobin (range 0.022–0.047). In contrast no significant interference was seen in the controls and aqueous standards.


ConclusionsDue to the constant relationship between paracetamol

concentration and H index we are reporting corrected paracetamol results for patient samples with an H index up to 600 mg/dL using the following equation: reported paracetamol = measured paracetamol – (0.03 * H index). The lower reporting limit was increased to 5 mg/L to allow for the uncertainty associated with the correction. We noted that haemolysis interference in patient samples is different than in QC samples and aqueous standards.P36. URINARY ETHYL GLUCURONIDE AS A MARKER OF ETHANOL INGESTION

R Scott, E White, Q Lam, N Crinis

Biochemistry Department, Austin Pathology, Austin Health, Heidelberg, Vic

[email protected]

IntroductionEthanol ingestion is an exclusion criterion for

patients on the liver transplant waiting list. However, monitoring compliance is difficult, due to the rapid elimination of ethanol from both blood and urine, and because ethanol may be produced in vitro by fermentation. Ethyl glucuronide (ETG) is a direct metabolite of ethanol, formed in the liver by enzymatic conjugation with glucuronic acid. ETG may be detected in urine up to 80 hours after ethanol ingestion, depending on the amount consumed, and the cut-off used. We evaluated the Microgenics DRI Ethyl Glucuronide Immunoassay on a CDx90 analyser.Methods

Imprecision was evaluated above and below the cut-off of 500 ng/ml, and at a level of 1250 ng/ml. Spot urine samples were collected from patients attending the liver transplant outpatient clinic. Samples were assayed for ETG, ethanol, creatinine and CEDIA sample check. Confirmation of ETG results was performed by liquid chromatography-mass spectrophotometry (LCMS)Results

The coefficient of variation (CV) of the three control samples was 8.0% at 250 ng/ml, 3.9% at 750 ng/ml, and 2.7% at 1250 ng/ml. Fourteen patient samples were analysed for ETG by both DRI ETG and LCMS. Eleven of the fourteen were greater than the 500ng/ml cut-off by both methods. Ethanol was detected in one sample.Conclusions

The immunoassay and LCMS methods correlated well, with all elevated results by immunoassay being confirmed by LCMS. ETG levels ranged from undetectable to over 200,000 ng/ml. One patient assayed on four occasions over a period of three weeks returned values between undetectable and 21,000 ng/ml, despite insisting that he had not ingested any ethanol. We believe ETG analysis is valuable in monitoring ethanol abstinence.

P37. EVALUATION OF THE CHEMPAQ XBC POINT OF CARE INSTRUMENT

PA Simpson, R Tirimacco, PA Tideman

Integrated Cardiovascular Clinical Network SA, Bedford Park, SA 5042

[email protected]

IntroductionThe Chempaq XBC is a point of care instrument for

the quantitative determination of leucocytes, haemoglobin and three part differential count (granulocytes, lymphocytes and monocytes) in capillary or venous whole blood. Approximately 20 µL of blood is applied to the test cartridge and automatically diluted by a reagent solution. The Chempaq XBC dilutes the sample and uses a sensor to count the blood cells and a result is displayed within 2 minutes.Methods

Accuracy was evaluated by testing K-EDTA venous whole blood samples on both the Chempaq XBC instrument and hospital laboratory analyser (Beckman Coulter LH750). Precision was evaluated by performing replicate tests on a control solution.Results

Samples tested (n=104) showed good correlation between the Chempaq XBC instrument and the laboratory analyser for leucocytes, haemoglobin, granulocytes and lymphocytes (r≥0.90). Poor correlation was observed for monocytes (r=0.35). Precision analysis of the Chempaq XBC gave CV levels of 3.5%, 2.4%, 6.5%, 21.2% and 10.6% respectively for leucocytes, haemoglobin, granulocytes, monocytes and lymphocytes (n=20).

A high error rate was obtained in the first batch of test cartridges (17%, n=69). However, this appeared to be batch specific as a second batch of test cartridges tested displayed a much lower error rate (4%, n=50).Conclusions

The Chempaq XBC displayed adequate analytical performance for all analytes except monocytes. It may be clinically useful if the laboratory cannot provide appropriate turnaround times. The instrument should not be used for determining a patient’s monocyte count due to the poor accuracy and precision displayed. Further investigation into correlations with the laboratory using capillary samples would be recommended as this would be the most common blood type used at the point of care.


P38. AUDIT OF TROPONIN REQUESTS AT TWO QUEENSLAND TEACHING HOSPITALS: PRELIMINARY FINDINGS

S Sykes, J Tate, N Salmon, W Ferguson, L Cullen

Central Laboratory, Pathology Queensland and Emergency Medicine, Royal Brisbane Hospital, Herston, Qld 4029

[email protected]

IntroductionThe diagnostic and prognostic significances of

borderline elevations of Troponin I (TnI) are controversial. Although guidelines for diagnosis of myocardial infarction (MI) include a TnI rise or fall, this does not indicate a primary coronary thrombotic aetiology (type 1 MI). This is of particular relevance in patients admitted with other serious conditions who may have coincident coronary artery disease or risk factors. Methods

TnI results in the 6 months of 2007 Quarter 4 and 2008 Quarter 1 were retrieved from a common Pathology database of two Queensland teaching hospitals. Computerised hospital discharge summaries were also searched for a diagnosis code of MI and matched with grouped TnI episodes, which included TnI baseline, peak and delta values. The study also included a further prospective period of 15 months. The same TnI Beckman® methodology and 99% cut-off (0.04µg/L) were in use at each hospital. MI incidence was assessed in three TnI episode groups: Negative, Grey, Positive i.e. peak TnI<=0.04, >0.04 and <0.15, >=0.15µg/L). Statistical significances were calculated from differences between the cut-off or serial TnI values.Results and Conclusions

Of the 8373 TnI episodes, 1145 (21.3%) were from admissions with episodes in the Grey area. MI occurred in 233/1145 (20%), with 88/233 (38%) in the period after the relevant Quarter and 134/233 (58%) within the relevant Quarter. 21/134 (16%) were associated with episodes in the Positive Group with or without the diagnosis of a second MI. Since the TnI changes in the Grey area Group are small the incidence and final classification of MI are likely to depend largely on supporting ECG or clinical findings and the influences of coexistent comorbidities.

P39. AUTOMATED EDTA ASSAY FOR THE DETECTION OF SPURIOUS HYPERKALAEMIA DUE TO POTASSIUM EDTA CONTAMINATION

SCD Thomas, BD Rumbelow, GH White, PS Coates

Chemical Pathology, SA Pathology, SA

[email protected]

IntroductionSpurious hyperkalaemia due to in vitro EDTA

contamination is well documented, and can also lead to artefactually low Ca, Mg, Zn and ALP. We evaluated the prevalence of K3EDTA contamination of patient specimens referred for routine biochemistry tests from a tertiary level hospital. Methods

Plasma EDTA concentrations were measured using a previously published method (Davidson DF, Ann Clin Biochem 2007; 44: 294-96) implemented on a Roche Modular® analyser. The method utilises the ability of EDTA to extract Cu from PAN-Cu (pyridylazonaphthol-Cu) followed by colourimetric quantitation of Cu free PAN. EDTA was measured in consecutive specimens received over 1 month for electrolyte analysis. EDTA concentrations >0.2 mmol/L were considered significant as this level causes an artefactual increase in K of approximately 0.5 mmol/L, confirmed by spiking plasma samples with EDTA. Haemolysed samples were excluded from the analysis.Results

The limit of EDTA detection was 0.157 mmol/L (mean of blank + 3SD); reproducibility CV% was 0.27%. Eight-five of 11,896 patient specimens had EDTA >0.2 mmol/L; 68 of the 85 were excluded due to haemolysis, which causes significant positive spectrophotometric interference in the EDTA method. The daily percentage of EDTA-contaminated specimens ranged up to 0.9%, 70% being from wards and 30% from the Emergency Department.Conclusions

Automated analysis of EDTA in plasma is a rapid method to confirm contamination in a suspected sample and to explain moderately raised K levels and low Ca levels in non-haemolysed specimens. We now routinely measure EDTA in all non-haemolysed samples with a K >6.0 mmol/L, or in samples with unexpectedly low Ca, Mg or ALP.


P40. REPEAT ANALYSIS OF CRITICAL VALUES: ARE WE TRADING OFF TIMELY REPORTING AND PATIENT CARE FOR ANALYTICAL CERTAINTY?

S Vandergert,1 ZH Lu,1,2 JCG Doery1,2 1Biochemistry Unit, Pathology Department, Monash Medical Centre2Department of Medicine, Monash University, Clayton, Vic 3168

[email protected]

Introduction‘Critical’ results may be defined as results sufficiently

abnormal as to require urgent and sometimes ‘invasive’ intervention. This raises the dilemma as to what extent results should be repeated and confirmed to the highest level of analytical certainty at the expense of urgent reporting and effective, and possibly life saving, intervention.

In this study we have examined the effect of repeat analysis on the quality of results as well as on the turn around time to report them.Methods

Critical potassium results (<3 and >6 mmol/L) were measured by indirect potentiometry on a Beckman Coulter DxC 800 while critical troponin I (>0.08 µg/L) was measured by double antibody immunometric assay on the Beckman Coulter DxI 800. All critical potassium results were repeated prior to reporting while troponin I was only reanalysed after repeat centrifugation of the serum. Results (326 for potassium and 161 for troponin I) were audited over a 1 month period.Results

Using a 2 sided t-test the duplicate potassium results were within the measurement uncertainty (MU) and troponin I was also within MU but 13.4% were not concordant in that the original result was marginally above the positive cut off of >0.08. Repeat troponin I testing prolonged TAT approximately 45 min.Conclusions

Using the particular Beckman Instruments in this study we were able to satisfy the analytical goal of all ‘first time’ potassium results providing reliable basis for immediate medical management. The time, reagents and labour of confirming results could not be justified within the limitations of this 1 month audit. Repeat troponin I testing however was essential and was a significant contributor to the unacceptable (>4hr) management time of chest pain patients in our Emergency Department.

P41. PSEUDO-HYPERTHYROXINAEMIA: UNCOMMON CAUSE OF IMMUNOASSAY INTERFERENCE DUE TO BIOTIN THERAPY

N Wijeratne,1 JCG Doery,1,2 ZX Lu1,2

1Biochemistry Unit, Pathology Department, Monash Medical Centre, Clayton, Vic 31682Department of Medicine, Monash University, Clayton, Vic 3168

[email protected]

IntroductionUnusual immunoassay results due to interferences

are a well recognised problem and may cause unnecessary investigations and treatment. Here we present our experience on a rare but known cause of interference in immunoassays using biotinylated antibodies.Case History

Baby WN, one of non-identical twins born with features of liver failure and lactic acidosis. Thyroid function tests (TFT, Beckman DxI) at 1week of age: highly elevated FT4 (>77.7*) and FT3 (24.9*) but normal TSH (3.75). Mother and other twin had normal TFT’s excluding any interference from maternal antibodies, however all three individuals had elevated TPO antibodies. Methods and Results

Heterophile antibody interference was excluded using antibody blocking tubes (Scantibodies). Furthermore, TFT’s were normal when measured on Abbott Architect and Siemens Advia Centaur analysers. All results were reproducible at one month and 6 weeks of age.

Increasingly assay interference was suspected either from metabolites related to the underlying liver failure and organic acidosis or drugs. Further questioning revealed the organic academia was being treated with biotin 10mg 8hrly since day 2 of life.

Review of the TFT assay formats indicated potential interference in the FT3 and FT4 assays due to use of biotinylated antibodies. Biotin was then discontinued and all TFTs rapidly normalised. Ingestion of 30mg of biotin by one of the authors reproduced the observed interference.Conclusions

Beckman FT3 and FT4 assays utilise biotinylated antibodies and streptavidin coated paramagnetic particles. Excess of biotin in blood competes with biotinylated antibodies for the binding site on streptavidin resulting in apparently high FT3 and FT4 measurements. A number of manufacturers employ biotinylated antibodies that may be subject to both positive and negative interference from therapeutic doses of biotin depending on the exact assay format.


P42. A RARE CASE OF FALSE NEGATIVE URINE HCG RESULT WITH POINT-OF-CARE (POC) KITS BIOCHEMISTRY

G Dimeski,1 B Lowe,2 G Ward3

1Pathology Queensland2Emergency Department, Princess Alexandra Hospital, Brisbane, Qld3S&N Pathology, Brisbane, Qld

[email protected]

IntroductionA 19 year old sexually active female patient presented

to ED with per vaginam(PV) bleeding that had persisted for a month. The extended abdomen approximated to 4 months gestation suggestive of miscarriage. The urine pregnancy test performed in ED was negative on two different POC kits.Methods

Qualitative urine hCG was assessed using 3 POC kits with samples neat anddiluted 1/10, 1/100 with normal saline. Urine and serum samples were also analysed on three different automated immunoassay systems.Results

Sample Siemens Clinitest®hCG PregnancyTest

Siemens Healthcare Diagnostics

hCG Urine with OBC

kit Inverness Medical

Clearview hCG Combo

Inverness Medical

Beckman Dx1800

IU/L

Abbott Architect

IU/L

Roche E170 IU/L

Urine(neat) Negative Negative Negative 961,000 760,000 >1,000,000

Urine 1/10 Positive Positive Positive

Urine 1/100

Positive Positive Positive

Serum 470,000 486,000 383,000

The stated upper limits on the kits are Siemens Clinitest <600,000 IU/L, hCG Urine with OBC kit <1,000,000 IU/L and the Clearview hCG Combo has no stated upper measurable limit. Values >25 IU/L are detected as positive on all three kits.Conclusions

Presence of hCG in very high concentration, in this case due to molar pregnancy can result in high dose hook effect which can affect both POC kits and laboratory methods, resulting in false low or negative results. Falsenegative results can also be due to hCG isoforms not being detected by assay antibodies. Any mismatch or uncertainty with urine hCG results should be checked by a laboratory test using serum or plasma sample beforeintervention is initiated.

P43. HEART TYPE FATTY ACID BINDING PROTEIN AS A POSSIBLE MARKER OF TRAUMATIC BRAIN INJURY

N Wijeratne,1 C Morganti-Kossmann,2 N Turck,3 J-C Sanchez,3 HG Schneider1

1Clinical Biochemistry Unit, Alfred Pathology Service2National Trauma Research Institute; Melbourne, Vic3Biomedical Proteomics Research Group, University of Geneva, Geneva, Switzerland

[email protected]

IntroductionBiochemical assessment of the extent of damage

after traumatic brain injury (TBI) might help in the management of these patients. Heart type- fatty acid binding protein (h-FABP) was initially detected in cardiac myocytes but is also found in the brain. In this pilot study we investigated the value of h- FABP measured in cerebrospinal fluid (CSF) and blood of patients with severe TBI as a potential marker of brain damage and predictor of neurological outcome.Methods

We measured h-FABP in CSF and serum samples of 31 patients with severe TBI (GCS≤10) and 15 patients without TBI. For control h-FABP was quantified in serum samples of 16 healthy volunteers. Patient outcomes were assessed according to the extended Glasgow outcome scale (GOSE) at 6 months post-injury.Results

Patients with severe TBI showed significantly high h-FABP in CSF and serum up to day 3 post TBI compared to patients without TBI( Mann-Whitney U test: p<0.001 for CSF and p< 0.05 for serum). Serum h-FABP values of TBI patients were significantly increased up to day 5 compared to healthy volunteers (p<0.001). TBI patients were categorised into 2 groups.( Poor outcome: GOSE 1 to 5, Good outcome: GOSE 6 to 8) Significant inverse correlation was found between peak levels of h-FABP (highest value D0-D2) detected in serum and patient outcome (Spearman r = -0.4, p<0.05). CSF peak values in contrast did not predict outcome.Conclusions

This pilot study shows that h-FABP in serum might have the potential to be used as a marker of brain damage severity and patient outcome in TBI patients.


P44. LEAD POISONING DUE TO VATYOG, A PROPRIETARY AYURVEDIC MEDICINE

N Wijeratne,1 JCG Doery,1,2 A Graudins3 1Biochemistry Unit, Pathology Department, Monash Medical Centre2Department of Medicine and 3Southern Clinical School, Monash University, Clayton, Vic 3168

[email protected]

IntroductionAyurvedic medicine is a system of alternative

medicine native to the Indian subcontinent. Today it is manufactured on an industrial scale and formulated into pills and capsules with sophisticated packaging. However while exported products are subjected to some regulation the local market within India is essentially unregulated. Clinical presentation

28 yr old male presented to the GP with one month history of epigastric pain and constipation. There was a past history of low back pain for which he had been taking three Indian Ayurvedic tablets (Vatyog, Sahacharadi, Gandharvahastadi), two of each tablets per day for three months.Results

FBE: Hb 106 g/L (RR: 130–180) with basophilic stippling. Blood lead: 4.14 µmol/L (<0.48). After stopping all Ayurvedic medicines and undergoing oral dimercaptosuccinic acid (DMSA) chelation therapy blood lead level was 0.88 µmol/L. The Vatyog tablets contained 448 µg (2.16 µmol) of lead per tablet although this was not listed in the ingredients. The Sahacharadi tablet was lead free. No Gandharvahastadi tablets were available for testing.Conclusions

There are numerous reports in the medical literature about the dangers of heavy metal poisoning from lead, mercury and arsenic in Indian Ayurvedic medicine. Sophisticated packaging is no guarantee that such preparations are not highly toxic. It is unclear whether the lead in Vatyog tablets is due to deliberate formulation or contamination of the raw materials. With the increased influx of ethnic Indians in Australia it is likely that cases of heavy metal poisoning will increase until such time as the manufacturing of such preparations is brought under regulatory control in the country of manufacture. Australian doctors should be aware of this potential source of poisoning.

P45. THE WAR OF THE ROSES OR ROSE DUST CAN BE BAD FOR YOUR HEALTH.

G Smith, MP Metz

Biochemistry, Clinpath Laboratories, Kent Town, SA

[email protected]

IntroductionSulphaemoglobin is an acquired haemoglobinopathy,

much like methaemoglobin, produced by the exposure of blood to environmental oxidising agents in the presence of sulphur-containing compounds. Many of these environmental agents are drugs. It has been called pseudomethaemoglobin and can be confused with methaemoglobin. It presents with a brown/green cyanosis at very low concentrations. We report an avid gardener who presented undistressed but cyanosed to his physician.Case report

An 82 year old male with recognised, well compensated chronic lung disease presented to his physician cyanosed. He was not distressed (except by his colour) with a stable resting pulse and respiratory rate and no increased work of breathing. His arterial blood gas obtained in room air revealed haemoglobin 130 g/L (130-175), p02 98 mmHg (65-83), pCO3 41 mmHg (35-45), pH 7.38 (7.35-7.45), and 0 2 Saturation (calc) 87.5% (95.0-98.0). An instrument flag stated sulphaemoglobin was detected.

Discussion with the patient revealed his interest in gardening. He had been dusting his roses the day before presentation. Commercial rose dust can be 75% sulphur by weight. He was sent home without intervention and his colour improved gradually over a long time.Conclusions

Sulphaemoglobinaemia is a condition of which we should be aware. It differs from the other environmental haemoglobinopathies in that it does not respond to methylene blue infusion and is clinically manifest by cyanosis well before any adverse effects due to diminished oxygen carrying capacity. Laboratory workers should know if the blood gas analyser in use in their laboratory is able to detect it.


P46. UNUSUAL PRESENTATION OF ACUTE PORPHYRIA

N Wijeratne,1 D Holt,2 JCG Doery,1,3 R Fullinfaw4 1Biochemistry Unit, Pathology Department, 2Department of Clinical Nutrition, Monash Medical Centre3Department of Medicine, Monash University; Clayton, Vic 3168 4Department of Pathology, Royal Melbourne Hospital, Melbourne, Vic

[email protected]

IntroductionAcute porphyrias are rare metabolic disorders

associated with enzyme defects in the heme synthetic pathway and can present with diverse symptoms. Although the classic presentation is with acute abdominal pain, other less common manifestations may predominate.Clinical presentation

62 year-old lady presented with 3 month history of upper and lower limb weakness, severe pain in the finger tips and feeling generally unwell. She had ‘band like’ sensation around costal margin. After several admissions and normal gastroscopy she was referred for psychiatric counselling. No similar family history. She had 40 yr history of rheumatoid arthritis managed with methotrexate for past few years. Results

General biochemistry normal. Urine porphobilinogen (PBG) screening: strongly positive. Urine porphyrins: PBG 1,629 µmol/L (RR<10), total porphyrin 5,762 nmol/L (<300) and uroporphyrin 4,358 nmol/L (<40). Faecal porphyrins: total porphyrin 256 µmol/kg (<200), isocoproporphyrin 13 µmol/kg (<2), coproporphyrin, protoporphyrin and C3/C1 ratio -normal. Plasma total porphyrin: 62 nmol/L (<10).Discussion

The very high urine PBG confirmed the acute attack of porphyria. Normal faecal coproporphyrin, protoporphyrin and C3/C1 ratio excludes variegate porphyria and hereditary coproporphyria. Therefore, the diagnosis of acute intermittent porphyria (AIP) was made. However, red cell porphobilinogen deaminase (PBGD) was normal indicating that the AIP is probably due to PBGD defect restricted to the non-erythroid cells (AIP-Type II). In addition, the raised isocoproporphyrin in faeces with raised plasma porphyrin and uroporphyrin in urine is suggestive of porphyria cutanea tarda (PCT). Uroporphyrinogen decarboxylase estimation will clarify whether this is congenital or acquired. Conclusions

Acute porphyria is commonly considered but seldom diagnosed in cases of recurrent abdominal pain. Acute porphyria can present late in life and, as in this case, without a history of abdominal pain. The

peripheral neuropathy and psychiatric overlay were the clues to a correct clinical diagnosis. The co-existing but asymptomatic PCT findings added an additional twist to the biochemical findings.P47. A 20 YEAR AUDIT OF SCREENING FOR LEAD POISONING: CAN WE REDUCE THE COST?

N Wijeratne,1 JCG Doery1,2

1Biochemistry Unit, Pathology Department, Monash Medical Centre 2Department of Medicine, Monash University, Clayton, Vic 3168

[email protected]

IntroductionEnvironmental lead exposure is now a rare

occurrence as a result of removal of lead from both petrol and paint and stricter workplace and environmental policies. Nevertheless lead exposure and toxicity still occurs but usually from more exotic sources. Methods

We audited lead results from 1990–2010 to establish the yield from this investigation as well as haematological features that may assist in establishing whether lead analysis is justified. The sources of lead poisoning were reviewed.Results

Approximately 32 patients per year were tested for lead toxicity. Over 20 years 12 individuals (1.9%) had lead levels above 0.48 µmol/L (NH&MRC recommended cut-off for further clinical assessment). Only 7 symptomatic patients (1.1%) with lead level above 2.4 µmol/L (upper limit for occupational exposure) were found.

Basophilic stippling was always seen with lead >4.0 µmol/L but absent if lead ≤3.0 µmol/L. There’s significant negative correlation between lead level and Hb concentration among lead poisoning patients (Spearman correlation: r = -0.839, p <0.001). All patients with lead >2.4 µmol/L had Hb <12.0 g/dL. At a cost of $32/lead analysis and yield of 1.1% the cost per case of lead poisoning is approximately $2900.

Ayurvedic and herbal medicine were identified as the cause of poisoning in 3 patients, 2 were related to the occupational exposure, one domestic exposure from lead soldered antique copper kettle and a child case was due to ingestion and retention of a lead curtain weight.Conclusions

Lead poisoning is commonly investigated in patients with unexplained abdominal pain or neurological deficits however it is rarely the cause. We saw no cases of lead poisoning (lead >2.4 µmol/L) when Hb was >12 g/dL suggesting that investigation for lead poisoning is not cost effective unless this criteria is met. The addition of basophilic stippling makes lead poisoning much more


likely. Asymptomatic lead exposure (lead 0.48–2.4 µmol/L) may be present without haematological manifestations.P48. MEASUREMENT OF SERUM RIFAMPICIN BY HIGH-PERFORMANCE LIQUID CHROMATOGRAPHY WITH ULTRAVIOLET DETECTION - SAMPLE PREPARATION AND STABILITY CONSIDERATIONS

G Woollard, H Madhavaram, W Chiu

Department of Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand

[email protected]

IntroductionR i f a m p i c i n ( 3 - ( 4 - M e t h y l - 1 -

piperazinyliminomethyl)rifamycin SV) is a semisynthetic antibiotic used in the treatment of tuberculosis in combination with other drugs such as isoniazid, ethambutol and pyrazinamide. Therapeutic drug monitoring of rifampicin can be useful for patients with poor treatment response, suspected non-compliance and malabsorption. We developed an HPLC-UV method to assay serum rifampicin. Methods

The stability of rifampicin is well known to be a problem and this was addressed in both specimens and extracts. Serum and plasma aliquots were measured repeatedly for the first few hours and thereafter until 24 hours. Sample preparation was by simple protein precipitation. Several organic solvents were tested and the stabilities of the resulting extracts were examined. The extracts were chromatographed on a Phenomenex Prodigy ODS3 column and monitored by photodiode array detection at 334nm wavelength. Results from the HPLC method and our existing spectrophotometric method (adapted from McConnel et al 1979) were compared.Results

Serum and plasma rifampicin stored at room temperature, 4°C or -20°C showed no deterioration until at least 24 hours, 1week and 3months respectively. Specimens precipitated with acetonitrile were stable for at least 24 hours at room temperature which is entirely sufficient for our purposes because batches are short and are run quickly. Extracts in methanol or 50% acetonitrile/methanol mixtures are far less stable. The deterioration rate in methanolic solutions is too fast to be of use despite being utilised in several published rifampicin methods.

Comparison of HPLC vs. spectrophotometric method (n=14) revealed slope of 0.9994, r2 = 0.9447Conclusions

This HPLC-UV assay is a robust method for the measurement of serum or plasma rifampicin. The specimens and extracts are more stable than anticipated from the literature.

P49. IMPROVEMENTS IN CARTRIDGE RELIABILITY ON THE GEM PREMIER 4000 BLOOD GAS ANALYSERS

G Koerbin,1 H Robins,1 P Talsma,1 A Hatzilias2

1ACT Pathology, Canberra, 2Abacus Diagnostics, Brisbane

[email protected]

IntroductionAfter routine evaluation, GEM Premier 4000

blood gas analysers were installed into the Canberra and Calvary Hospitals in 2009. The only reagents required are disposable cartridges, GEM Premier 4000 PAK, comprising all components necessary for analysis, including quality controls. Of the first 62 cartridge replacements 32 were unscheduled indicating a reliability of <50%.This failure rate caused angst among our clients and required significant scientist time in cartridge replacement and client liaison. The manufacturer (Instrument Laboratory) acknowledged our concerns and agreed that the system/cartridge performance experienced was unacceptable. The manufacturing processes were reviewed and changes were made to improve the performance of the sensors. We report on those changes and subsequent cartridge reliability.Methods

Gold Epoxy was used to seal the back of the sensor wires to prevent air leakage and new cold formed pins were used to eliminate gaps between the sensor well and sensor wire. Visual inspection of all cards prior to their assembly into the cartridges was also implemented. Comparison of failure rates before and after modifications was undertaken. Results

In the first 8 months since the introduction of the modifications to the sensors the average reduction in cartridge failure rate fell from 52% to 19%. This failure rate was reduced to 12% in those areas where high numbers of blood gas analyses are performed. Failure to detect process control solutions was the main cause of error after the modifications.Conclusions

Improvements to the sealing of the sensor wires to prevent air leakage and the elimination of gaps between the sensor wells and sensor wires has reduced the failure rate of cartridges used on the Gem premier 4000.


P50. COMPARISON OF MEASURED AND CALCULATED FREE PSA ON THE SIEMENS ADVIA CENTAUR

HD Martin, K Lefrank

Clinical Biochemistry, Healthscope Pathology, SA

[email protected]

IntroductionFree PSA (fPSA) and its ratio to total PSA (FTR) are

useful in determining a man’s risk for prostate cancer and hence the necessity for a prostate biopsy. Until recently there was no assay available for the direct measurement of fPSA on the Advia Centaur. Instead users could calculate the fPSA by measuring complexed PSA (cPSA) and subtracting this from the tPSA, measured separately. This work compares the newly available fPSA assay with the previously available calculation.Methods

Sera from 364 patients aged between 40 and 87 years and without known prostate cancer were stored frozen until they could be concurrently analysed for fPSA, cPSA and tPSA. All methods were run according to manufacturer specification on the Advia Centaur.

Measured and calculated FTR (mFTR, cFTR) were compared using linear regression and clinical concordance grids.Results

Correlation between measured tPSA and tPSA calculated from (cPSA+fPSA), r2 = 0.99 was excellent, suggesting no significant loss of fPSA due to storage. The correlation between calculated fPSA and measured fPSA was r2 = 0.77 and r2 = 0.80 for mFTR vs cFTR. Quartile and tertile risk categories based on FTR are in common use; overall risk category concordance was 61/70 % respectively. Within and between run precision based on QC replicates was excellent, no CV value being >4.1%.P51. EFFICIENCY GAINS DUE TO AUTOMATION IN THE CLINICAL BIOCHEMISTRY LABORATORY

G Streitberg, K Ericksen

Dept. of Pathology, Southern Cross Pathology Australia, Monash Medical Centre, Clayton, Vic 3168

[email protected]

IntroductionIn 2004 the central biochemistry laboratory at

Monash Medical Centre installed a system of total laboratory automation (TLA) from Beckman Coulter – sample inlet, centrifugation, aliquotter, three analytical instruments, outlet and sample storage and retrieval. This resulted in the Dandenong and Moorabbin laboratories sending the non-urgent routine samples, out-patients and non-urgent ward patients, to the central laboratory. The benefits of TLA envisaged were improved turn around

times, decreased dependence on the central reception staff knowledge base, predictable process times, elimination of turn around time outliers, assistance to the evening and night shifts, improved efficiencies on the day shift, coping with increased work across all shifts without an increase in staff, decreased number of analytical platforms.Methods

Data extracted from the pathology laboratory information system for the turn around time for potassium, workload increase and for result validation time outliers.Results

Turn around time for potassium from the emergency department was substantially improved: 50% of the pre-automation and 88% of post-automation of samples were validated within the 60 minute window.

The number of time outliers decreased (sample collection to result validation): pre-automation 44 + 18 minutes, post-automation 27 + 4 minutes.

The workload increase for biochemistry since the introduction of total laboratory automation has been 59%. The staff numbers in the central clinical biochemistry laboratory have remained constant, whereas the staff numbers at the Dandenong and Moorabbin laboratories has decreased.Conclusions

Turn around times for automated chemistries has decreased, outliers have been substantially reduced, greater efficiency in the utilisation of staff has been achieved. The aliquotter has enabled the biochemistry laboratory to change work procedures to a parallel, rather than a serial, analytical process.P52. SIMULTANEOUS DETECTION OF COMMONLY FOUND SINGLE NUCLEOTIDE POLYMORPHISMS USING A SEQUENOM MALDI-TOF MASS SPECTROMETER

F Gray, K Byron, D Deam, A Dear, L Paiman, R McCoy, E Hrysoudis

Molecular Department, Healthscope Pathology, Clayton, Vic 3168

[email protected]

IntroductionMany common genetic disorders arise from a

single base mutation where there is substitution of one nucleotide for another, resulting in a single nucleotide polymorphism (SNP). The polymerase chain reaction (PCR) can be used in conjunction with a variety of techniques to detect commonly occurring SNPs. An alternate technique for SNP detection is mass-array SNP genotyping. This method, using a Sequenom MALDI-TOF Spectrometer, was compared with PCR, to test for the commonly occurring SNPs associated with the disorders of haemochromatosis and thrombophilia.


MethodsA single-well assay was set-up on the Sequenom

Mass-array Spectrometer to simultaneously detect the common SNPs associated with haemochromatosis (C282Y, H63D, S65C), and thrombophilia, namely Factor V Leiden G1691A mutation, Prothrombin gene G20210A mutation, Methylene TetraHydrofolate Reductase (MTHFR) C677T and A1298C.

150 EDTA whole blood samples sent for routine genetic testing for haemochromatosis and thrombophilia were run on the Sequenom Mass-array Spectrometer, and the results were compared with those obtained by the routine real-time PCR performed on the Corbett (Qiagen) Rotorgene 3000 (haemochromatosis) and the Roche LightCycler 1 (thrombophilia). Results

There was 100% concordance between the Sequenom Mass-array platform and the routine real-time PCR methods, in the detection of commonly identified Haemochromatosis, Factor V Leiden, Prothrombin gene and MTHFR SNPs. Conclusions

We demonstrate a high-throughput, efficient and sensitive assay, that simultaneously determines the presence of the commonly occurring SNPs in the genes associated with the genetic disorders of haemochromatosis and thrombophilia. The Sequenom Mass-array Spectrometer is now in routine use for genetic testing in our laboratory, replacing multiple PCR tests. P53. CONTRIBUTION OF SMOKING TO AMBULATORY BLOOD PRESSURE IN A POPULATION WITH A HIGH PREVALENCE OF THE ANGIOTENSIN-CONVERTING ENZYME GENE DD GENOTYPE

J Maseko, AJ Woodiwiss, R Brooksbank, OH Majane, GR Norton

Cardiovascular Pathophysiology and Genomics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

[email protected]

IntroductionA number of studies have established that smoking

is associated with hypertension, however few studies have looked at genetic factors that influence this relationship. Our aim was to determine whether the acute effects of smoking on blood pressure (BP) translate into an appreciable effect on out-of-office or central BP at a population level, and whether this effect is genetically pre-determined.Methods

In 689 randomly recruited participants of African descent with 24-hour BP and central hemodynamic measurements, we assessed the relationship between smoking and 24-hour or central BP and whether the

angiotensin-converting enzyme (ACE) insertion-deletion (D/D) variant modifies these effects.Results

Independent of age, sex, body mass index (BMI), treatment for hypertension, diabetes mellitus or an HbA1c >6.1%; smoking was associated with 24-hour (p<0.0005) blood pressure. This relationship BP was only present in participants with the DD genotype of the ACE gene (p<0.001), but not in participants with the I allele (p=0.26). The adjusted day diastolic blood pressure (DBP) in smokers (81.8±1.1 mm Hg) was greater than that in non-smokers (76.9±0.41 mm Hg, p<0.0001) a difference that was enhanced in participants with the DD genotype (smokers day DBP=83.3±1.7 mm Hg; non-smokers day DBP=76.1±0.59 mm Hg, p<0.0005). Although smoking was independently related to the aortic reflected pressure wave, this effect did not translate into an association between smoking and central (p=0.24) or 24-hour (p=0.35) pulse pressure. Conclusions

Smoking contributes to ambulatory blood pressure in populations with a high prevalence of the ACE DD genotype.P54. INVESTIGATION OF LOWER SENSITIVITY OESTRADIOL ASSAYS

L Boscato

Chemical Pathology, St Vincent’s Hospital, Darlinghurst, NSW 2010

[email protected]

IntroductionMeasurement of oestradiol (E2) levels in

postmenopausal women and children requires an assay sensitivity not achieved by most automated systems. The Diasorin E2 RIA assay was used for this purpose by a number of laboratories in Australia until the assay was unexpectedly withdrawn in 2009. The aim of this study was to find a suitable replacement assay.Methods

The following E2 assays were studied; Orion Spectria Sensitive RIA (O), Pantex RIA (P), DSL Ultra-sensitive RIA (D), Elecsys Estradiol II (E) and results compared to the DiaSorin RIA (DS) where possible. Assay bias was investigated by comparing sample analyte levels using regression analysis and difference plot. Standardisation was assessed by testing kit and in-house standards in all assays. Between and within run precision were determined using pooled sera of appropriate E2 levels.Results

Although results correlated well for all assays (n=31, O-r2= 0.96; P-r2=0.99, D-r2=0.90, E-r2=0.97), three of the assays displayed considerable bias. P and E had a positive bias (mean ratio P/DS-1.4, E/DS-1.7) and D a negative bias (mean ratio D/DS-0.77). In contrast the mean ratio


O/DS was 0.99 indicating good comparison of values for O. Assay of kit and in-house standards indicated that the bias differences could be accounted for by standardisation. Correction for the standardisation differences improved the comparability in results (mean ratio P/O-1.1, E/O-1.1, D/O-1.1, DS unavailable). Between and within run precision were acceptable for all assays and functional sensitivity (pmol/L) was found for O<39(CV 12%), P<49 (CV 6.2%), D<33 (CV 4.6%), E=43 (CV 20%), DS <33 (CV 14%).Conclusions

The O assay is the most suitable replacement assay for the DS because of the comparability of sample values eliminating the need to re-establish and change reference intervals. P55. FACTORS IN THE POOR REPEATABILITY OF ROUTINE ORAL GLUCOSE TOLERANCE TESTS

M Botros,1 ZX Lu,1,2 KA Sikaris1

1Melbourne Pathology, Collingwood, Vic 3066, 2Department of Medicine, Monash University, Clayton, Vic 3168

[email protected]

IntroductionThe 75g oral glucose tolerance test (OGTT) has

been the “gold-standard” for diagnosis of diabetes for decades although it is recognised that its reproducibility in people with diabetes is poor (~70%) due to high intra-individual variability (fasting glucose (FPG): CVi=7%; 2-hr glucose (GLU-2h): CVi=15%). We examined potential factors causing discordant classifications in repeat OGTTs available in a large private pathology.Methods

OGTT data (n=63,972) were reviewed. Glucose (fluoride-preserved, Roche Hexokinase method) had CVa<3%. OGTT interpretations (mmol/L): ‘Normal’ (FPG≤6.0 and GLU-2h≤7.7); ‘Impaired’ (FPG 6.1–6.9 and/or GLU-2h 7.8–11.0) or ‘Diabetes’ (FPG ≥7.0 or GLU-2h ≥11.1). Results

Overall, 9,577 (15%) had repeat OGTTs but majority of the repeats (n=6,626, 69%) were performed after one-year. Only 101 (1.1%) were repeated within one-month (see table below):

Normal: A ‘Normal’ OGTT is likely to be ‘Normal’ when repeated (79%). The only ‘Diabetic’ on repeat was due to error: the glucose load was not given initially! Impaired: An ‘Impaired’ OGTT was as likely to repeat as ‘Impaired’ or ‘Normal’ but not ‘Diabetic’. Diabetes: Only 42% of the initial ‘Diabetic’ OGTTs remained ‘Diabetic’ on repeat and all had significantly lower FPG (9.5 vs 7.1, p<0.03) with no difference in GLU-1h (15.6 vs 16.0) or GLU-2h levels (14.0 vs 14.6), indicating better patient

preparation prior to repeat. Three out of five ‘Normal’ repeats had initial FPG higher than the initial GLU-1h or GLU-2h values, indicating probable initial sample mixed up.

Initial OGTT Repeat OGTT

Normal Impaired Diabetes

Normal 34 (79%) 8 (19%) 1 (2%)

Impaired 17 (53%) 15 (47%) 0 (0%)

Diabetes 5 (19%) 10 (38%) 11 (42%))

ConclusionsOGTT is poorly reproducible in routine practice

due to not only the known biological variability of glucose levels but also a mixture of other factors including improper patient preparation; insufficient glucose load and sample mix up.P56. EVALUATION OF 25-OH VITAMIN D ASSAY ON THE IDS-iSYS ANALYSER

ZN Cluse,1 AN Fudge,1 PD O’Loughlin,1 and M J Whiting2

1Chemical Pathology, SA Pathology, Royal Adelaide Hospital, SA 5000 2Chemical Pathology, SA Pathology, Flinders Medical Centre, SA 5042

[email protected]

IntroductionThe continued global demand for 25-hydroxy

vitamin D (25-OHD) assays has created significant pressure for laboratories to seek more automated reliable platforms for analysis. The recently released IDS iSYS 25-OHD automated chemiluminescence assay was evaluated and compared to an IDS-EIA assay and a validated LC-MS/MS method.Methods

Serum samples were compared against both LC-MS/MS (n = 115) and IDS-EIA (n = 64) methods. Precision was assessed by analysis of 3 levels of QC material and an in-house serum pool, twice a day for 5 days. Linearity was assessed by diluting a serum pool with demonstrated high 25-OHD in a serum pool with low 25-OHD. Samples from 3 cycles of the DEQAS proficiency survey were also analysed to establish accuracy.Results

Regression between LC-MS/MS and iSYS methods gave a Passing-Bablok fit of -8.0 + 1.05x, with a bias of -4.4 nmol/L (R2 0.82). This was an acceptable deviation with 5.2% of the population falling outside the 95% limit of agreement. Regression between IDS-EIA and iSYS methods gave -1.61 + 1.07x, with a bias of 1.9 (R2 0.86). Acceptable reproducibility was obtained for 3 levels of the IDS controls (9.4% at 23.6 nmol/L, 9.0% at 65.8 nmol/L, 6.9% at 146.7 nmol/L), with excellent recovery (100%, 97%, 97%). The in-house pool also showed acceptable precision (5.5%CV) and a recovery of 92%


from the mean established by LC-MS/MS. Linearity gave 91 – 117 percent recovery between 24 and 217 nmol/L. The average percentage difference of the DEQAS samples from the all laboratory trimmed mean (ALTM) was -2%, ranging from -20% to 7% difference.Conclusions

The iSYS assay has performance characteristics suitable for routine estimation of vitamin D status, and enables our laboratory to process approximately 400 patient samples per day.P57. SEASONAL VARIATION IN THE DIAGNOSIS OF DIABETES MELLITUS IN ADULT MALES: A FIVE YEAR REVIEW

J Conradie, N Hadlow, R Wardrop

Department of Biochemistry, Western Diagnostic Pathology, Perth, WA

[email protected]

IntroductionA recent study investigated seasonal variation in the

diagnosis of Type 1 diabetes Mellitus (T1DM) in children worldwide. The study concluded that the incidence of T1DM showed a clear seasonal pattern. The investigators were able to demonstrate an increase in the number of T1DM diagnosed during the winter months compared to the summer months. This finding held true for both Southern and Northern Hemisphere countries. We were curious to see if we could demonstrate a similar pattern, looking at the number of Type 2 Diabetes Mellitus (T2DM) over a five year period.Methods

We analysed 65,572 (27,466 male and 38,106 female) glucose tolerance tests (GTT) done between January 2001 and December 2005. The data were grouped according to gender, month and the year the test was performed. Using WHO diagnostic criteria, we constructed a time series graph looking at the occurrence rate (%T2DM diagnosed) for each month. We then tested for seasonality at 3 locations (Darwin, Perth and Albany), looking specifically at GTTs done on adult males before 10 AM.Results

The mean fasting glucose levels did not differ significantly between summer and winter months (P= 0.3)

Surprisingly, the mean post load (2 hour) glucose was 0.5 mmol/L lower during the winter months (P= <0.001). We also noticed a 6.9% rise in abnormal GTTs (impaired glucose tolerance and diabetic levels) during the summer months. Reactive hypoglycaemic events seem to increase during winter compared to summer months (P = 0.03).

ConclusionsThese unexpected findings suggest a significant

seasonal pattern in the occurrence of T2DM (opposite seasonality to T1DM) and redistribution of post load glucose .This may have several implications.P58. COMPARISON OF THREE METHODS FOR QUANTIFICATION OF SERUM FREE CORTISOL

JP Galligan, BC McWhinney, SE Briscoe, CJ Pretorius

Pathology Queensland, Herston Hospitals Complex, Herston, Qld 4029

[email protected]

Introduction Serum free cortisol is a better indicator of cortisol

bioactivity than total cortisol. Recently there has been increased interest in methods for measuring serum free cortisol. We have compared three of these methods to measure serum free cortisol.Methods

Serum samples were assayed for total and free cortisol using LC-MS/MS. Serum free cortisol was separated from protein-bound cortisol using temperature controlled ultra-filtration. Calculated free cortisol incorporated transcortin measurement by radioimmunoassay. Free cortisol was also estimated using tracer dilution of 1,2,6,7-3H(N) cortisol. Results

Total cortisol levels ranged from 23–1162 nmol/L (median 554 nmol/L) whilst the range of free cortisol levels was <1.0–95 nmol/L. The free cortisol levels measured by LC-MS/MS equated to 1.4–11.1 % (median 3.6%) of total cortisol. The calculated percent free cortisol ranged from 2.2–13.2% (median 5.3%) and the tracer dilution free cortisol ranged from 7.5–17.5% (median 10.8%), purified tracer, 4.6–13.5% (median 9.7%). There was a strong correlation between LC-MS/MS % free cortisol and calculated % free cortisol (r2 = 0.910) with regression parameters: Calc % FC = 0.96* LC-MS/MS % FC + 1.6. The difference between the median values of the LC-MS/MS and tracer dilution groups of % free cortisol was significant (p<0.004) with regression parameters: Tracer dilution % FC = 0.89* LC-MS/MS % FC + 5.8 (r2 = 0.832). Conclusions

There was an excellent correlation between free cortisol levels measured by LC-MS/MS and calculated levels but levels of free cortisol estimated from tracer dilution were significantly different to levels measured by LC-MS/MS. Ease of isolation of free cortisol by controlled ultra-filtration and measurement by LC-MS/MS has made the assay of free cortisol levels much more accurate and accessible.


P59. MACROPROLACTIN: EXPERIENCE WITH 2 ASSAY SYSTEMS

P Giannopoulos, GRD Jones

Division of Chemical Pathology, St Vincent’s Hospital, Sydney, NSW

IntroductionMacroprolactin is prolactin complexed to IgG.

While macroprolactin is not biologically active it is recognised in all common prolactin assays with the potential to provide misleading results. We describe our experience with routine determination of macroprolactin and compare results with published reference intervals for monomeric prolactin. Methods

Prolactin and PEG precipitation techniques were performed according to manufacturer’s guidelines on the Siemen’s Centaur and Roche E170. A positive macroprolactin control was obtained from a known positive patient with ongoing supply of material. The calculation for the monomeric prolactin is provided in the respective macroprolactin manufacturer’s protocols. Macroprolactin was measured in patients with prolactin > 400 mIU/L (Centaur) and >500 mIU/L (E170).Results

Siemen’s Centaur data set: n=342, positive=6.4%, borderline=6.1%, negative=87.5%. E170 data set: n=127, positive=4%, negative=96%. QC - Centaur: n=45, mean=28% recovery, SD=5.9%, CV=21%, Monomeric Ref.Ints – Centaur: 1 / 20 patients outside reference intervals. QC – E170: n=24, mean=36% recovery, SD=6.1%, CV=16.8%. Monomeric Ref.Ints – E170: 1 / 5 patients outside reference intervals.Conclusions

The positive rate in each system is similar although the Centaur also classified additional patients as borderline. Our detection rate is similar to a published figure of 4%. The positive QC allows control and assessment of the PEG step. The use of monomeric reference intervals is an alternative method of reporting, however, the available literature shows variation in the reference interval data. P60. ASSAY INTERFERENCE CAUSING FACTITIOUS HYPERPARATHYROIDISM

S Ho,1 R Maguire,2 D Bell,1 M Gillett,3 S Corsbie1

1Biochemistry Department, St John of God Pathology, Osborne Park, WA, 2Biochemistry Department, PathWest QE II Medical Centre, Nedlands, WA, 3Biochemistry Department, PathWest Fremantle Hospital, Fremantle, WA

[email protected]

IntroductionThe presence of heterophile antibodies in serum

can induce false elevations of analytes measured via

immunoassays. Commercial automated immunoassays are formulated to reduce the effect of heterophile antibodies, however the potential for heterophile antibody interactions is not completely eliminated.

We present a case where interference in the 1-84 parathyroid hormone (PTH) assay led to falsely elevated PTH levels and an incorrect diagnosis of primary hyperparathyroidism. A 50 year old man had a PTH of 26 pmol/L (reference range 1.0–6.8) measured on the Siemens Healthcare Diagnostics Immulite 2500. The corrected calcium was 2.37 nmol/L (2.20–2.55). He underwent surgical exploration; biopsies on the parathyroid glands confirmed normal parathyroid tissue. Methods

A further sample was collected on this patient. Plasma samples were analysed on the Abbott Diagnostics Architect i2000SR and Siemens Healthcare Diagnostics Immulite 2500. The nature of the interferant was investigated via serial dilutions analysis and treatment with Heterophile Blocking Tubes (HBT, Scantibodies Laboratory).Results

Neat plasma PTH level measured on the Architect i2000 SR was 4.8 pmol/L whilst on the Immulite 2500, PTH was >263 pmol/L. The discrepancies were investigated via serial dilutions on the Immulite 2500 and showed a non-linear correlation, consistent with positive interference. Treatment of the plasma with HBT gave a PTH level of 5.6 pmol/L on the Immulite 2500, confirming the presence of heterophile antibodies.Conclusions

Antibody interference should be considered when PTH results are inconsistent with clinical findings. While the potential for antibody interference in immunoassay is well known, there have been few reports of this problem in PTH assays. Close clinician-laboratory communication is essential to prevent incorrect diagnosis and potentially harmful consequences for patients.P61. COMPARISON OF THREE 25-HYDROXYVITAMIN D METHODS

N Jenkins,1 M Black,1 J Pasco,2 HG Schneider1

1Clinical Biochemistry, Alfred Pathology Service, Melbourne, 2Geelong Osteoporosis Group, Barwon Health, Geelong

[email protected]

IntroductionMeasurement of 25-hydroxyvitamin D is the

accepted clinical indicator of vitamin D status. However standardisation of results between methods and laboratories remains a significant problem. Significant discrepancies were found between results obtained using our method (Roche Elecsys E170) with a previous measurement


(DiaSorin radioimmunoassay). Subsequently we measured 25-hydroxyvitamin D in the discrepant samples using the gold standard method (liquid chromatography-tandem mass spectrometry- LC-MS/MS) and compared the results.Methods

Fasting sera from a subset (n=55) of female participants (mean age 57 years; range 21–92 years) from the Geelong Osteoporosis Study (n=1265) were analysed for 25-hydroxyvitamin D using three different methods; the DiaSorin radioimmunoassay, the Roche Elecsys Vitamin D3 (25-OH) assay, and the LC-MS/MS method (RMIT Drug Discovery Technologies). Serum aliquots were stored for up to 8 years at -70oC before analysis.Results

In a selected subset of discrepant samples the Roche method correlated poorly with the DiaSorin method, however, both methods correlated similar with the LC-MS/MS method (Passing-Bablok regression; Roche = 0.46 DiaSorin + 4.62, r2 = 0.39; LC-MS/MS = 1.59 Roche + 3.12, r2 = 0.66; and LC-MS/MS = 0.92 DiaSorin + 6.74, r2 = 0.69).

Only one specimen (1.8%) contained measurable amounts (>4.0 nmol/L) of 25-hydroxyvitamin D2.

When using 50nmol/L as the cut-off for vitamin D sufficiency the Roche immunoassay determined that 83% of subjects were vitamin D insufficient. This was compared to 55% and 52% of subjects testing vitamin D insufficient using the DiaSorin and LC-MS/MS assays respectively.Conclusions

In regards to vitamin D, these findings showed the DiaSorin radioimmunoassay has slightly better agreement with LC-MS/MS than the Roche assay. The Roche assay seems to underestimate vitamin D levels. P62. LH MEASUREMENT - COMMUTABILITY OF QC AND QA MATERIAL

GRD Jones, L Nguyen


[email protected]

IntroductionBias assessment between methods requires patient

samples or commutable material. Material is commutable between two systems when it behaves in the same manner as patient samples. In this study we assess the commutability of Quality Assurance (QA) and Quality Control (QC) material for 6 commonly used systems for Luteinising Hormone (LH) measurementsMethods

LH measurements were made in patient samples, QA material from the RCPA QAP Endocrine Program and Liquicheck and Lyphocheck QC material from BioRad.

Measurements were made in duplicate in single runs on the Abbott AxSYM, Abbott Architect, Siemens Centaur, Roche E170, Beckman-Coulter Dxi, Ortho Clinical Diagnostics ECi and Siemens Immulite analysers. Data was analysed by comparison between each instrument pair for each material. Assessment was for linearity, and for bias at 10 and 20 IU/L using an acceptance criteria of +/- 10%.Results

The QAP material was linear in all 21 analyser pairs but only unbiased for AxSYM v Centaur; AxSYM v E170, Centaur c E170 and Immulite v OCD. Liquicheck was only linear compared to patient samples for Centaur v E170, OCD v Immulite and OCD v Dxi but only Centaur v E170 also passed bias criteria. Lyphocheck was linear in all systems except the Immulite v E170 and AxSYM v E170 with the bias criteria met by only 1/3 of the analyser pairs.Conclusions

The QA and QC material tested was not commutable for the majority of analyser pairs. This may indicate differences in assay specificity and differences between the molecular species of LH in the materials or the presence of some cross-reacting substances. This work indicates that commutability of materials for immunoassay must be confirmed with experimental data.P63. REVIEW OF 5 YEARS MACROPROLACTIN TESTS AT RPAH

K Lee,1 K Tan,1 P Williams1,2

1Department of Endocrinology, SSWPS, RPA Hospital, Camperdown, NSW 2050 2Discipline of Medicine, Department of Endocrinology, University of Sydney, Sydney, NSW 2006

[email protected]

IntroductionHyperprolactinaemia can indicate a prolactin

secreting tumour, investigation of which is expensive and invasive. Significant levels of prolactin also circulate as macroprolactin (MP) which is not biologically active and accumulates because of its long half life. The presence of high monomer prolactin levels must be confirmed before initiating unnecessary investigation. We reviewed 7,000 prolactin assays over 5 years at RPAH and report on the analysis for MP and monomeric prolactin (P) in these samples.Methods

Total prolactin (TP) levels were determined on the Immulite 2000. MP was determined after precipitation of high molecular weight proteins with 12.5% final polyethylene glycol according to standard protocols. P levels were determined in the supernatant and the difference between TP and P determined MP.


ResultsAn average of 150 samples exceeded 30 ng/ml/year

and including macroprolactin requests but excluding repeat samples resulted in 684 individual samples investigated for MP between January 2005 and May 2010 (9.7% of total assays). Females (F) comprised 81% and males(M) 19% of investigated patients. Macroprolactin was present in 154 patients, 72% f and 28% m and was even present in 19 patients in the absence of hyperprolactinaemia (<30ng/ml TP, <15ng/ml P). Of 116 MP patients, 72 had P values in the normal Range (<16 male,-<20 female ng/ml) but 44 had elevated biologically active P. 25 Patients were investigated for MP that did not have MP or elevated P.Conclusions

It is critical to examine and report on samples for P even in the presence of high MP as it is the critically active component producing the clinical condition.P64. HbA1c FOR SCREENING AND DIAGNOSIS OF DIABETES: AGE AND GENDER EFFECT

ZX Lu,1,2 KA Sikaris1


[email protected]

IntroductionHbA1c is now recommended for screening and

diagnosis in the USA although not in Australia yet. Recently we have also reported using our own data that HbA1c ≤5.5% confidently rule-out while HbA1c ≥7.0% rule-in diabetes in adults. Here, we aimed to examine whether these HbA1c cut-off values for screening and diagnosis of diabetes are age or gender related. Methods

Data from patients (n=6,743) who had a 75g-OGTT and an HbA1c (Bio-Rad Variant II Turbo analyser) performed within 2-weeks was extracted from our pathology database. Diabetes was classified as FPG ≥7.0 mmol/L and/or GLU-2h ≥11.1mmol/L. Patients were grouped by their HbA1c levels.Results

Of the 6,743 (47.2% females) individuals, 45.7% were diabetic and 18.7% normal. The age and gender-related prevalence of diabetes are below: age HbA1c Categories

Sex (y) n All ≤5.5 (n=200)

5.6-6.0 (n=528)

6.1-6.4 (n=488)

6.5-6.9 (n=389)

≥7.0 (n=305)

Both all 6743 46% 13% 23% 41% 67% 92%

M all 3562 47% 15% 24% 41% 65% 94%

18–40 241 43% 3% 18% 42% 56% 95%

40–60 1411 43% 13% 20% 36% 58% 92%

>60 1910 50% 20% 27% 44% 70% 95%

F all 3181 45% 10% 23% 40% 70% 91%

18–40 344 26% 4% 6% 43% 59% 90%

40–60 1121 42% 8% 18% 31% 68% 92%

>60 1716 50% 22% 28% 44% 71% 89%

The prevalence of diabetes rises exponentially as HbA1c increases in all the groups. To rule-in diabetes using HbA1c≥7.0%, almost all the people in each group would have diabetes. Confidence in rule-out diabetes using HbA1c≤5.5% is much higher in young (<40y) than in the older adults (≥60y) of both genders.Conclusions

The utility of HbA1c≥7.0% for diabetes diagnosis is independent of age and gender. However, confidence in using HbA1c ≤5.5% to rule-out diabetes is age-dependent.P65 MACROPROLACTIN: REPORTING OF THE MONOMERIC FORM

M Ridgwell, CCG Wood, P Ward

Endocrinology, Pacific Laboratory Medicine Services (PaLMS), Pathology North, Royal North Shore Hospital, St Leonards, NSW 2065

[email protected]

IntroductionMacroprolactin is a high molecular weight complex

of prolactin bound to an immunoglobulin molecule and is a source of immunoassay interference that may lead to misdiagnosis of hyperprolactinaemia. Polyethylene glycol (PEG) is widely used to precipitate these biologically inactive complexes from the biologically active monomeric prolactin. Results of PEG precipitation have traditionally been reported as percent total prolactin recovery with a 40% cutoff to distinguish macroprolactinaemia from true hyperprolactinaemia. Recent publications have called for a change in reporting to one based on monomeric prolactin levels.Methods

Prolactin was measured on the Siemens Immulite 2000 platform. High molecular weight complexes of prolactin in serum were precipitated using a final concentration of PEG of 12.5%. Samples with a normal level of prolactin were precipitated with PEG in order to establish a monomeric prolactin reference range. Samples with levels of prolactin >500 mIU/L were also subjected to PEG precipitation and their resulting monomeric prolactin levels assessed against this reference range to determine the presence of macroprolactinaemia.Results

A monomeric prolactin reference range was established as being <500 mIU/L (n=70). This correlated to prolactin recovery levels greater than 80%. Hyperprolactinaemia was established at monomeric prolactin levels >500 mIU/L (prolactin recovery >80%) whilst macroprolactin precipitated into the monomeric reference range with prolactin recoveries less than 40%. Combined Hyperprolactinaemia and Macroprolactinaemia was seen in those samples with monomeric prolactin above the reference range (prolactin recovery >40<80%).


ConclusionsA report that includes the initial prolactin level,

the recovered monomeric prolactin level, the percent recovery together with appropriate reference ranges and an interpretative comment provides an easy to understand format.P66. FREE TRIIODOTHYRONINE (T3) MEASUREMENTS: ANALYTICAL ISSUES WITHIN TWO POPULATIONS

P Ward, M Ridgwell, CCG Wood


[email protected]

IntroductionImmunoassays used to estimate levels of free

thyroid hormones are problematic and subject to possible interference from a number of sources particularly drugs and binding proteins. The measurement of Free T3 is appropriate in pregnancy when TSH is suppressed and Free T4 normal as antithyroid drugs may affect the foetus.Methods

TSH, Thyroxine Binding Globulin (TBG) and thyroid hormone measurements, both free and total, were made using a Siemens Immulite 2000 platform.Results

In a population of pregnant subclinical hyperthyroid women, elevated levels of Free T3 were present far more frequently than expected. Comparisons of normal pregnant women and those with subclinical hyperthyroidism using measures of TBG, Total T3 and Free T3 clearly established erroneous elevations of Free T3 in pregnancy. A population of neonates (n =78) were all clinically euthyroid with normal levels of both TSH and Free T4. Thirty four (44%) showed distinct elevations of Free T3 levels. There was no indication of increased levels of TBG but 29 % of the babies with elevated Free T3 levels also had elevated levels of Total T3 (when measured). In the elevated Free T3 group (n =34), 23 had clinical comments on the request form. Of these 23 clinical comments, 21 (91%) indicated some form of maternal thyroid disease with "Maternal Hypothyroidism on Thyroxine" the most prevalent.Conclusions

Two clinical populations showed erroneous elevations of Free T3. Elevated levels of TBG appear to be the primary cause of the false elevation of Free T3

in pregnancy. The mechanism for the falsely elevated levels of Free T3 in euthyroid neonates admitted to the NIC is less clear.

P67. EFFECT OF NEW GESTATIONAL DIABETES MELLITUS CRITERIA ON AGE-SPECIFIC PREVALENCE

KA Sikaris,1 ZX Lu,1,2 EM Briganti3

1Melbourne Pathology, Collingwood, Vic 30662Department of Medicine, Monash University, Clayton, Vic 31683 Epworth Hospital, Richmond, Vic 3121

[email protected]

IntroductionNew diagnostic criteria for gestational diabetes

mellitus (GDM) using a 75goral glucose tolerance test (OGTT) have recently been recommended. We examined the impact of these on the GDM prevalence.Methods

Data from women who had a 75g-OGTT performed during pregnancy (n = 12,409) were reviewed. GDM was classified using the current criteria (FPG %5.5 or GLU-2h %8.0 mmol/L) and the new criteria (FPG 5.1 or GLU- 1 h % 10.0 or GLU-2h % 8.5 mmol/L). Age-specific GDM prevalence by both criteria was calculated.Results

Overall, 3,218 women had GDM either by current or new criteria. Of these, 55.6%, 14.3% and 30.2% met both criteria, current criteria alone and new criteria alone, respectively.

age (years) number prevalence of GDM

current criteria % (95% CI)

new criteria % (95% CI)

Difference (new-current/

current)

all 12,409 18.1 (17.4-18.8) 22.2 (21.5-23.0) 23%

<20 30 13.3 (0.4-26.2) 10.0 (0.0-21.4) -25%

20-24.9 292 11.6 (7.9-15.3) 15.8 (11.6-20.0) 36%

25-29.9 1974 15.4 (13.8-17.0) 19.5 (17.7-21.2) 27%

30-34.9 5011 18.2 (17.1-19.2) 21.4 (20.3-22.5) 18%

35-39.9 4085 19.0 (17.8-20.2) 23.7 (22.4-25.0) 25%

40-44.9 953 21.6 (19.0-24.2) 28.3 (25.5-31.2) 31%

≥45 64 15.6 (6.5-24.8) 23.4 (12.8-34.1) 50%

The new criteria identified 23% more women as having GDM compared to the current criteria. This increase is age-dependent as the new criteria identified 25% less in the young (<20y) but 50% more in the older group (45y) as having GDM. Moreover, the foregoing in the new guidelines of the glucose challenge test (GCT) as an initial screening would only increase the GDM prevalence further, given GCT is associated with a 18% false negative rate.

Conclusions The increased prevalence of GDM by the new criteria has workforce implications not only in antenatal/postnatal care by the medical profession, but also in pathology services for the provision of the increased number of OGTTs required during pregnancy as well as post-partum follow-up.


P68. EVALUATION OF HE4 AND CA125 IN CANCER

K Tan,1 J Tran,1 P Williams1,2

1Department of Endocrinology, SSWPS, RPA Hospital Missenden Road, Camperdown, NSW 20502Discipline of Medicine, Department of Endocrinology, University of Sydney, Sydney, NSW 2006

[email protected]

IntroductionHuman Epididymis Protein 4 (HE4) alone is not

recommended as a screening test for malignancy, however, we wished to evaluate HE4 was a useful adjunct test to CA125 in assessing malignancy risk.Methods

For 2 weeks samples requested for CA125 analysis at RPAH were tested for HE4 and the risk of ovarian malignancy algorithm (ROMA) value calculated (menopausal status considered). HE4 assay performance was also evaluated. Results

The HE4 assay had an intra-assay CV of 3.30% and 1.96% at 25.1 pmol/L and 357.7 pmol/L respectively. The inter-assay CV at 3 levels was 4.7%, 2.7% and 2.7%. An average 98% recovery was found with samples serially diluted up to 64 fold.

73 of 118 samples were from O&G and Oncol/Gynae wards and likely to have the highest incidence of malignancy. Of these 17 were positive and 36 were negative for all 3 parameters (CA125, HE4 & ROMA). When CA125 alone was used 31 out of 73 exceeded the reference range, HE4 alone had 19 samples above the reference range and when both were combined 37 of the 73 patients exceeded the reference ranges. In the whole group 50.8% were normal, 22.9% were distinctively positive, 26.3% were found to be in the grey-zone. On a test-by-test basis, 39% had CA125 above the normal, 26.3% had HE4 above the normal but when combined 44.1% were found to be above the reference. Conclusions

HE4 and CA125 may be useful in assessing malignancy or the therapeutic response in cancer patients. This finding is preliminary and the validity of its use requires clinical validation to determine true effectiveness.

P69. TESTOSTERONE SURVEY RESULTS FROM THE AACB (WA BRANCH) QC SUBCOMMITTEE

M Taranto1 and members of the AACB WA Branch QC Subcommittee1Core Clinical Pathology and Biochemistry, PathWest, Royal Perth Hospital, Perth, WA 6000

[email protected]

IntroductionIn 2007, a survey was undertaken to determine the

variability of testosterone results in Western Australian (WA) laboratories. The study focussed on the clinically critical lower end of the assay and results were compared to a gold standard method (LC-MS/MS, Mayo Clinic, Rochester, Minnesota, USA).Methods

Seven linearly related male serum samples (series A) and four linearly related female serum samples (series B) were assayed by all eight public and private pathology laboratories in WA offering testosterone measurement. Immunoassay platforms included Roche Elecsys and E170 Modular, Siemens Immulite 2000, Centaur and coat-a-count RIA, Abbott Architect and OCD Vitros Eci. In 2009 a local LC-MS/MS method became available and was retrospectively included in the survey. Results

For male series A, mean testosterone ranged from 0.6–11.9 nmol/L (between-method CV 64.9%–16.7%). Immulite overestimated testosterone concentration compared to LC-MS/MS (mean difference +18%), whereas Architect, Roche and Vitros platforms recovered lower results (mean difference -13% to -44%). For female series B, mean testosterone ranged from 0.3–4.1 nmol/L (between-method CV 94.1%–27.4%). For samples 2–4, all assays except Vitros overestimated testosterone when compared to LC-MS/MS (mean difference +9% to +146%).Conclusions

The wide range of these results for these 11 samples demonstrates the need for improved harmonisation of testosterone assays to enable laboratories to provide comparable patient results. For example, a sample with a mean result of 8.4 nmol/L had a range of 5.3–11.0 nmol/L. Further investigation is required to determine the causes of poor between-method agreement for low-level testosterone measurement which may indicate inadequate calibration or non-optimisation of assays.


P70. EVALUATION OF THE NEW THERMOFISHER QMS EVEROLIMUS ASSAY

J Tran,1 J Ray,2 K Gao,3 P Williams,1 M James3

1Department of Endocrinology, SSWPS, RPA Hospital, Camperdown, NSW 2050 2Clinical Pharmacology and Toxicology, SydPath, St Vincents Hospital, Darlinghurst, NSW 20103Diagnostics, Thermofisher Scientific, Lidcombe, NSW 2141

[email protected]

IntroductionEverolimus is an immunosuppressant for the

prevention of transplant rejection. The current TDx assay has a limited life and a high positive bias against the HPLC-MS/MS. We evaluated the new Thermo Scientific QMS Everolimus turbidimetric assay on the CDx90 analyser against HPLC-MS/MS.Methods

Two pooled samples, a high control and a non-transplant patient sample were used to determined assay performance (CLSI guidelines). Both stored and fresh patient samples were quantitated with HPLC-MS/MS (SydPath). Onboard reagent stability and interference by Cyclosporine metabolites were determined. Results

The correlation between the two methods was high (R=0.976) with a linearity coefficient of 0.994. Bland Altman plots showed a negative bias for the QMS assay 18.7% with an absolute difference at zero concentration of 17.4%.

Intra-assay precision (CV) at levels of 3.99 ng/mL, 8.02 ng/mL and 16.18 ng/mL were 5.87%, 3.66% and 3.77% and inter-assay precision was 6.42%, 3.64% and 2.99% respectively.

Onboard reagent stability increased when capped after each run. Cyclosporine metabolites did not interfere with the assay and fresh samples correlated better (R=0.970) than stored refrigerated samples. (R=0.939).Conclusions

The new QMS Everolimus assay, yet to be released worldwide, had a constant bias but correlated well with HPLC-MS/MS. The increased reliability and accuracy of the QMS assay compared to the TDx technology provides a timely replacement. The random access assay will reduce the need to batch samples and provides a suitable alternative method to LCMS/MS to monitor Everolimus concentrations.

Kits and consumables subsidised by Thermo Scientific.

P71. EFFECT OF LITHIUM AND COMMON ANTICONVULSANTS ON THYROID FUNCTION: QUANTIFYING THE EFFECTS

R Wardrop, N Hadlow


[email protected]

IntroductionCommon anti-convulsants such as Phenytoin and

Carbamezapine lower FreeT4 (FT4) however the effects of Valproate and Lithium are less clear. The aim of this study was to quantify these effects.Methods

Subjects with simultaneous requests for thyroid function and therapeutic drug (TD) were extracted from the database from over 5 years (n=12,969). Cases then removed included any with undetectable drug levels, known thyroid or anti-thyroid therapy and those on more than one TD. In subjects with more than one record over the timeframe results were averaged. Thyroid function tests were then compared to a reference group. Four groups were considered, those on Carbamezapine (n=841), Phenytoin (n=616), Lithium (n=1830) and Valproate (n=1989). A secondary data extraction examined subjects on Lithium and Valproate (n= 325 ). Results

Those on Phenytoin, Carbamezapine and combination Valproate/Lithium had reduced FT4 levels of 1.2, 1.1 and 0.7 pmol/L on average respectively (p <0.01) compared to the reference group. Lithium had no significant effect on FT4. Valproate alone elevated FT4 levels by 0.9 pmol/L on average (p<0.01). All 5 groups had mean and median TSH values above the reference group (p<0.01), both when all TSH data was examined or when analysis was limited to subjects with TSH within the reference interval (0.40-4.00 mIU/L). Compared to a reference population, those taking a TD had increased likelihood (14.7%) of an abnormal TSH. Similarly they were more likely (9.5%) to have an abnormal FT4 with the exception of patients on Lithium alone. Conclusions

FT4 was only modestly reduced by Phenytoin and Carbamezepine in this population. Subjects on Valproate had variable FT4 effects. The rate of abnormal TSH results in this group was increased in comparison to a reference population.


P72. BIOLOGICAL VARIATION AND THE EFFECTS OF AGE, SEX, TIME OF COLLECTION, ON TSH LEVELS IN A EUTHYROID POPULATION (10 YEAR AUDIT).

R Wardrop,1 J Grasko, 2 N Hadlow1

1Biochemistry Department, Western Diagnostic Pathology, Perth. WA 61542Core Clinical Pathology and Biochemistry, Royal Perth Hospital, Perth, WA 6000

[email protected]

IntroductionLiterature suggests that the biological variation of

TSH is ~ 20% for euthyroid patients. We undertook a retrospective review of patients euthyroid over 10 years to investigate factors which effect TSH levels and to verify the biological variation.Methods

Records of patients with a TSH in the reference interval (0.40-4.00 mIU/L) between 1st Jan and 30th June 2000 were extracted from the database. All subsequent thyroid function records and thyroid antibodies were then extracted for a 10 year period until 31st Dec 2009. Cases with more than 3 TSH records were retained (n=17,171). Any subject with a thyroid result outside the reference interval or with history which could effect TSH in any records was removed. The remaining data set (n = 12,569) was then examined for population distribution, sex, age, time of collection trends and biological variation.Results

There were two populations contained within the reference interval, the first with a median TSH of 1.50 mIU/L. There were analytically significant changes in TSH mean/median values based on age and time of collection. The biological variation for any individual lay within a large range (6% - 54%) and varied with the mean/median TSH value. The average biological variation remained relatively constant between TSH of 0.5 and 2.75 mIU/L at ~ 24%. Thereafter it fell and at an average TSH of 3.75 mIU/L was 12.2%. Conclusions

The use of a generic reference interval of 0.4-4.0 has limitations. Age and time of collection should be considered when reviewing TSH especially near the upper limits of a reference interval. Biological variation of TSH is markedly individual and may not be constant across the whole reference interval.

P73. VARIATION OF FEMALE PROLACTIN LEVELS WITH MENOPAUSAL STATUS AND MENSTRUAL CYCLE

N Hadlow,1,2 M Tanner1,2 R Wardrop1

1Department of Biochemistry, Western Diagnostic Pathology, Perth, WA,2Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, QEII Medical Centre, Perth, WA

[email protected]

IntroductionProlactin is not commonly recognised as a hormone

that changes significantly within the menstrual cycle or menopause. The aim of this study was to determine the variability of prolactin and establish prolactin reference intervals for our laboratory.Methods

Prolactin levels obtained from 6540 subjects between January 2006 and November 2008 were divided into 5 groups - males, postmenopausal females and premenopausal females in follicular/non-cycling, ovulatory and luteal phases. The 97.5th centile defined the upper reference limit of prolactin for each group.Results

The prolactin upper limit was not significantly different in males and postmenopausal females (430 and 440 mU/L respectively). It was significantly higher in premenopausal females (590 mU/L) compared to males and postmenopausal females. Within premenopausal females, the prolactin upper limit was significantly higher in ovulatory phase (680 mU/L) compared to follicular/non-cycling (540 mU/L) and luteal phases (580 mU/L), and in luteal phase compared to follicular/non-cycling phase. Women in ovulatory phase had an upper reference limit 54% higher than postmenopausal women.Conclusions

Prolactin varied significantly throughout the menstrual cycle. The utility and accuracy of testing may be improved by applying specific reference intervals for each phase of the menstrual cycle. Alternatively, a single reference interval could be used in premenopausal women if prolactin was always measured in the follicular phase, well before midcycle. A premenopausal woman may have a prolactin result up to 50% higher than a postmenopausal woman and use of a similar reference interval for all women may not be optimal. Prolactin levels in postmenopausal females and males were not significantly different and a common prolactin reference interval could be applied for these groups.


P74. ELEVATED FASTING INSULIN AND REDUCED SHBG: DIFFERENCES IN MALES AND FEMALES

Narelle Hadlow, R Wardrop, L Merton


[email protected]

IntroductionSex hormone-binding globulin (SHBG) is produced

in the liver and levels regulated by insulin. Low levels of SHBG are correlated with hyperinsulinaemia. We assessed proportions of men and women with insulin resistance, using criteria of Kidson et al (MJA 2005), at varying levels of SHBG.Methods

Moderate insulin resistance was defined as fasting insulin >14 mIU/L with normal or elevated glucose if requested. Retrospective analysis of 5 years data for concurrent fasting insulin and SHBG was performed. SHBG results were stratified in deciles for men and women and proportions of patients with insulin >14 mIU/L determined for each decile.Results

3,416 records with concurrent fasting insulin and SHBG were available, 2386 in females and 1130 in males. The rate of moderate insulin resistance in men with lowest SHBG results (0–10 nmol.L) was 26.7% compared to a rate of 22.7% in men with highest SHBG levels (>50 nmol/L). In women the rate of moderate insulin resistance increased progressively with lower SHBG. Women with SHBG results over 50 nmol/L had an average rate of insulin resistance of 11.6%. In women with lowest SHBG results (0–10 nmol/L) the rate of insulin resistance was 75.0%, a much higher rate than that in men with similarly low SHBG levels. In subjects with an SHBG in the lowest decile (0–10 nmol/L) the average insulin was 21.5 mU/L in women and 12.7 mU/L in men.Conclusions

In this population the relationship of SHBG and insulin was different in men and women. The rate of moderate insulin resistance and the average insulin were higher in women than men for a given decile of low SHBG. The reasons for this are unclear but further study may be warranted.P75. EFFECTS OF TIME OF COLLECTION ON SERUM MORNING CORTISOL LEVEL

N Hadlow, N Varis, R Wardrop

Department of Biochemistry, Western Diagnostic Pathology, Perth, WA

[email protected]

IntroductionVarying morning cortisol cut points (550, 500,

300, 100 nmol/L) and their implications for assessment

of adrenal function have been reviewed in the literature. Cortisol has a well-known diurnal variation and time of morning collection may vary. This study assessed the effect of time collection on cortisol levels.Methods

Cortisol results (n=13,953) were extracted from the WDP database over a 4 year period. Dexamethasone suppression, Synacthen tests and results >1,000 or <30 nmol/L were excluded. The proportion of morning cortisol results falling below 100, 300 and 500 nmol/L were determined in 15 minute intervals from 7.30-9.45 am. Results

The proportion of cortisol levels over 500 nmol/L fell from 40% to 21% from 7.30–9.45 with an average of 5% more patients below the cut-point every 30 minutes. Including cortisol levels at all times of the morning, most results (69%) fell in an intermediate range (100–500 nmol/L). The proportion of cortisols below 100 nmol/L remained relatively constant with a mean of 1.3% (range 0.2–2.6%) results below this cut point. The percentage of patients with levels <300 nmol/L increased from 12.3% to 31.7% over the morning and more than doubled between 8.00–9.15 am.Conclusions

A cortisol of <100 nmol/L only occurs in a small proportion of patients and is relatively consistent over the morning. Not many patients would be considered as likely adrenal sufficient (level >500 nmol/L) using morning cortisol. The percentage of patients with levels >500 nmol/L is halved over the morning from ~40 to 20%. Follow-up of all intermediate results (100–500) would require Synacthen testing in up to 79% of patients. Careful attention to time of collection is important in interpretation of morning cortisol levels. P76. ROCHE TESTOSTERONE II IMMUNOASSAY & LC/MS: HOW DOES IT COMPARE?

M Coelho,1 R Wardrop,1 K Hoad, 2 N Hadlow1

1Biochemistry Department, Western Diagnostic Pathology, Perth, WA2Special Chemistry, Core Clinical Pathology and Biochemistry , PathWest, Royal Perth Hospital (RPH), Perth, WA

[email protected]

IntroductionThe aim was to evaluate the new Roche Testosterone

II assay (Testo II) for DHEA-S cross-reactivity, precision and accuracy compared to LC/MS.Methods

The Roche Testo-II & I, performed on the Roche Cobas e601, were compared to LC/MS (Royal Perth Hospital). Male and female samples (n=42) were analysed. Female patients (n=16) with varying DHEA-S were


measured on the three assays. Two female patient pools (n = 76) and QC data were used to assess precision of Testo II. Routine patient testosterone data at WDP was collected for January 2009 and January 2010. The two data sets were compared to one another. Results

Females (n = 25) with testosterone concentrations 0 – 5 nmol/L demonstrated ~ 26% negative bias with Testo II compared to Testo I. Female testosterone population data for January 2009 (n = 848) and January 2010 (n = 603) were compared using a z-test for the sample means. Two-tail p-value at α = 0.05 (95%) was 3.8 x 10-13 confirmed a significant difference. Male testosterone population data for January 2009 (n= 680) and January 2010 (n = 574) were similarly compared using a z-test for the sample means. Two-tail p-value at α = 0.05 (95%) was 0.55, no significant difference. Testo I and II, compared to LC/MS, demonstrated correlation r2 = 0.990 and r2 = 0.995. Female patients with varying levels of DHEA-S were assayed on Testo I, II and LC/MS. For the same sample Testo I gave higher results than Testo II. Testo II precision was 3.3%, 2.5 %, 4.1 % and 6.7 % for concentrations of 21.8, 8.3, 1.6 and 0.6 nmol/L.Conclusions

Testo II has provided flexibility, precision and a good solution to previous interference and performance issues.P77. DIRECT MEASUREMENT OF VMA, HVA AND HIAA IN URINE BY HPLC AND TANDEM MASS SPECTROMETRY

MJ Whiting, S Wood, C Ewers

Chemical Pathology Laboratory, SA Pathology, Flinders Medical Centre, Bedford Park, SA 5042

[email protected]

IntroductionTandem mass spectrometry (LC-MS/MS) is a highly

specific detection method that can profile many analytes simultaneously. The aim of this work was to develop a rapid ‘dilute-and-shoot’ method for the quantitation of the tumour markers vanillyl-mandelic (VMA or HMMA), homovanillic (HVA) and 5-hydroxy-indole acetic (HIAA) acids in urine.Methods

Urines (20 µL), calibrators (Recipe) and QCs (BioRad) were diluted with water containing 3 deuterated internal standards. Samples were injected onto an Atlantis T3 column (50 x 2 mm) at 40oC and analysed by negative electrospray MS/MS with multiple reaction monitoring on an AB SCIEX 3200 Q-Trap instrument with a run time of 5 min. Analytes were measured using peak area ratios with Analyst 1.4 software. Results

Under the LC conditions used, elution times for VMA, HIAA and HVA were 1.0, 2.0 and 3.2 min

respectively, and assay linearity was established over the range 1–1000 µmol/L for each analyte. Between-run imprecision of the assay over 3 months was 5.9, 4.9 and 5.3% for normal urinary concentrations of VMA, HIAA and HVA. Method comparison studies were carried out against an existing HPLC method with fluorescence detection (FLD) using over 30 urines. Passing-Bablok regression equations relating LC-MS/MS (y) to HPLC-FLD (x) were y=0.97x-1.7 for VMA (r=0.99), y=0.96x+0.5 for HIAA (r= 1.00) and y=0.59x+0.2 for HVA (r=0.61). Chromatographic interferences from other urinary fluorescent compounds were problematic for HVA, which was often over-estimated by FLD even after solvent extraction.Conclusions

A rapid and highly specific isotope-dilution LC-MS/MS method has been developed for the simultaneous measurement of VMA, HVA and HIAA in urine with no extraction step required.P78. SENSITIVE MEASUREMENT OF PLASMA FREE METANEPHRINES AS DEUTERATED ETHYL DERIVATIVES BY LC-MSMS

MJ Whiting

Chemical Pathology Laboratory, SA Pathology, Flinders Medical Centre, Bedford Park, SA5042

[email protected]

IntroductionThe measurement of plasma free metanephrines has

become an important diagnostic test to exclude a diagnosis of phaeochromocytoma. Tandem mass spectrometry (LC-MS/MS) has high analytical specificity for the assay of metanephrines, but the sensitivity of detection can be limiting and is instrument-dependent.Methods

A simple method involving deuterated (d4)-acetaldehyde and reductive amination for 30 min at 37°C was used to convert metanephrine, normetanephrine and 3-methoxytyramine, and their deuterated internal standards, to d4-monoethyl or d8-diethyl derivatives. Precursor and product ion mass spectra were recorded to allow multiple reaction monitoring methods for both derivatised and non-derivatised plasma metanephrines to be compared under reverse-phase LC-MS/MS conditions. Positive electrospray ionisation was used on an AB SCIEX 3200 Q-Trap instrument.Results

Conversion of metanephrines to less polar deuterated-ethyl derivatives increased their mass by 32 or 64 amu, and greatly enhanced the intensity of their molecular ions and fragments. Derivatisation also improved the chromatographic properties of the metanephrines, and mobile phase containing 20% methanol was used for separation on reverse-phase HPLC columns in under 5 min. The sensitivity of tandem mass spectrometric


detection of metanephrine, normetanephrine and 3-methoxytyramine was increased up to 20, 30 and 5-fold respectively compared to underivatised compounds.Conclusions

The LC-MS/MS detection of plasma free metanephrines is greatly enhanced by ethyl derivatisation, which is easy and rapid to perform. Advantages are a smaller plasma volume requirement and lower limits of quantitation to improve the measurement of normal plasma concentrations of free metanephrines under reverse-phase HPLC conditions.P79. IS IT TIME TO RECOMMEND ANALYSIS OF NON-EXTRACTED URINE CORTISOL?

R Williams, DA Bell, AA Musk, R Lambert, P Glendenning

Core Clinical Pathology and Biochemistry, PathWest, Royal Perth Hospital,Perth, WA

[email protected]

IntroductionUrine cortisol is frequently analysed during the

investigation of clinically suspected hypercortisolism. Urine contains cortisol metabolites and related steroids so analysis is frequently performed after manual extraction. The Abbott Architect® urine cortisol assay does not specify if extraction is required, but reference a poster by Hoffman et al which suggests that urine cortisol results from the Architect urine cortisol assay compare favourably to LC-MS/MS, with a slope of 1.06, intercept of 23.1 nmol/L and r = 0.997. We examined if extraction was required prior to urine cortisol analysis by comparing results from non-extracted samples with dichloromethane extracted samples on the Architect analyser.Method

40 patient samples of non-extracted and extracted urine were analysed using a competitive chemiluminescent microparticle immunoassay. Urine cortisol competes with acridinium labelled cortisol conjugate for binding to mouse monoclonal anti-cortisol coated microparticles. 1.0 mL of urine was extracted with 2.0 mL of dichloromethane, evaporated to dryness, and reconstituted with a cortisol free diluent.Results

Linear regression analysis of extracted and non-extracted urine cortisol results demonstrated a slope of 0.9852, intercept of 24.3 nmol/L and R2 of 0.9934. Conclusions

Our data confirms the Abbott Architect® urine cortisol assay provides comparable results without the need for extraction. Analysis of non-extracted urine cortisol may be appropriate for the investigation of suspected hypercortisolism. Confirmation using LC-MS/MS to verify our findings, including analysis of urine samples from cases with hypercortisolism is suggested prior to

recommending the analysis of non-extracted urine for the routine investigation of suspected hypercortisolism.P80. FREE TRIIODOTHYRONINE (T3) MEASUREMENTS – ANALYTICAL ISSUES WITHIN TWO POPULATIONS

P Ward, M Ridgwell, CCG Wood


[email protected]

IntroductionImmunoassays used to estimate levels of free

thyroid hormones are problematic and subject to possible interference from a number of sources- particularly drugs and binding proteins. The measurement of Free T3 is appropriate in pregnancy when TSH is suppressed and Free T4 normal as antithyroid drugs may affect the foetus.Methods

TSH, Thyroxine Binding Globulin (TBG) and thyroid hormone measurements, both free and total, were made using a Siemens Immulite 2000 platform.Results

In a population of pregnant subclinical hyperthyroid women, elevated levels of Free T3 were present far more frequently than expected. Comparisons of normal pregnant women and those with subclinical hyperthyroidism using measures of TBG, Total T3 and Free T3 clearly established erroneous elevations of Free T3 in pregnancy.

A population of neonates (n=78) were all clinically euthyroid with normal levels of both TSH and Free T4. Thirty four (44%) showed distinct elevations of Free T3 levels. There was no indication of increased levels of TBG but 29 % of the babies with elevated Free T3 levels also had elevated levels of Total T3 (when measured). In the elevated Free T3 group (n=34), 23 had clinical comments on the request form. Of these 23 clinical comments, 21 (91%) indicated some form of maternal thyroid disease with “Maternal Hypothyroidism on Thyroxine” the most prevalent.Conclusions

Two clinical populations showed erroneous elevations of Free T3. Elevated levels of TBG appear to be the primary cause of the false elevation of Free T3 in pregnancy. The mechanism for the falsely elevated levels of Free T3 in euthyroid neonates admitted to the NIC is less clear.


P81. REFLEX TESTING TO DEFINE TRULY CRITICAL RESULTS FOR A COMMUNITY LABORATORY

J Barron, C Ng, L Aspin, L Robinson, G Smith

Biochemistry Department, Labtests, Auckland & Southern Community Laboratories, Christchurch, New Zealand

[email protected]

IntroductionTests may be added to a request using algorithms.

This practice is not well established or defined. Critical results may be divided into truly critical required to be phoned 24/7 and those required to be phoned during the day. Requestors based in the community would prefer not to be contacted unless a result was truly critical and contacting a community based requestor out of usual office hours requires substantial staff resource. We have derived algorithms to attempt to define that a result is truly critical. Methods

The literature on critical results was reviewed and a critical phoning list was agreed. Algorithms with reflex tests added, were devised to help define a truly critical result. Each algorithm was costed, so as to justify the reflex tests, by audit of results in the laboratory database and test costs. Results

This affects 75 tests per month and the total cost of the reflex tests added is $48 per month. Tests are only reflex added if not previously assayed. If s-creatine kinase >1999 µ/L, then s-creatinine and s-potassium are added. If glucose >24.9 mmol/L, then bicarbonate is added. If s-lithium >1.49 mmol/L, s-creatinine is added. If s-magnesium <0.31 mmol/L then s-potassium & calcium are added. If an isolated raised s-ALT is present with normal GGT and ALP, then s-creatine kinase is added. If s-digoxin >2.49 nmol/L, s-potassium, calcium and magnesium are added. Conclusions

The use of reflex tests with critical results has helped to inform a two tier critical result phoning system. This system both avoids disturbing requestors and conserves staff time at night.

P82. STANDARDISATION OF TERMINOLOGY FOR ELECTRONIC REPORTING OF PATHOLOGY RESULTS

R Flatman

Chair AACB LOINC Working Party

Biochemistry Dept, Sullivan Nicolaides Pathology, Taringa, Qld 4068

[email protected]

IntroductionAn essential prerequisite for electronic ordering or

reporting of pathology results to electronic health records (EHR) is clear identification of each test. Numerous terminologies now exist to perform this role including:

• Systematized Nomenclature of Medicine – Clinical Terms (SNOMED-CT);

• Logical Observation Identifiers Names and Codes (LOINC);

• IFCC-IUPAC Nomenclatures Properties and Units (NPU).

In Australia, most laboratories electronically reporting results utilise LOINC. The National eHealth Transition Authority (NEHTA) recommends a future transition to SNOMED-CT, so it is important that laboratories are both aware of developments in this field and using an optimal code for test identification.Methods

The AACB LOINC Working Party (WP) is a group of scientists, pathologists and IT professionals, representing both public and private pathology institutions throughout Australia, working on the following LOINC related issues:

• Codes currently in use• Recommended standard terms• Identifying unnecessary code variation between

laboratoriesResults

The WP has reviewed approximately 80 common tests representing the majority of high volume biochemistry performed in Australia. Approximately 10% of the surveyed entries for each lab/test combination showed unnecessary variation that would complicate the task of comparing results between different laboratories, or worse, potentially leading to the misidentification of a result in an EHR.Conclusions

The WP has worked to establish relationships with NEHTA, Standards Australia and the Medical Software Industry Association to clarify what codes should be in routine use. The WP recommends the “Austpath” codes (http://www.ahml.com.au/austpath) and continues to work with Standards Australia (IT 014-06-05 committee) to ensure these codes represent “state of the art”. The


makeup of the WP, with very wide representation, is an important component in this process.P83. INCREASED PRODUCTIVITY IN HBA1C ANALYSIS USING THE BIO-RAD HB-ADVISOR™ SYSTEM

T Higgins, D Stewart, B Rose, J Dayton, D Holmes, J Peralta

Chemistry Department, DynaLIFEDx, Edmonton, Alberta, Canada

[email protected]

IntroductionAlthough high performance liquid chromatography

(HPLC) methods for HbA1c analysis show superior precision and detect the presence of haemoglobin variants, there is a reluctance to use these methods in laboratories analysing large volumes of HbA1c tests because of the time involved in manually checking the chromatograms for sampling errors or the presence of haemoglobin variants. The recently introduced Bio-Rad Hb- Advisor™ System, a middleware software, eliminates the need to manually review normal chromatograms while allowing review, based on pre-established criteria, of abnormal chromatograms.Methods

Studies were performed to compare the time needed to review chromatograms from both the Bio-Rad VARIANT™ II TURBO and VARIANT™ II HbA1c methods manually and using the Bio-Rad Hb-Advisor System. The ability of Hb-Advisor to correctly identify samples that failed to meet established criteria due to sampling errors or the presence of a variant was tested by submitting samples containing a haemoglobin variant or samples with low haemoglobin.Results

For both Bio-Rad systems, the time needed (technologist dependent) to manually review and release a normal chromatogram varied from 8 to 20 seconds and 25 to 50 seconds for those chromatograms with sampling errors, and 60 to 120 seconds for a haemoglobin variant chromatogram. With use of the Hb-Advisor, only the latter 2 categories (1.9 to 2.4% of total chromatograms) are manually reviewed. Following review of Hb-Advisor flagged chromatograms, release to the laboratory information system takes 8 seconds independent of batch size. The Hb-Advisor detected all sampling errors and identified all haemoglobin variant samples. Conclusions

The Bio-Rad Hb-Advisor System increases productivity in HbA1c analysis without compromising quality.

P84. EFFECT OF HAEMOLYSIS, RAPID CHILLING AND MALEIMIDE ON STABILITY OF ACTH

J Livesey,1 B Dolamore2

1Endolab, Christchurch Hospital, Christchurch 8001, New Zealand2Christchurch Polytechnic Institute of Technology, Christchurch 8011, New Zealand

[email protected]

IntroductionThere are no quantitative reports on the effect

of low levels of haemolysis on the stability of ACTH although it is often recommended that samples should be chilled immediately. Additionally, no inhibitors of the haemolysis-induced loss of ACTH have been reported. We have examined the effect of haemolysis, rapid chilling and a protease inhibitor on the stability of ACTH.Methods

Whole blood (EDTA anti-coagulated) was collected from 9 volunteers and an aliquot from each was haemolysed and added back to the same sample at 37° to produce 0, 0.1, 0.25, 0.5 or 1.0% haemolysed blood. Four treatments were then carried out at each level of haemolysis. Aliquots were either A) immediately centrifuged at 4 and the plasma stored frozen for later analysis, or B, C and D), treated as for A, but incubated in ice/water for 30' before centrifugation. Post-centrifugation D had 2 mM N-phenyl maleimide (NPM) added. After thawing, samples were analysed for ACTH (Roche Elecsys 2010 analyser) either immediately (A and B), or after one hour at 21º (C and D).Results

Median levels of haemolysis for 10% loss of ACTH were 0.19, 0.32, 0.11 and 0.86% (0.26, 0.44, 0.15 and 1.2 g/L Hb) for sample treatments A, B, C and D respectively (p = 0.001 and 0.0003 for difference between A and B, and between C and D respectively).Conclusions

1. Very low levels of haemolysis (0.1 – 0.2%, 0.15 – 0.3 g/L Hb) can quickly result in significant loss of ACTH immunoreactivity.

2. Rapid chilling of blood after collection reduces the adverse effect of haemolysis.

3. NPM reduces the loss of ACTH due to haemolysis.


P85. CAN FLUORIDE OXALATE PLASMA BE USED FOR ENZYMATIC CREATININE AND VITAMIN D ANALYSIS?

W Louey,1 ZX Lu,1,2 KA Sikaris1


[email protected]

IntroductionFor investigating relationships between vitamin D

and the risk of diabetes and kidney disease, we planned to analyse 25-hydroxy-vitamin D (25OHD) and enzymatic-creatinine (enzCr) in the serum from 11,247 people who participated in the Australian national survey in 1999-2000, the Australian Diabetes, Obesity and Lifestyle (AusDiab) cohort, for prevalence of diabetes. However, 5.6% of specimens had insufficient serum but had fluoride oxalate (FO) plasma available. We thus evaluated whether FO plasma was suitable for 25OHD and enzCr analysis.Methods

Bloods from 101 staff were collected into serum separator tubes (SST) and FO tubes. Both tubes were processed and analysed simultaneously for 25OHD (DiaSorin Liaison) and enzCr (Roche Modular). Reportable limit for 25OHD was 10 nmol/L. Differences were analysed using Bland-Altman plot and paired T-test.Results

25OHD data: Range of serum 25OHD was from <10 to 197 nmol/L. Correlation was done only for levels between 10 and 120 nmol/L as only two people had values above 120 nmol/L. There was no difference in 25OHD (mean±SD) between the FO plasma and the paired serum (60±23 vs 61±24 respectively, n=98, p=0.32). The correlation for FO vs serum was: y=0.97x +2.5 (r²=0.89). Bland-Altman plot showed a 1.4% positive bias for 25OHD from the FO plasma.

EnzCr data: Serum enzCr range: 36–108 µmol/L. Mean enzCr values were 62±13 vs 59±12, respectively, for FO vs serum (n=90, p<0.01). Bland-Altman plot showed a negative bias of 3 µmol/L (95%CI: -2.3 to -3.8 µmol/L) for enzCr from the FO plasma. The equation was: y=0.89x+3.8 (r²=0.93) for FO vs serum.Conclusions

For 25OHD, results from serum or FO plasma were very similar. For enzCr, there was a small negative bias when measured in FO plasma. This small bias, however, will have minimal clinical significance. Thus, FO plasma was accepted for 25OHD and enzCr analysis.

P86. WHICH BLOOD COLLECTION TUBE IS BETTER FOR HOMOCYSTEINE?

W Louey,1 ZX Lu,1,2 KA Sikaris1

1Melbourne Pathology, Collingwood, Vic 3066 2Department of Medicine, Monash University, Clayton, Vic 3168

[email protected]

IntroductionHomocysteine (Hcy) concentration can rise after

blood collection in certain tubes due to on going release by the red blood cells in vitro. Our routine practice was to collect into EDTA tubes, spin and separate the plasma immediately then to send the frozen plasma on dry ice to the laboratory. This minimises the problem, however, not always practical especially when the blood was collected by referring doctors at their clinics where a centrifuge is not available. Here, we aimed to evaluate the effectiveness of the Vacuette® Hcy (V-Hcy) tube for Hcy analysis. Methods

Seven tubes of blood each were collected from eight laboratory staff: six in V-Hcy tubes and one in EDTA tube (routine). One V-Hcy and the EDTA tube was processed within 30–60 min after collection (reported as 0 h) and the remaining V-Hcy tubes were kept at room temperature for further 2, 4, 6, 8 and 24 hours before centrifugation. All the plasma from the tubes were separated from the cells after centrifugation and analysed in duplicates immediately. The average values of the duplicates were used in the final analysis. Results

The mean Hcy at 0 h from the V-Hcy tubes was 11.1±7.2 (mean±SD) µmol/L) which was significantly lower than that from the EDTA tubes (12.7±8.0 µmol/L) (p<0.01). The levels of Hcy in V-Hcy tubes remain the same when kept at room temperature for the entire duration (24 h prior to centrifugation) of the study. At the 24 h time point, the mean Hcy was 10.8±6.3 µmol/L which was not significantly different than that from the 0 h (p=0.94).Conclusions

The Vacuette® Hcy tube adequately stabilises Hcy in vitro for 24 h at room temperature before centrifugation. It minimises pre-analytical errors for Hcy analysis thus permits blood collections in doctors’ clinics and remote areas for assessment of patient’s Hcy status.


P87. OUTCOMES AND CHALLENGES OF IMPLEMENTING AN ISO 14001:2004 ENVIRONMENTAL MANAGEMENT SYSTEM

E Reid,1 T Badrick2

1Environmental Systems, Sullivan Nicolaides Pathology, Taringa, Qld 4068 2Executive Manager, Sullivan Nicolaides Pathology, Taringa, Qld 4068

[email protected]

IntroductionIn 2006 Sullivan Nicolaides Pathology (SNP)

began working towards ISO 14001:2004 Environmental Management Systems (EMS) implementation and certification at the Coffs Harbour and Grafton Laboratories. SNP had recognised it’s corporate responsibility to respect our environment and to manage any environmental impacts associated with our pathology work practices. The ISO 14001 standard provided a framework by which this could be achieved. Methods

Local and corporate environmental policies, procedures and initiatives were introduced concurrently, with elements of the existing Quality Management System, Safety Management System and LEAN policies and procedures included in the EMS framework. EMS implementation has included the provision of training for staff and contractors; initial environmental reviews, the determination of significant environmental aspects and impacts; identification of legal requirements and establishment of a legal register; setting of objectives, targets and programmes; establishment of documentation; corporate audit / system review; management review. Results

The Grafton and Coffs Harbour laboratories were certified to ISO 14001:2004 at an audit held in May 2009. Using the new EMS framework, implementation is continuing at a number of sites across the Practice. The aim is to establish an integrated management system, encompassing Environment, Quality, Safety and LEAN principles. Conclusions

The benefits of the established EMS to the organisation have been improved environmental awareness and performance (e.g. decreased usage of energy, water, consumables, increased recycling) cost savings, business efficiencies, compliance with regulations, improved corporate image, marketing opportunities, reduced risk of disaster and improved relationships with the public and community. Since the implementation process began, SNP has seen a cultural change, with Environmental Management being at the forefront of many business decisions.

P88. CALCULATION AND PRESENTATION OF TURNAROUND TIME (TAT)

AW Ukich

Core Clinical Pathology and Biochemistry Department, Royal Perth Hospital, Perth, WA

[email protected]

IntroductionTAT is the time from sample receipt in the laboratory

to result release to a Clinical Information System. In our laboratory transfer is usually complete within 1 minute of release. This presentation demonstrates a graphical method of calculating the key performance parameters which allows them to be easily monitored over an extended period of time.Methods

TAT is calculated as 3 or 5 minutes segments, or hours or days, together with various categories. The number of TATs per time slot is counted and from this the cumulative total up to the various time slots is calculated thus allowing the cumulative percentage of tests resulted to the time slots to be determined. Resultant data plotted as “% completed tests” versus “time slots” enables percentile values of TAT to be read from this chart. This method is suitable for a limited number of category plots with 5 being the maximum number such that trends may not be easily seen. An application has been developed, using a bar-chart format, allowing large amounts of data to be assessed with up to 50 category plots visible per screen and trends being more discernable. This presentation can show overall performance for an analyte and also of subsets based on urgency, source, time and day of the week resulted.Results

The data presented for potassium and D-dimer tests demonstrate the effect of changed workflows and new instruments on result performance.Conclusions

A graphical method of summarising vast amounts of performance data is presented with improved applications for management and technical reviews. It can be used to assess past performance, set realistic targets and measure on-going performance as a Performance Index as well as provide other useful data, e.g. samples outside specified limits. This form of presentation would be best applied directly on-line.


P89. MODERNISING WORKFORCE CAPABILITIES: THE INTERNATIONAL FEDERATION OF CLINICAL CHEMISTRY AND LABORATORY MEDICINE’S (IFCC) KEY INITIATIVES

S Matthews,1 K Adeli,2 E Jacobs3

1Biochemistry Department, Royal Melbourne Hospital, Parkville, Vic 3050 2Hospital for Sick Children & University of Toronto, Ontario, Canada3Department of Pathology, Bellevue Hospital Center, New York University School of Medicine, New York, USA and Chair, Communications & Publications Division, IFCC

[email protected]

IntroductionRapid advancements within modern medical

laboratories have resulted from an improved knowledge and understanding of pure science, medical science methodologies and automated technologies combined with the drive for evidence-based laboratory medicine. Delivery of the resultant evolving service requirements within Clinical Chemistry and Laboratory Medicine demands a substantial investment in modern workforce capabilities.

The International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) is representative of approximately 45,000 laboratory specialists worldwide through National, Regional, Corporate and Affiliate membership. The IFCC, recognising its role as the “leading organisation in the field of Clinical Chemistry and Laboratory worldwide”, has strengthened existing programs and developed new key initiatives to align with major outcome areas essential for workforce development. Strategically, the IFCC goals were implemented to:

1. raise awareness of the profession and career paths to recruit and sustain diverse quality graduates,

2. nurture leadership, scientific expertise and innovation by review, discussion and preparation of standardised best practise guidelines, and

3. encourage global information and technology exchange using specialised IFCC partnered courses, conferences and other scientific exchange programs.

ConclusionsImprovements to existing IFCC workforce

development programs such as the “Labs are Vital” campaign, IFCC website, e-Journal, e-newsletters and the Public Relations toolkit are reviewed. Application criteria for newer IFCC workforce initiatives including, Young Investigator Award, Professional Exchange Program, Visiting Lecturer Program are outlined and the implementation of the Young Scientist Task Force,

Distance Learning Programs and Quality Medical Laboratory Competency are described.

P90. THE PATHOLOGY WORKFORCE CRISIS: A NOVEL APPROACH USING REMOTE VERIFICATION AND UPSKILLING

J Milburn, T Badrick

Sullivan Nicolaides Pathology, Taringa, Qld 4068

[email protected]

IntroductionThe effect of the pathology workforce crisis on the

pathology industry has been widely discussed. Sullivan Nicolaides Pathology (SNP), a comprehensive central laboratory service, provides 24 hour stat laboratory services via peripheral laboratories to metropolitan and regional private hospitals throughout Queensland. The challenge is to maintain this service in the face of a change in the skill base of the workforce.Methods

Routine laboratory testing in each laboratory was reviewed and the competencies needed to perform each step were identified. A minimum standard of competency was defined to allow non-scientifically trained staff to perform all pre-verification steps in the analytical process and training programs implemented. The LIS allows remote access to a laboratory’s test and quality control results. Test results which meet the criteria set by SNP auto-verify, meaning these results are not viewed by laboratory staff. Test results that did not auto-verify are able to be verified locally or remotely by scientists with appropriate authorisation privileges. Results

Specially designed training programs were developed to equip staff with the appropriate skills which included equipment troubleshooting and quality control interpretation. Testing at the peripheral laboratory is performed by a competent person, and results either auto-verify, or are remotely verified by a scientist either locally or at the remote (verifying) laboratory. This remote verification has been successfully employed in five peripheral laboratories. The role of Remote Verification Coordinator was created to manage the process.Conclusions

Substituting non-scientifically qualified staff for scientifically qualified staff and employing remote verification allows SNP to continue to provide essential 24 h 365 day/year service to metropolitan and regional hospitals despite the pathology workforce crisis.


P91. IS IgG ONLY A BETTER CLINICAL MEASURE THAN IgGAM FOR THE DIAGNOSIS OF HEPARIN INDUCED THROMBOCYTOPENIA?

A Al-Boraich; G Gilmore,1 J Thom,1 RI Baker1,2

1Department of Haematology, Royal Perth Hospital, Perth, WA 2Centre for Thrombosis and Haemophilia Research, Murdoch University,Perth, WA

[email protected]

IntroductionThe laboratory diagnosis of Heparin Induced

Thrombocytopenia (HIT) can be difficult. There are different assays that test for HIT antibodies. Immunoassays detect antibodies produced against the heparin/Platelet Factor 4 (PF4) complex. These antibodies are of different subtypes (IgG, IgA, IgM). Some studies have suggested that immunoassays that test for IgG only should be used as it is the only subtype that can activate platelets and therefore result in HIT. Methods

Two STAGO ELISA kits were used to test the samples. An IgG specific ELISA (ASSERACHROM HPIA-IgG) and a polyspecific IgGAM ELISA (ASSERACHROM HPIA). Samples tested were citrated plasma stored at -80°C from 77 patients received over a period of 10 years. All were suspected by the clinician to have HIT, were thrombocytopenic and on heparin. They were deemed to have HIT if they also were positive by aggregometry in the presence of 0.5 units/ml heparin but negative in the presence of 100 units/ml.Results

Using the criteria mentioned above 65 samples were HIT positive and 12 were negative. 44 (68%) of the HIT positive samples were positive using the IgGAM kit but only 36 (55%) were positive for IgG only antibody. 21 (32%) were negative by both techniques and presumed to be HIT due to antibodies other than platelet factor 4. Of the 12 negative by aggregometry all were positive by ELISA IgGAM but only 4 (33%) were also positive for IgG only.Conclusions

Some clinically significant antibodies may be missed if testing for HIT IgG only. P92 Evaluation of the Siemens Berichrom Factor XIII assay on the Vitros 5,1 FS and Establishment of an age-related reference range.

P92. EVALUATION OF THE SIEMENS BERICHROM FACTOR XIII ASSAY ON THE VITROS 5,1 FS AND ESTABLISHMENT OF AN AGE-RELATED REFERENCE RANGE

S Yong,1 E Haworth,2 L DeRosa1

1Dept of Haematology, Laboratory Services, Royal Children's Hospital,Parkville, Vic 3052 2Core Biochemistry, Laboratory Services, Royal Children's Hospital, Parkville,Vic 3052

[email protected]

IntroductionCoagulation Factor XIII deficiency is a rare

autosomal recessive disorder characterised by delayed wound healing, neonatal umbilical bleeding, delayed onset bleeding and intracranial haemorrhage following little or no trauma. Acquired deficiencies is associated with liver disease, ulcerative colitis and more recently reported in patients on long-term valproate therapy. FXIII is a transglutaminase which functions as a clot stabilising factor by crosslinking polymerised fibrin.Methods

The SIEMENS Berichrom FXIII kit was adapted for use on the Vitros 5,1 FS Chemistry System. The Berichrom FXIII assay is a chromogenic method whereby the activity of FXIII is based on the measurement of ammonia released in the first step of the transglutaminase reaction. The performance of the assay was correlated with an established method using the Berichrom FXIII assay on a Beckman Coulter UniCer DxC 800 Synchron® analyser. Adult reference ranges were established using Normal Donor Set, Precision Biologic.Results

52 samples were correlated resulting in a R2 = 0.94. Assay Sensitivity was shown to be 2.75% 0.08. A Linear range for clinical application was as 5% to 140%. Adult reference ranges correlated with manufacture's data with 95% CI of FXIII = 70% - 140%.Conclusions

The SIEMENS Berichrom FXIII kit is easily modifiable to work using an open channel on the Vitros 5,1 FS Analyser. The FXIII kit compares well with other chemistry systems that accommodate open channel assays and removes the need and inaccuracy of a qualitative clot solubility screening test.


P93 A COMPARISON OF TWO COMMERCIAL POOLED NORMAL PLASMAS FOR USE IN ACTIVATED PARTIAL THROMBOPLASTIN TIME MIXING TESTS

Daniel Orellana, GW Kershaw

Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, NSW 2050

[email protected]

IntroductionThe unexpected occurrence of a prolonged

activated partial thromboplastin time (APTT) in a non-anticoagulated patient necessitates investigation as to its cause. The most common approach is to repeat the APTT as a 1:1 mix of test plasma with pooled normal plasma (PNP), where subsequent correction suggests factor deficiency, and non-correction inhibitor presence. Because there is no consensus as to definition of correction/non-correction we evaluated two PNPs and four formulae for ability to differentiate factor deficient plasma from inhibitor-containing plasma.Methods

Automated 1:1 mixes by APTT were performed on the STA-R analyser with both Trinicheck Level 1 and Cryocheck Pooled Normal as PNP. Test samples included single factor deficiencies (n=29), oral anticoagulant-induced deficiencies (n=16), liver disease (n=13), lupus anticoagulants (LA)(n=17) and factor VIII inhibitors (n=7). The APTT reagent was TriniCheckAPTT S.Results

The four methods of calculating degree of correction produced variable degrees of separation of factor deficiency from inhibitors, but no method with either type of PNP gave complete separation. Of 27 inhibitor-containing plasmas between 5 and 9 corrected to a degree that overlapped with the correction of factor deficient samples. These inhibitors were mainly weaker, but included both LA and factor inhibitors. Overall performance of the two PNPs was equivalent.Conclusions

This study highlights some of the limitations of 1:1 mixing test interpretation, particularly the tendency of samples with weak inhibitors to correct, or the occasional failure of factor deficient plasma to fully correct. Some of this behaviour may relate to the APTT reagent-analyser-PNP combination in use, so individual laboratories should establish their own guidelines for mixing test interpretation.

P94. ESTABLISHING AGE-RELATED REFERENCE RANGES FOR THROMBOPHILIA SCREENING TESTS ON THE STAGO COMPACT.

O Sargisson,Z Howell

Haematology Department, St John of God Pathology, Ballarat, Vic 3350

[email protected]

IntroductionAnticoagulant protein levels are known to vary

significantly in children, neonates and in pregnancy. Currently we do not report specific age-related ranges, although neonatal ranges have previously published in a landmark paper byAndrew et al (Blood 1987). Using the STA Compact analyser in combination with the STAGO reagent systems (Diagnostica STAGO, France) we are conducting a retrospective audit of data collected over a six-month period to investigate any age-related variance in levels of Protein S (PS), Protein C (PC), and Antithrombin 3 (AT3) in patients over 18 years of age. We plan to introduce new reportable reference ranges within our laboratory that are specific for our analyser and reagent. There are known difference between analysers mainly due to the difference in assay techniques, in particular, method of detection (chromogenic vs. clotting) and reagents.Method

Citrated plasma samples were analysed on a Stago Compact for PS, PC and AT3. The results were then categorised according to age and gender, and a 95% confidence interval derived.Discussion

Our data demonstrates a need to take into account gender and age in the reporting of thrombophilia screens. Data for all parameters tested will be presented.P95. GENETIC POLYMORPHISM OF CXCL12 GENE ON HUMAN COLON CANCER GENETICS

M-D Shi,1,2,3 LY Tsai,1 JH Chen3

1Kaoshiung Medical University2 Yongkang Veterans Hospital3Chung Hwa University of Medical Technology

IntroductionColon cancer is the major cause of malignancy-

related deaths worldwide, and the third most prevalent cancer in Taiwan. However, the genetic factors influencing its appearance remain far from being fully characterised. The chemokine(CXCL12), also known as stromal cell-derived factor-1 (SDF-1), is a small protein that regulates leukocyte trafficking and it is variably expressed in a number of normal and tumor tissues. CXCL12 plays a key role in hematopoiesis, and it is involved in migration, homing, and survival of hematopoietic progenitors. CXCL12 is identified as a ligand and its receptor CXCR4 has been implicated in colorectal cancer progression,


including angiogenesis and metastasis. CXCL / 2-G801A, a single nucleotide polymorphism (SNP) in the 3' untranslated region, had been previously reported to correlate with breast and lung cancer in Iran. In this study we compared it's expression in colorectal cancer patients from a Taiwan series.Methods

The results from an independent analysis of CXCL /2-G801A in colorectal cancer series of Taiwan origin were analysed in order to test the robustness of this association within the population. The polymorphism was analysed with PCR and denaturing high performance liquid chromatography (DHPLC) methods.Results

There was a significant difference in SNP distribution between colorectal cancer patients (n=40) and controls (n=20), P=0.0014. Furthermore, the analysis of allelic frequencies in both groups revealed that the frequency of G allele in patients and controls were 153 (78.9%) and 178 (89.9%) respectively, while the frequency of an allele in patients and controls were 41 (21.1%) and 20(10.1%) respectively. Therefore it was revealed that patients had more allele than controls. These differences were statistically significant (P=0.0026).Conclusions

Based on the above observation CXCL 12-G801A can be considered a genotype associated with colorectal cancer in Taiwan patients. P96. HB EAST TIMOR, A VARIANT HAEMOGLOBIN ASSOCIATED WITH NORMAL HAEMATOLOGY GENETICS

C Newbound, 2 J Finlayson, 1,3 R Ghassemifar, 1,3

P Holmes,1 L Figliomeni,2 N Pell,2 M Kersten, 2 M Jennens,2 L Greenwood,2 J Beilby2,3

1Departments of Haematology and 2Molecular Biology, PathWest Laboratory Medicine, QEII Medical Centre, Nedlands, WA3School of Pathology and Laboratory Medicine, University of Western Australia, Nedlands, WA

[email protected]

IntroductionStructural haemoglobin (Hb) variants are typically

the consequence of a point mutation in the globin gene that produces a single amino acid substitution in the encoded globin chain. Many structural variants that affect diagnostic screening are phenotypically silent and of limited clinical significance. We report such a haemoglobin variant, detected in a family from East Timor undergoing routine health screening at the Migrant Health Unit in Perth, WA. Methods

Cation exchange liquid chromatography was performed on whole blood lysate using VARIANT2.0 β Thalassaemia-short HPLC (Bio-Rad). Direct DNA sequencing for the beta globin gene was performed from

amplified genomic DNA using Big Dye Terminator v3.1 (Applied Biosystems).Results

While routine blood counts were normal, a variant peak was detected on cation exchange HPLC accounting for approximately 40% of total haemoglobin and eluted in the S window. The elution time varied from 4.42-4.43 minutes in different family members. DNA sequencing identified a novel transversion mutation AAC>CAC, resulting in an amino acid change from asparagine to histidine at codon 80, in the heterozygous state.Conclusions

The novel mutation is located on the exterior of the haemoglobin molecule and does not play a significant role in either haem binding or the alpha:beta contacts. This would account for the phenotypically silent presentation. The substitution of the basic amino acid histidine for the neutral asparagine, alters the haemoglobin charge and would account for the changes in the HPLC profile.P97. A CASE OF PLATELET INTERFERENCE ON THE CELL DYN SAPPHIRE

G Roche, M Pett, C Smith

Haematology, Austin Health, Heidelberg, Vic

[email protected] Cell Dyn Sapphire performs routine platelet

counting based on both optical flow cell and impedence transducer measurement principles. Significant discrepancies between these two counts may occur due to various interferences including microcytes, schistocytes, leucocyte cytoplasmic fragments and giant platelets. Impedance technology relies on cell size determination alone and is therefore prone to interfering phenomena. Twodimensional optical counting is performed on the Cell-Dyn Sapphire at 7 and 90 degrees to the vertically polarized laser beam axis to provide an accurate platelet count. Although infrequent, abnormal optical platelet scatterplots may require elucidation on the Sapphire via CD61 monoclonal antibody analysis.

A 75 year old male, previously diagnosed with hepatitis C, presented with recurring fever. His optical and impedence platelet counts were similar at 299 x109/L and 286 x 109/L respectively although there was an associated 'platelet clump' flag. Scatterplot review showed a minimal platelet clump pattern and an unusual vertical band involving nil events within the optical platelet discrimination zone. Blood film examination reported a severe thrombocytopenia and apparent bite cells. A consequential CD61 monoclonal analysis revealed a platelet count of 8 x 109/L.

A review of protein electrophoresis results showed a mild polyclonal increase in serum gamma globulins and no Bence Jones proteins in the urine. There was however


a highly elevated cryoglobulin concentration of 1.71 g/L (NR <0.1gIL).

Following incubation at 37C the FBE specimen was re-analysed with no change in analytical findings. A further FBE specimen was collected and strictly maintained at 37C until analysis. The optical, impedence and CD61 platelet counts from this specimen were all markedly reduced at 14 x10^9/L, 20 x10^9/L and 11 x10^9/L respectively. This case highlights the potential interference of cryoglobulins in platelet counting and the diagnostic value of CD61 monoclonal analysis. P98. CEREBROSPINAL FLUID ANALYSIS: COMPARING ROUTINE MANUAL METHODS AND SYSMEX XE500 AUTOMATED COUNTS AT THE ROYAL HOBART HOSPITAL

K Saunders, T Kidd

Haematology Department, Royal Hobart Hospital, Hobart, Tas 7000

[email protected] , [email protected]

IntroductionCerebrospinal fluid analysis is routinely performed

to investigate and aid in the diagnosis of a variety of central nervous system disorders. Elevated white cells counts at different quantifications are consistent in disorders such as viral, fungal and bacterial meningitis. In comparison, increased erythrocytes may be indicative of a subararchnoid haemorrhage and/or suggestive of a traumatic lumbar puncture procedure.Methods

The evaluation of the CSFs was performed using a two Sysmex XE5000 haematology analysers and the manual method using a Fuchs-Rosenthal counting chamber. The XE5000 software provides a FDA approved body fluid analysis mode. Both methods utilise a 2 part differential i.e. enumeration of polymorphs and mononuclear cells. Results

The results compared between the XE5000 analysers duplicated well with on average no greater than 10% variation. There was, as expected, a greater numerical difference between the XE5000s and the manual method at both ends of the scale.Conclusions

Both methods provide relevant information in a clinical setting to aid in the diagnosis of CNS disorders. Due to the viability of the sample and requirement for a quick turn around time (TAT) raises the question of where and by whom these counts should be performed. The XE5000 compared to the manual methods provides a quicker TAT for cell counts with a less intensive work load and decreased financial expense to the laboratory. Other benefits for moving to automated counts are the standardisation

P99. VENOM PRODUCTION IN THE INDOCHINESE SPITTING COBRA

AE Woods, JM Logan

School of Pharmacy and Medical Sciences and Sansom Institute for Health Research, University of South Australia, Adelaide, SA

[email protected]

IntroductionVenoms have proved to be a valuable source of

pharmaceutical products. However, obtaining these components is expensive and not bioprospectively viable. To produce these components synthetically an in-depth understanding of venom production mechanisms is needed. We have investigated the regulation and production of venom during embryonic development in an animal model, the Indochinese Spitting Cobra (Naja siamensis).Methods

Embryos were removed, fixed in 4% paraformaldehyde and processed via routine paraffin wax embedding schedules. Production of venom proteins was investigated by immunohistochemistry (IHC) using an HRP-conjugated antibody derived from a therapeutic antivenom directed against cobra venom. In situ hybridisation (ISH) was utilised to assess when venom-related mRNA was initially expressed in the venom glands in embryos using a probe generated against cobra venom factor (CVF).Results

CVF mRNA expression was indicated by blue reaction product located within the cytoplasm of secretory epithelial cells of the developing venom glands. CVF mRNA was initially identified in all three clutches at different time points, specifically 18, 31 and 39 days post-oviposition. The intensity of ISH staining increased over the next few days before stabilising at the original level. However venom protein was only observed by IHC in one embryo at day 30 post-oviposition. Immunostaining was visualised towards the apical region of the secretory epithelial cells and exhibited a granular appearance.Conclusions

This study enabled the identification of the initial expression of CVF mRNA in several Naja siamensis clutches, with positive immunostaining observed in one clutch illustrating the presence of venom protein. This is the first such study to identify the initial expression and production of of venom in developing snakes.
















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DATE!

AIMS NZIMLS South Pacific Congress8 - 12 August 2011Gold Coast Convention CentreQueensland

The Australian Institute of Medical Scientists and the New Zealand Institute of Medical Labo-ratory Science is proud to host and invite you to the South Pacific Congress, 8-12 August 2011. The Congress will bring to the Gold Coast Convention Centre a top level forum of leading national and international speakers to address topical issues in the medical science industry.

Keynote speakers include:• Dr Barbara Bain (UK), Haematology• Associate Professor Mark Shephard, PoCT• Dr Robert Webb, Director, Hyperbaric Medicine Service• Carol Turnbull (UK), Anatomical Pathology• Professor Peter Rathjen, Stem Cell Research

The Congress theme ‘Lights! Camera! Action!’ has been chosen as a call to action for dele-gates to spend a focussed 4½ days in the vibrant Gold Coast at a Congress filled with topical and relevant presentations. Daily sub-themes will logically group presentations and have a little fun based on the Congress theme!

• ‘Waterworld’ – water trauma/diseases• ‘Basic Instinct’ – back to basics• ‘Aliens’ – the immune system• ‘Back to the future’ – new technology• ‘That’s all folks!’ – closing day


For further information about the Congress please contact All Occasions Management A. 41 Anderson Street, Thebarton, 5031, South AustraliaT. +61 8 8125 2200 F. +61 8 8125 2233 E. [email protected]. www.allocasionsgroup.com/AIMSNZIMLS11

N o ve m b e r 2010 Vol. 31 No.4 - Australian Institute of ...

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