Biochemistry Newsletter issue 5 - Barking Havering and Redbridge ...

BHRUT BioNews
April 2011 Volume 2, Number 1
In This Issue
• Information available
via our website
• Food Allergy – a
NICE place to start
• User feedback
• Books of Interest:
Primary Care and
Laboratory Medicine
• New tests in the
literature:
cardiotrophin-1
Welcome
Welcome to the First issue of BioNews in 2011, a newsletter from the
Department of Clinical Biochemistry at BHRUT. In this issue we have a report
on the new NICE Clinical Guideline 116, “Food Allergy diagnosis and
assessment of food allergy in children and young people in primary care and
community settings” (CG116) by Dr
Matthew Buckland, Consultant Immunologist Barts and the London NHS Trust.
The full guideline and the quick reference guide are available on the NICE
website (or can be accessed directly via this link
http://guidance.nice.org.uk/CG116).
As a way of introduction to our team – each issue includes a short cameo of
one of our staff – so that you can get to know us a little better. See below
Funmi Akinlade, Principal Clinical Biochemist, Queen’s Hospital. You can
view previous issues of our newsletter via the website.
Contact Us
biochemistry@bhrhospi
tals.nhs.uk
Please note that the
Biochemistry email
address should only
be used for general
enquiries.
Food Allergy – A NICE place to start
The first NICE guidance on allergy testing has been recently published. When
thinking where NICE might start, food allergy in children and young people was
perhaps not the obvious choice. It would have been simpler perhaps to think
about guidance on managing seasonal allergic disorder. Credit where it’s due,
tackling a tough problem head on makes the next hurdle easier. The positive
part of this will be raising awareness of allergy as a clinical problem and a
rational approach to testing and treatment paradigms. The difficult part will be
that allergy testing by laboratory methods (i.e. specific IgE testing) is likely to
increase and that there will be no increase in funds allocated to the laboratory
to accommodate this at a time of great financial pressure.
The NICE guidance states that clinicians should think about testing more by
skin prick testing or specific IgE when you have a patient with a history of an
IgE mediated reaction. Since very few people in community based practice use
skin prick testing, this will largely be specific IgE testing. So here I would like
to introduce a word of caution that we should introduce careful targeted testing
to those things that the patient is clear that they have a history of reactions to,
because the NICE guidance does move on quite quickly from history to testing,
without exploring in too much detail the causality step in the history and for
food allergy the devil is in the detail. Non-IgE mediated reactions need to be
carefully delineated from IgE mediated reactions. Urticaria or angioedema are
common and are frequently not causally related to food, but may be
temporally related because we all eat so often! A positive test, be it a skin
prick test or specific IgE tells you that someone is sensitized, and therefore
potentially atopic, but not that they are allergic to something, only the history
can tell you that. Equally a negative test may need confirmation with a
diagnostic challenge in an appropriate clinical environment if there was a

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compelling history and in the case of food allergy this should be done by
appropriately qualified individuals.
The purpose of the test should be to focus the further clinical management as
with all tests. If the result of the test is not going to modify management then
should it be done This is especially true with specific IgE testing where
evidence of multiple sensitization is often found and patients rapidly end up on
very restrictive diets, even though they are not allergic to many of the
components.
I think the guidance may be very useful as a source of discussion and debate,
but would like to caution against an increase in additional “allergy testing” but
perhaps better tools for allergy histories.
User Feedback
Many thanks for those that completed the feedback questionnaires sent out in
Dec.2010. Your evaluation and comments have been noted and will in part
form part of our planning for 2011.
We were quite pleased to find the high overall level of satisfaction of our
services. Below is a summary of our responses to your comments:
1. For clinical advice on the interpretation of results or advice on further
investigations you can contact the Duty Biochemist:
Queen’s Hospital 01708 435 000 ext. 6194
King George Hospital 0208 970 8021/8023
2. To obtain laboratory results for Biochemistry or Haematology please use the
following numbers:
Queen’s Hospital 01708 435 422
King George Hospital 0208 970 8021/8023
3. The Bio e-newsletter will continue to be used as medium to get information
out to our users.
4. Biochemistry staff are keen to attend GP teaching sessions to assist in the
appropriate use of our services and interpretation of results. If you would like
to arrange a session please contact us either by email:
biochemistry@bhrhospitals.nhs.uk or on one of the numbers above.
5. Please note that when a test such as thyroid function tests or HbA1c is not
performed because it is too close to a previous request we currently report the
previous result/s on that report. If you encounter instances where the previous
result has not been provided please contact us with the details as it may well
be an IT issue. If you would like to receive the full report of the user feedback
please contact us and this can be sent to you.
Requests for Vitamin D
There have been a number of surgeries sending in non-standard request forms upon
which Vitamin D is printed as an integral part of the bone profile tick box. Please
note Vitamin D is not part of a routine bone profile and must be requested
separately with a valid reason for the test. Vitamin D will NOT be processed if
seen to be within the Bone profile tick box.

Books of Interest: Primary Care and Laboratory
Medicine
ACB Venture book Primary Care Lab Medicine,
Frequently asked questions. Stuart Smellie, Cliodna
Mcnulty and Mike Galloway. ISBN 978-0-902429-
46-8.
Primary care is an area where collaboration and cooperation
is required between general practitioners and
laboratory staff in order to achieve effective use of
resources. This text aims to bridge the gap between
general practice and the laboratory by providing a
single reference text in an easy-to-use format. The first
three chapters of the book concentrate on the
relationship between the GP and the laboratory, with
discussion on the position of primary care within the health service, the workload
in general practice, the provision of a laboratory service and the interpretation of
laboratory data. The four subsequent chapters discuss each of the four main
laboratory disciplines in detail: clinical biochemistry; haematology;
histopathology/cytology; and microbiology. Particular emphasis is on presentation
and laboratory investigation of common clinical conditions.
This book sets out to consider a wide range of the questions that are frequently
asked of laboratory medicine specialists by primary care practitioners. It is
intended as a guide for doctors, nurses, those in training, and perhaps also the
laboratory specialist who is looking for brief guidance on unfamiliar topics. In
many cases the questions have no single right answer, but what is offered is a
review of the guidance available nationally and internationally to seek to offer ‘the
best answer we can’.
http://www.acbstore.org.uk/site/product.aspxproductuid=255445&ClickProductO
nPage=/site/index.aspx
New tests in the literature
Monserrat et al. (2010) Cardiotrophin-1 plasma levels are associated with the
severity of hypertrophy in hypertrophic cardiomyopathy Eur Heart J (2011)
32 (2): 177-183. doi: 10.1093/eurheartj/ehq400
Cardiotrophin-1 (CT1) is part of the IL-6 cytokine family and has been shown to
induce cardiomyocyte growth and survival and thus promoting structural changes
in the myocardium. CT1 is secreted by the coronary sinus into the peripheral
circulation. Levels of CT1 have been found to be elevated and correlated with the
severity of heart disease in patients with left ventricular failure typical of cardiac
diseases such as hypertensive heart disease, aortic stenosis, coronary aortic disease
and dilated cardiomyopathy. The study above investigated CT-1 concentrations in
patients with Hypertrophic cardiomyopathy (HCM), a genetic condition
characterized by the development of left ventricular hypertrophy (LVH) in the
absence of hypertension and valve disease. CT1 concentrations were found to be

significantly (p

Cyberlab results
When requesting tests please note that where no hospital or NHS number is
recorded on the requests for then it is likely that the results will not go into
Cyberlab and you will be unable to access results electronically.
Access to information on our website
Please note that we are improving the information on the BHRUT website to
make information more widely available. Currently the following is available on
the website:
• Pathology User Guide
• Allergy Testing User Guide and Request form
• Previous issues of BioNews
• Reference Ranges
• Referral Laboratories used by the Biochemistry Department
Access it directly from here:
http://www.bhrhospitals.nhs.uk/gp/gpbiochemistry.php
A dedicated Pathology microsite is coming soon. This will contain more user
friendly versions of the above documents and much more.