clinical cases launched video links making a stand at focus establishing€¦ · broomfield...

In this issue

Clinical CasesBookLaunched

Video Links to Advise onMaking aStand at Focus

Establishingan Enteric Labin Sierra Leone

Focus Abstracts Time Again

The Association for Clinical Biochemistry & Laboratory Medicine | Issue 620 | December 2014

ACBNews

About ACB NewsThe Editor is responsible for the finalcontent. Views expressed are not necessarily those of the ACB. EditorDr Jonathan BergDepartment of Clinical BiochemistryCity HospitalDudley RoadBirmingham B18 7QHTel: 07792-912163/0121-507-5353Fax: 0121-507-5290Email: [email protected]

Associate Editors Mrs Sophie BarnesDepartment of Clinical Biochemistry12th Floor, Lab BlockCharing Cross HospitalFulham Palace RoadLondon W6 8RFEmail: [email protected]

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

Dr Derren Ready Microbial DiseasesEastman Dental Hospital University College London Hospitals (UCLH) 256 Gray’s Inn Road London WC1X 8LD Email: [email protected]

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

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Printed by Swan Print Ltd, BedfordISSN 1461 0337© Association for Clinical Biochemistry &Laboratory Medicine 2014

ACBNews

General News page 4

Practice FRCPath Style Calculations page 12

Council Matters page 14

Current Topics page 15

Federation News page 17

Meeting Reports page 18

Christmas Crossword page 25

Situations Vacant page 26

Issue 620 • December 2014

The monthly magazine for clinical science

Issue 620 | December 2014 | ACB News

Front cover: Beverly Harris, William Marshall and Jane French,authors of the Clinical Cases book,along with Paul Newland whooversees Venture Publications

http://www.focus-acb.org.uk/

ACB ExtrasACB Extras is the latest addition tomembership. As an ACB Member, you haveaccess to a fantastic portfolio containingmoney-saving discounts, designed to supportyou both personally and professionally. There is no sign-up process, nor any extracharge to access these benefits!Benefits include discounted cinema tickets

at many major cinema chains, great savings on a wide range of Apple products, discounted 4G phone tariffs, retail cashback at over 50 major retailers, discounts onpackage holidays from many of the major touroperators, hotel bookings, car hire, foreigncurrency, car insurance, home insurance, CV and interview training, IT and professionaldevelopment training and much more. �

4 | General News

ACB News | Issue 620 | December 2014

SudokuThis Month’s Puzzle

LastMonth’sSolution

Clinical Cases BookLaunched in Liverpool

The launch of the latest ACB VenturePublications book was held duringEuroLabFocus in Liverpool. Clinical Cases inLaboratory Medicine is jointly authored byJane French, Beverley Harris and WilliamMarshall. It contains a total of 80 cases andsuggested interpretations. Ideal for thosecoming up to professional exams and alsothose wishing to use it as a refresher.Priced at £25 the book can be purchased

from the ACB website or can be ordered from your laboratory book supplier. ISBN 978-0-902429-56-7 �

And last month’s Crossword Solution . . .

http://www.cityassays.org.uk/


6 | General News

Liverpool ClinicalLaboratories

The EuroLabFocus exhibition had someinteresting stands including several fromclinical laboratories. Of note was the LiverpoolClinical Laboratories stand, run by Jane Millsand a team of laboratory staff. LiverpoolClinical Laboratories (LCL) is a clinically led NHSshared service launched in 2014. LCL’s key aimis the provision of pathology services and theventure is jointly owned by Aintree UniversityHospital NHS Foundation Trust and RoyalLiverpool & Broadgreen University HospitalsNHS Trust.

Stand at CardiffThe LCL stand was certainly busy but Janekindly took time out to help with a short videoclip explaining why they had taken the standand what their key aims at EuroLabFocuswere. Shortages of skilled staff are a problemon Merseyside as elsewhere and part of thestand’s aim was to help with the currentrecruitment issues. Highlighting some of thespecialist tests that are offered by LCL was alsopart of the plan. Based on the success of theirEuroLabFocus presence LCL has decided toconsider a stand to attend the Focus meeting next June in Cardiff. You can see the YouTubeby putting “Liverpool Clinical LaboratoriesYouTube” in as a Google/YouTube searchwhere you will find it may be the first hit.Alternatively, if reading the electronic versionof ACB News then just click on the imageabove or click here…. �

ACB News Archive CopiesThe ACB Office would like to get copies of theACB News from 1999 to 2008 to supplementthe archive copy we already have.Please email [email protected] if you have

copies you would like to donate to the ACB fortheir archives. �

LTOL is Ten . . . the Video

Next month we look at how Lab Tests Online-UK is helping with patient resultinitiatives. For now there is a fun video givinga feel for the Liverpool celebrations. If reading the electronic copy of ACB News just click on the image above or if you arereading this on paper then go online towww.labtestsonline.org.uk and find the videolink on the website. �

Photos for ACB News

We value photos to go with ACB Newsarticles. Occasionally photos taken on a goodquality mobile phone may be of sufficientquality to be used. Indeed, we used a photofrom an iPhone 4 on the front cover a year orso ago. However, often mobile phone photosare not of acceptable quality. Please considerusing a proper camera and sending us the

original JPEG. Send the JPEG image separateto the Word document – embedded images

are not suitable. �

https://www.youtube.com/watch?v=t3kaEa1OM2s


https://www.youtube.com/watch?v=IGjvOZmsa-g

In support of National Pathology Week 2014,Scientists from the West Midlands gottogether for a fun, interactive “Meet theScientist” event at the Birmingham Thinktankscience museum. The event, organised by Dr Sukhbir Kaur (Senior Clinical Scientist atHeart of England NHS Foundation Trust),tackled the topical themes of diabetes andpatient access to medical records whilst raisingawareness for pathology.Children of all ages were given a lab coat

and clipboard and taken on a journey frompresentation to diagnosis of three patients.Along the way the children practised takingblood from a fake arm and learnt all aboutwhere your blood goes and what happens to it once it has been taken. They thenperformed various tests to correctly diagnoseType 1 and Type 2 diabetes, were introducedto chromatography and even went away witha bracelet coding their names in DNA.

Positive for Access to Medical Records

Whilst the children experimented, parentswere given the opportunity to voice theirviews on the following question “What accesswould you like to your medical records, if any?”. Only 8 out of 75 survey responseswere against the idea of patients having accessto their own results. Of these 8 responses, the primary reasoning was a concern forsecurity of privacy and “hackers” or “thegovernment” having access to medicalinformation. One other response that stood

out was “confusing and possibly worrying”,what do you do with information aboutyourself that you don’t understand? Ninetypercent of people were positive and in favourof more access. However, some of these alsocommented that they would only want accessthrough a secure medium and if terminologycould be explained to them.Overall the Thinktank event was extremely

successful with everyone involved havingsomething to take away. The children got ahands on laboratory experience and a goodiebag whilst adults were given pause forthought on one of the most talked aboutissues in pathology today. As for the scientists,we gained two exciting days of publicengagement and can reflect on someinteresting public opinion. �

General News | 7


Meet the Scientist in Brum

World Quality Day, instigated by the UnitedNations in 1990, is an annual event promotingawareness of quality. It provides organisationsacross the globe the opportunity to reinforcetheir ultimate quality goal of achievingexcellence and highlights the importantfactors required to achieve this, includinginnovation and sustainability. Noting thesimilarity with Viapath’s values – innovation,collaboration and expertise, we decided tojoin in the fun. Our aim was to broadcast themessage of the 2014 theme ‘Building a QualityWorld Together’ across our organisation andmaking a ‘pledge’ to show our ongoingcommitment to quality.

Quality Jigsaw

Our challenge consisted of teams from each of our five sites transporting puzzle piecesapproximately 100 km from Bedford GeneralHospital to Guy’s Hospital without the use ofany motorised transport. At the end of thechallenge these pieces would be fittedtogether to reveal our Quality Pledge for theyear ahead.Viapath’s employees voted from a shortlist

of suggested pledges. After an overwhelmingresponse, a single pledge was the outrightwinner taking more than 50% of the availablevotes. The challenge route included a 5 kmrun, two 40 km cycle legs and two 10 km runsto finish. A team captain was chosen for eachteam who in turn selected their team mates.

Our teams joined forces to collaboratively raisesponsorship of around £1,400 for our chosencharity which was Children in Need.

Running Legs in Golders Green

The day began in Bedford with a 5 km run,illustrating that the combination of dedicationand training is important to achieve success.These individuals had previously volunteeredto complete the ‘NHS couch to 5 kmprogramme’, showing that continualcommitment can lead to improvement infitness over a nine week period. This wasfollowed by the two 40 km cycle legs taking usto Golders Green where the first of the tworoad running legs began. The second runningleg from St Thomas’ Hospital to London Bridgewas especially exciting as it saw participantscheered home by a large contingent of theircolleagues at the finish line. First through thefinish line was Susan Bint. The day ended withthe assembling of the five puzzle pieces, which fit side by side, revealing Viapath’sQuality Pledge for the year ahead:

‘We pledge to continually improve ourservice by listening to our patients,customers and colleagues and takingpositive action as a result of eachinteraction.’

This year’s ‘2014 Viapath World Quality DayChallenge’ Cup was awarded to the team fromGuy’s Hospital who accumulated the greatestnumber of challenge points during the day. �

8 | General News


Well Done Guys!Kaiya Chowdhary, St Thomas’ Hospital, London

General News | 9


The venues for the social events at FocusCardiff, 2015 have now been confirmed and Iam delighted to announce that thanks to thework of the Social Programme Organisers,Michael Melhuish and Meeting Makers, thefollowing exciting venues are now awaiting usin June 2015!

Cardiff Bay Corporate EveningThe Corporate Evening on Monday 8th June2015 will be held in the stunning Terra Nova,located in Cardiff Bay and only a couple ofminutes walk from the conference venue, The Millennium Centre. The Terra Nova offers a sophisticated, relaxed environment towind-down after work and spend an eveningoverlooking the quay. You can enjoy a fullrange of Cardiff’s finest Brains cask ales andsmooth beers and also an extensive range ofgreat wines and champagne.

Brewery Quarter FringeThis year’s Focus Fringe will be taking place at “The Yard” which is located within theBrewery Quarter in Cardiff. The Yard is verycentrally located making it an ideal venue tohold the Fringe for all Focus attendees. It is aperfect place to start a night in Cardiff for abite to eat for those who also wouldn’tnormally attend the Fringe as it is located onthe main”strip” known as St Mary’s Street inCardiff centre. The Yard has also beenawarded a Trip Advisor certificate of

excellence demonstrating its popularity assomewhere to eat and drink in a city wherethere is plenty to choose from! For the Fringeitself, a private area of The Yard upstairsknown as the Jam Jar has been reserved andamps etc will be provided for those wish tojam and plenty of comfy booths surround theperformance area for those who wish to enjoy the musical talents of their colleagues.There is also a private bar at the Jam Jar and a fantastic menu to choose from at the Yard(more details/offers will be provided nearer to the event).

National Museum BanquetAs always, Focus wouldn’t be completewithout the Conference Dinner held on thefinal evening. The Conference Dinner inCardiff will be held in the iconic NationalMuseum. It houses the Welsh nationalcollections of archaeology, geology, naturalhistory and art and there will be anopportunity to view the exhibits as drinks willbe served in the Art Gallery (don’t forget tolook out for the woolly mammoth and herbaby!). Ticket prices will be advertised on theACB Focus website as soon as they becomeavailable. Look forward to hearing you all at the

Fringe, and in the words of the recent numberone single . . . “Its all about the bass, ‘bout thebass, ‘bout the bass, no treble!”. �

Focus Fringe: Going the Extra Yard in CardiffGina Sanki, Focus Publicity

10 | General News


The programme for the Cardiff Focus meetinghas now been distributed. The sciences includetopics that will be of interest to all Pathologydepartments. Do consider the importantopportunities:

Poster SubmissionThere will be an emphasis on interaction atthe posters. The key date is 16th January whenyou need to ensure you have made yourelectronic submission. Guidelines on the posterabstract are given on the Focus web page withtips on what to include in your 300 wordabstract to ensure success. To see more visitwww.focus-acb.org.uk

Making a Stand in CardiffThere have been a number of laboratories andnon-commercial organisations with interests inPathology who have exhibited at Focus overthe years. This can really be an excellent wayof meeting those you want to communicatewith. If you are busy developing yourlaboratory marketing communications plan for 2015 why not consider a stand at Focus inCardiff as part of your strategy. To understandmore about this listen to some of the exhibitorsat the EuroLabFocus meeting in Liverpool withtips on how to have a successful stand byclicking on the thumbnails on the electronicversion of ACB News in the next column.

Electronic Links to Video ClipsLiverpool Labs: Click here for key reasons toget out there and be an exhibitor at Focus:

City Assays NHS: Tips from an NHS PathologyDepartment on a successful Focus standpresence:

NIHR: Understand more about the NIHRDiagnostic Evidence Co-operative:

To find out more about your laboratory having a stand at Focus 2015 in Cardiff please contact: Vicki Grant at:[email protected] News hopes to offer further

practical tips on stand success for commercialand non-commercial exhibitors in the New Year. �

Focus Update


https://www.youtube.com/watch?v=a40ZShoKL0E

https://www.youtube.com/watch?v=0WVUqRKqJPI


General News | 11

To celebrate National Pathology Week 2014,The Royal College of Pathologists held a freeevent for students aged 14-18. This gavestudents the opportunity to meet Pathologistsand discover the different disciplines withinpathology.Four London-based Biochemistry Trainees

were involved in an interactive session whichgave students the chance to find out aboutthe different pathology specialties, learn whatpathologists do and also take part in activitiesthat explore why pathology is important tohealthcare. Zoe Barclay (Imperial), Amy Dunne(St George’s), Danni Fan (UCL) and HannahFearon (King’s College) hosted two stands atthe event to show students some of the testsperformed in the laboratory, and to provideinformation on the STP training scheme.

Pros & Cons of POCTThe first stand gave students the opportunityto use point of care glucose meters and discuss their use in the management of

diabetes. The advantages and disadvantagesof such point of care testing were discussed,and the STP trainees were able to describe theprocess of laboratory based testing, frombarcoding samples to entering results. Thestudents were also shown kits for pregnancytesting and drugs of abuse screening. At thesecond stand the students were able toperform a screening test for bowel cancerusing FOB cards – with some surprisinglyrealistic fake samples – and also find out howurinalysis can be useful in patient testing. Thestudents had to guess what might be wrongwith patients from the appearance of theirurine – including a case of beeturia andfrothing proteinuria – and were able toperform various dipstick tests to investigatethe pH and content of the urine.This was an excellent opportunity for the

trainees to be able to inform students aboutthe STP Training Scheme, and to advertise notjust biochemistry but all clinical sciences as acareer for eager young scientists. �

STP Trainees Involved in National PathologyWeek OutreachAmy Dunne, St George’s NHS Trust, London

Coming Next Year . . .A special thank you to everyone who has helped on ACB News, from those directly working on each issue, Associate Editors, our publishers,and to everyone in all areas of production. Also a big thanks to everyonewho has contributed over the year. We will continue to experiment

with electronic links from ACB Newseditorial and adverts for theelectronic copy of ACB News.Remember we Tweet a link as soon asACB News goes online.Next year we continue to try and

report news and views of ourpathology environment and welcomecontributions from everyone. In January we will be looking at Lab Tests Online-UK and in February we look at how to have a successfulpresence at a Focus exhibition. �

12 | Practice FRCPath Style Calculations


Calculate the loading dose of intravenous aminophylline required to achieve a plasmatheophylline concentration of 15 mg/L in a 65 kg man, given that the volume of distribution oftheophylline is 0.5 L/kg and that aminophylline is 80% w/w theophylline. What infusion ratewould be required to maintain this concentration if the half-life is 8 hours?

FRCPath, Autumn 2013

Loading dose (LD) = Plasma concentration (Cp0) x Volume of distribution (Vd)

Purity (S) x Bioavailability (F)

Cp0 = target plasma concentration = 15 mg/LVd = volume of distribution = 0.5 L/Kg. Body wt = 65 Kg.

Total Vd = 0.5 x 65 = 32.5 LS = salt factor or purity = 80 % = 0.8 F = bioavailability. Not given so assume value of 1 (probably irrelevant as IV route used)

LD = 15 x 32.5 = 609 mg 0.8 x 1

If the drug is infused to maintain a constant plasma concentration (Cpss) then a steady stateexists in which the administration rate is equal to the rate of removal.

Rate of administration = Infusion rate x F x S

Rate of removal = Clearance x Cpss

Therefore: Infusion rate x F x S = Clearance x Cpss

Infusion rate = Clearance x Cpss

F x S

Cpss = plasma steady state concentration = 15 mg/L

F = bioavailability = 1; S = salt factor or purity = 0.8

The clearance is not given. However we are given the half life (8h) which is related to theelimination rate constant (kd) by the expression:

kd = 0.693 Therefore kd = 0.693 = 0.0866 h-1

t1/2 8

Deacon’s Challenge No 163 - Answer

Clearance is related to kd by the expression

Clearance = kd x Vd Therefore, clearance = 0.0866 x 32.5 = 2.81 L/h

Substituting these values to calculate infusion rate:

Infusion rate = 2.81 x 15 = 53 mg/h (2 sig figs)1 x 0.8

Practice FRCPath Style Calculations | 13


Question 164A neonate weighing 850 g is admitted to the Neonatal Intensive Care Unit. Followingintubation and artificial ventilation, blood gases reveal an arterial blood hydrogen ionconcentration of 120 nmol/L and a pCO2 of 6.2 kPa. Estimate the dose of sodiumbicarbonate (1.25%) required to reduce the hydrogen ion concentration to 80 nmol/L. Youshould assume that ventilator settings remain unchanged, and ignore any effects due tochanges in plasma volume and peripheral circulation. You should assume also that the totalbody water in neonates is 80% of body mass, due to an expansion of extracellular fluidvolume compared to adults, and is evenly distributed between intra- and extracellularcompartments.

FRCPath, Autumn 2013

Report of Council Meeting held on 13th November 2014

The first topic of the day at the NovemberCouncil Meeting was regional boundaries. Part of the reasoning for this discussion was toensure that all Members are able to accessregional meetings to keep pace witheducational developments and businessmatters of the Association. Previous discussionswith regional chairs suggested that mostregions were happy with their geographyexcept for two regions, Southern and Trent,Northern and Yorkshire. Council discussed thewider issues of meeting attendance andconcluded that regional boundaries was oneissue for limited attendance, but this wasmultifactorial including release of staff fromthe department becoming a difficult issue.Broader discussions on the potential use ofInnovative IT solutions such as videoconferencing and webinars took place. Limited conclusions were derived however itwas agreed that the two regions would reviewtheir boundaries and if required draw up aproposal for consultation.

Information Sharing Across RegionsThe discussion moved onto standardising theinformation received from each region andalso who should represent each region atCouncil. There was a view expressed that theregional chair should be the representative atcouncil and this was agreed. The expectationfrom this is that there would be a consistencyin how information is shared across each of

the regions. Additionally, to supportinformation sharing, a template has beenprepared for regional reports so they take aconsistent format. To support these changes, it was agreed that a generic job descriptionwould be prepared for the role of regional chair, together with guidance on this position.

Personalised EQAThe second topic of the day focussed onpersonalised EQA. There has been a documentprepared by our President, Eric Kilpatrick, incollaboration with Dr Bernie Croal, RCPathVice President for Professionalism, which waspresented to the College and was wellreceived. Council agreed that this documentwas far reaching, tackling the need forevidencing personal proficiency. Elementsdiscussed in the document includedemonstrating proficiency in knowledge,continuous learning and development, servicequality improvement or innovation, effectiveleadership and team work, demonstratedvalued teaching coupled with feedback fromcolleagues, staff, service users and patients.This document aims to give an outlineframework for future development of systemsto enable all Clinical Scientists from alldisciplines, at all grades to be able todemonstrate personal EQA in their specificrole.

Regional Chair to ProvideConsistencyIf you would like to give your view on thesetopics or have any ideas that would help toprogress them, please contact me at:[email protected] �

14 | Council Matters


Boundary Issues . . .Paul Newland, Alder Hey Children’s Hospital

Current Topics | 15


Sierra Leone experienced the worst Choleraoutbreak for 15 years in 2012. With over 300fatalities and more than 20,000 peopleaffected, the World Health Organisation(WHO) together with the Ministry of Healthand Sanitation (MoHS) established a CholeraCommand and Control Centre to manage thisnational emergency. The GastrointestinalBacteria Reference Unit, Colindale (GBRU), in collaboration with other Public HealthEngland (PHE) laboratories developed anenteric bacteria diagnostic and referencelaboratory – Central Public Health ReferenceLaboratory (CPHRL) in Lakka.Since PHE left CPHRL in 2013 Marie Anne

Chattaway, (GBRU, Colindale) and hercolleagues worked tirelessly to obtain fundingto reinforce and sustain activities with a viewto accredit the laboratory to ISO15189standards under ‘Strengthening LaboratoryManagement Towards Accreditation’ (SLMTA)guidelines. As a result a further Microbiologistrequest was released in February; interviewswere held in March and by April I was on myway to Freetown.

Self-SufficiencyDuring week one we undertook a two-dayworkshop led by PHE’s Global Consultant,Mark Salter, discussing the future of SierraLeone’s public health. It was a greatopportunity to meet key stakeholders anddiscuss the requirements to develop CPHRL capacity. A laboratory visit determined that without samples, generatorfuel or running water for hand washing, major issues needed addressing beforeundertaking some of my main objectives,

such as implementing antimicrobialsusceptibility testing. The project was aimed at helping CPHRL

become self-sufficient and independent, theavailable budget was therefore restricted toproviding expertise and consumables, notlaboratory infrastructure. During the followingweeks we began to adapt to the immediatechallenges, by sourcing and containing freshhand-wash water daily from the local village,communicating fuel availability so dailyactivities (e.g. media preparation or safetycabinet usage) were planned around powerprovision, and began to re-build relationshipswith local hospitals and district surveillanceofficers. This regenerated sample collectionand as a result helped maintain and develop

Establishing an EntericReference Laboratory inSierra Leone: A Six WeekElectiveChloe Eaton, Oxford University NHS Trust

16 | Current Topics


staff competency ensuring fulfillment ofCPHRL’s key purpose.

Tight TimescalesOutcomes were required within a very tighttimescale and being posted to Sierra Leoneindependently, time management between allaspects represented a real challenge. Despitethis, weekly action-plans ensured intensetraining activities, implementation of newtechniques, and improvement of qualitysystems such as audit training and introductionof an EQA scheme provided by the NationalInstitute for Communicable Diseases in SouthAfrica. It was encouraging to see thelaboratory making progress despite the initialsetbacks. Unfortunately Week 5 manifested another

unexpected course of events; Sunday morningI was called to an emergency meeting at theMinistry following reports of 4 fatalities in theKailahun district. Sadly, this represented thespread of the relentless Ebola outbreak fromneighbouring Guinea into Sierra Leone. With diarrhoea and vomiting being the

predominant features, Cholera was suspectedfirst and subsequently, highly infectioussamples ended up at CPHRL. It was traumaticexperiencing the fear instilled amongst thelocal community and healthcare workers

expected to manage this situation withoutrequisite training, and certainly not a situationI had anticipated being involved with. Actionwas needed and I was aware that postingspecialist response teams to manage theoutbreak would take time. I was fortunate tohave access to UK resources and support byPHE colleagues, Professor Noel Gill and Dr Colin Brown. After an overnight crash-course reading relevant guidance, the following morning we sourced storagecontainers from local markets and managed tostore and successfully dispose of infectioussamples safely. Upon returning to everyday comforts, my

peers have asked if I would ever return toundertake a similar project. Without anyhesitation, my answer is ‘Yes’; the uniqueexperience of being pushed to my limits,thinking spontaneously and meeting amazingpeople in stunning surrounds developed mypersonal and professional skills in anunimaginable manner. My experience will stay with me for a lifetime. �

Konneh Kelfala, laboratory technician in Sierra Leone,being trained to perform antimicrobial susceptibilitytesting

Eric Sefoi, Chloe Eaton and Marie Chattaway discussingwith staff at the Ola During Children’s Hospital,Freetown, the prospect of triaging Rotavirus negativesamples for enteric bacteriology at CPHRL

NHS Pensions 8: Choice 2 & MoreGeoff Lester, Federation Pensions Representative

Federation News | 17


By the end of November all staff in the groupsaffected by “Choice 2” should have receivedyour Choice 2 letter from your employer. Thisaffects those who opted to stay in the 1995scheme under Pensions Choice and who arenot in the fully protected group, i.e. at sometime on or after 1st April 2015 will beautomatically transferred into the 2015 CAREscheme. If you think you should have had aletter and have not had one in the first placecontact your employer’s Pensions Officer. If you have left NHS employment but still haveinvestment in an NHS pension contact eitheryour most recent employer or the NHS BSA atFleetwood quoting your National Insurancenumber. See their website for contact details.Originally we indicated that the deadline for

your Choice 2 decision was three months afterreceiving your letter. For simplicity this hasnow been revised by NHSBSA to a commondate for all of 16th March 2015. This is anabsolute deadline.This is 4 months away. However, FCS would

urge you to keep this decision at the top ofyour “to do” list. Do not let it get buriedbecause of that time scale. If you do notrespond the default decision is that you stay inthe 1995 scheme and that may not be the bestdecision. Make your decision a distinct actionunder your control base on thoughtfulconsideration.

2015 Scheme Regulations

The formal consultations on four StatutoryInstruments going before parliament over thenext few months to bring the 2015 Schemeregulations and the associated transitionarrangements into force have now beenissued. FCS officers are currently scrutinisingthese highly technical documents. Theconsultations close between the end ofNovember and mid-December in order to meetconsultation requirements and fit theparliamentary timetable ahead of next May’sgeneral election. One of the new provisions in the 2015

scheme that may be attractive to some

members is “ERRBO” – Early RetirementReduction Buy Out – where you can enter intoa contract to pay additional contributions sothat you can retire up to 3 years earlier thanyour 2015 pension age (your State PensionAge) without your 2015 pension beingactuarially reduced.

Salary Sacrifice

Salary sacrifice schemes are fairly commonacross the public sector and are trumpeted as abenefit for staff. The facility lets you give uppart of your salary in exchange for non-cashitems such as child care or lease cars onfavourable terms negotiated by your employeror the company they contract with to providethe facility. There may be tax advantages. The sacrificed salary however reduces your

pensionable pay. Both you and your employerpay pensions contributions on a lower grosssum and if that keeps you below acontributions tier threshold then it may besignificant. Under the 1995 and 2008 finalsalary schemes the negative impact on thepensionable pay on which your pensionbenefit is calculated can be removed bywithdrawing from the salary sacrificearrangement in your final years of workingthus maximising your “final” salary. You need to be aware that in the 2015 CARE

based scheme you can never “rescue” thatnegative impact and the reduced pensionablepay will reduce your CARE pension pot forgood and your loss will be index linked atCPI+1.5% until you retire.Those considering entering into new salary

sacrifice or continuing existing arrangementsbeyond your transfer date to the 2015 schemeshould consider the balance of the immediatepros and long-term cons carefully.

FCS Pensions Jargon Buster Glossary

Pensions is a mine-field of its own technicaljargon. FCS has posted its own jargon busteron the ACB/FCS members web pages athttp://www.acb.org.uk/docs/fcs/pensions-glossary.pdf �

18 | Meeting Reports


The programme at this year’s EuropeanCongress of Clinical Microbiology andInfectious Diseases (ECCMID) and ‘The year inClinical Microbiology’ session reflected clearlythe progress we have made and yet the largechallenges we face.Microbiology diagnosis is advancing rapidly

with an increase in automated instrumentsand emphasis on antibiotic stewardship, givingfaster results and optimised patientmanagement. As this occurs, the pathogenscontinue to evolve and change in parallel.Antimicrobial resistance has now been called

a ‘serious threat to public health’ by the WorldHealth Organisation and is a global problemthat without recognition and quick actionusing a multidisciplinary approach could bringthe end of the ‘antibiotic era’ faster thananticipated.ECCMID’s symposium debate on whether

new drugs should be used empirically or savedas a last resort highlighted the impact andworrying realisation of drug resistance. Theinappropriate use of antibiotics without globalantimicrobial stewardship or new drugdevelopment has been the main contributor tothis problem.Historical concerns of MRSA and ESBLs have

been added to with the rise in multi-drug

resistant gram negative and carbapenemaseproducing organisms (CPOs) since the 2000sfollowing an increased use of carbapenem.

Microbiology of CarbapenemasesCarbapenemases are β-lactamases thathydrolyse all or some of the antibiotics in thecarbapenem group, and may also conferresistance to all other β-lactam antibiotics.Although certain gram-negative bacteria areintrinsically resistant to some of thecarbapenems or contain the carbapenemasegene with the potential to express resistance;it is the acquired enzymes that are ofincreasing concern. Acquired carbapenemasegenes are typically carried on plasmids whichcarry determinants of resistance to multipleclasses of antibiotics, leaving few options foreffective therapy. These plasmids can betransferred between distinct strains andorganisms in different genera.

Screening Work from laboratories across Europe and the world was presented at ECCMIDdemonstrating a variety of detection methods.The difficulty with detection lies in the fact

that carbapenemase producing organisms(CPOs) do not always exhibit resistance to thegroup of antibiotics and not all carbapenem

Carbapenemase ThreatsSamantha Horridge

Ambler class Main carbapenemases Organisms of main concern

A (serine-β-lactamases) KPC Enterobacteriaceae KPC found mostSME, IMI commonly on Klebsiella pneumoniae

B (metallo-β-lactamases) VIM, NDM IMP VIM found mainly in Pseudomonas[MBL] aeruginosa, increasingly found in

Enterobacteriaceae

NDM found predominantly in coliforms, particularly E.coli and

Require zinc ion Klebsiellafor activity

D (serine-β-lactamases) OXA-48, OXA-23 OXA-48 found in Enterobacteriaceae OXA-23 frequently found in Acinetobacter baumannii

Meeting Reports | 19


resistance isolates are as a result ofcarbapenemase production. Briefly, an indicator carbapenem is tested

against clinically-significant gram-negativeorganisms either for patients being screenedto look for resistance or in isolates where theirsusceptibility profile indicates the possiblepresence of carbapenemases. Chromagenicagar is sensitive, but not specific, soconfirmatory tests are needed. Molecular testsare increasingly available, but may have costimplications.Confirmatory tests often act to show

synergy between an indicator carbapenem andβ-lactamase inhibitor. Ethylene-diamine-tetraacetic acid (EDTA) or dipicolonic acid canbe used in detection of MBL.Confirmatory tests available include Modified

Hodge test, but this shows poor sensitivity andspecificity. The CarbaNP assay is a promisingstep but many of the conference postersshowed poor sensitivity when used in routinelaboratories. Inhibitor based assays is anotheroption but no single assay inhibits all classes. The issue with screening in addition to

detection methods already identified isdeciding who to screen: Travel cases? All thosein high prevalence areas? ‘High-risk’ patients?

Carbapenemase

The symposium on carbapenemases addressedkey issues in prevention, detection andtreatment and demonstrated the worldwidefocus on this issue.Yehuda Carmeli highlighted the need for

strict infection control procedures and howthey can prevent the spread of CPOs followinga hospital outbreak in an Israeli hospital. Using local epidemiology to survey who to

screen and effective epidemiologyinvestigation to trace time and site ofacquisition is key. Subsequent tracing andscreening to reliably identify carriers early letsinfection control measures be put in placepromptly. Cohorting positive patients with adedicated nurse, rather than isolation rooms,was found to be an effective isolation method. Maria Virginia Villegas’ talk on ‘KPC around

the world’ described the global expansion ofKPC carrying sequence types ST258 of

K.pneumoniae, with some reports of it beingfound in Pseudomonas spp. in Latin America.There have been isolated cases in countriessuch as Spain, France, India and Scotland andthe occasional one described in Africa,Australia and New Zealand. Other countrieshave experienced disseminated infection fromtheir first case resulting in an endemicproblem, for example, Greece where KPC isthe most prevalent carbapenemase or KPC-3 inItaly. China faces concerns about contaminatedwater reservoirs serving as a source ofinfection. Following effective nationwideintervention, including active surveillance andisolating carriers, Israel managed to reducenumbers of new cases following widespreaddissemination of KPC. Timothy Walsh described the global spread

of NDM with an interesting insight suggestingthat NDM may be linked to reduced virulenceand potentially found in less virulent strains.He re-emphasised carbapenem resistance beingmore a public health problem rather than amedical one, with the focus needing to be oninfection control and vulnerable patients.

Treatment

The increased resistance of these oftenhospital-associated organisms dramaticallyreduces treatment options to mainly colistin,tigeycycline and fosfomycin; aminoglycosidesin some cases. These are not ideal as a singleagent due to toxicity, therapeutic levels andresearch presented at ECCMID showedincreased mortality with monotherapy versuscombination therapy. There is some hope for the future with the

use of avibactam, a beta-lactamase inhibitorthat is active against Ambler class A and D,therefore KPC and OXA-48 and effective whencombined with ceftazidime and ceftaroline.Unfortunately no drugs targeting class B areavailable or on the horizon.This new threat in resistant organisms is of

great concern, but ECCMID highlighted that itis a global problem that people are not onlyaware of but are improving detectionmethods, treatment options and re-emphasisesthe vital role effective infection control canplay in reducing transmission. �



I was supported by the ACB to attend theAnnual Conference of the InternationalFederation of Placenta Associations (IFPA),held alongside the meeting of the EuropeanPlacenta Group (EPG). Held within the LatinQuarter of Paris, the picturesque Campus desCordeliers hosted the conference in Septemberof this year.The conference was attended by over 400

international delegates including myself and alarge delegation from the Manchester basedMaternal and Fetal Health Research Centre.Sessions were structured to include plenarytalks, presentations by New Investigators andparallel sessions of specific interests, alongwith over 300 poster presentations. Talksspanned the scope of placenta research,including specific areas of research to clinicalintervention trials.

Placental Hormones

Hormones produced by the mother, fetus andplacenta act as environmental signals,regulating fetal growth and development inrelation to maternal stress and intrauterinenutrient availability. The placenta also containsreceptors that can respond to the hormones inthe maternal blood, acting to mediate levelsbetween the fetal and maternal circulations.Studies in both mice and sheep have shown

that maternal hormones such as cortisol,insulin and insulin-like growth factors havebeen shown to alter the morphological andfunctional characteristics of the placenta,which in turn affects the growth of the fetus.Monitoring these hormones may give insightinto the development of the fetus, and furtherresearch may dictate treatments given duringpregnancy.Currently, no biomarkers have been

identified that are sensitive or specific enoughto identify placental pathology. During theconference, the ideal characteristics of novel

biomarkers were discussed, with emphasis onobjective measurements, and discussion ofhow the biomarkers will be used inconjunction with existing screening techniquessuch as scanning. The ideal biomarkers will bespecific to certain pathologies, and would beable to identify those pregnancies that wouldrequire intervention, or rule out healthypregnancies.The use of genomic technologies, such as the

analysis of the placental and maternaltranscriptome was also presented. The use ofNext Generation Sequencing has allowed alarge number of genes related to placentalfunction to be analysed. Studies showed thatenvironmental factors when combined withcertain genetic haplotypes conferred thegreatest risk of a poor pregnancy outcome. As such, genetic screening alone may not be auseful predictive tool in pregnancy outcome,showing that any biomarkers or geneticchanges identified would have to contributeto a holistic management programme of anindividual patient.

Cohort Studies

With the production of large amounts of datacomes the importance of being able to sharedata in a manageable way, something that isrelevant across many scientific disciplines,including laboratory medicine. A number ofapproaches to the sharing of data weredemonstrated, including large databases thatconverted individual study data into useableand merged formats, and newer studies thathave standardised collection protocols andbiobanking facilities. In conclusion, this was an exciting

conference to attend, with much research stillto be undertaken in the field of placentalresearch, where findings and interventions arehelping to improve pregnancy outcomes forboth mothers and babies. �

Placenta in Paris’ LatinQuarterDaniella Nice, Manchester Royal Infirmary



Trainees from a variety of healthcare sciencespecialisms arrived at the BT ConventionCentre in Liverpool on a rainy Mondaymorning and were happy to be greeted withtea, coffee and cookies before the first lecturebegan! The Training Day started with a sessionabout the principles and clinical applicationsof mass spectrometry in clinical biochemistry.Brian Keevil began by describing the types ofinstruments available, and how they havebeen designed to increase sensitivity withoutincreasing the interfering background noise.This was followed by a discussion of accuratemass measurement using time of flight (TOF)detectors, which can increase analyticalspecificity. The session continued withpresentations from Laura Owen, whodiscussed the importance of selecting a goodinternal standard, and Joanne Adaway, who described how appropriate samplepreparation can reduce ion suppression.Overall, these lectures provided a greatpractical introduction with fantastic tips forany trainees undertaking assay development

on a mass spectrometer. This was followed byan interesting look at the application of massspectrometry in microbiology, with RebeccaGorton’s presentation on identification ofmicro-organisms from solid agar culture usingMALDI-TOF mass spectrometry. In the future,further developments may also allow thismethod to be used for the detection ofmycobacterium and fungi, which are difficultto grow and identify, and to identify micro-organisms direct from clinical specimens.

Norovirus and C. Diff

After lunch, the training day resumed with asession focusing on gastrointestinal disorders.Miren Iturriza-Gómara spoke about thedetection of norovirus, with a particular focuson the types that are common in healthcareassociated infections, and Derren Readydescribed the diagnosis of Clostridium difficileusing a rapid screening test followed by faecaltoxin detection. Both speakers discussed theuse of RNA analysis to link cases and monitoroutbreaks in hospitals. Next, Matthew Helbert

Training Days in LiverpoolKia Langford-Smith, Aintree University Hospital



gave a comprehensive overview of testingstrategies for a variety of immune relatedgastrointestinal diseases, including oral allergysyndrome, pernicious anaemia, Coeliac disease,Crohn’s disease and IgG40-related diseases. In the final session of the day, Susan Martindescribed the testing performed byhistocompatibility and immunogeneticslaboratories for both solid organ andhaematopoietic stem cell transplantation. It was particularly interesting to hear aboutthe introduction of more modern techniques,such as the use of PCR instead of serologicaltests for HLA typing, and the use of flowcytometry and bead arrays instead of cellbased assays for HLA antibody identification.

Blood Gas Unravelled

Following a delicious meal on Monday eveningat the atmospheric Alma De Cuba restaurant,Trainees began the second training day with apresentation from William Marshall on“unravelling” blood gas disorders. After aquick re-cap of acid-base homeostasis, theaudience were called upon to diagnose of avariety of cases, using the straightforwardtechniques that had been described. The keytip was to focus on the measurements ofhydrogen ion concentration and partialpressure of CO2, to avoid being confused bythe additional calculated parameters. This wasfollowed by an extensive overview of disordersinvolving sodium and water homeostasis fromAndrew Day, who highlighted the value ofmeasuring urine osmolality and urine sodiumto assist with diagnosis, rather than relying onthe assessment of volume status, which can bedifficult to do. In the next session, whichfocused on immunoglobulins, trainees heardfrom Berne Ferry about the testing strategiesfor myeloma screening, in particular the use ofserum free light chain measurements as amore analytically sensitive and biologicallyspecific test than urine electrophoresis. The detection of intact paraproteins using the“Hevylite” assay was also introduced as an

additional test that may be useful inmonitoring monoclonal proteins that aredifficult to quantify using serumelectrophoresis, or to allow earlier detectionof relapse. This was followed by an interestingpresentation on IgG4-related diseases by RossSadler, who described the discovery of theseunusual autoimmune diseases and theimportance of combining IgG4 measurementswith histological findings to confirm diagnosis.

Sequencing in Routine Use

A team from the West Midlands RegionalGenetics Laboratory described the use of nextgeneration sequencing (NGS) in diagnostics.First the trainees were introduced to thetechnology and the different sequencingapproaches, including sequencing of genepanels, whole exome sequencing, and wholegenome sequencing. Developing areas of NGSwere discussed, including non-invasive pre-natal screening through sequencing offree foetal DNA found in the maternalcirculation, and tumour profiling using NGS tosequence panels of genes that are associatedwith prognosis and treatment success. The massive data storage and processingcapacity required for NGS was astounding, aswere the huge number of bioinformaticsprograms required to properly assemble andinterpret the data generated. There are alsosignificant hurdles still to overcome regardingthe interpretation of results, determiningwhich variants are important, and the ethicalconsiderations of which results should bereported. This was followed by the final session of the

training programme, chaired by DanielleFreedman, in which six Trainees were selectedto present interesting clinical cases. Eachpresentation included interactive questionsallowing those in the audience to test theirknowledge. This was a fantastic way to end the training

programme, and one of the many highlightsof an enjoyable and educational two days. �



You might wonder why I attended thismeeting jointly organised by The Kings Fundand The Point of Care Foundation. There wereseveral reasons. During the Carter Review acommon theme of discussion was the need forpathologists, meaning all staff working inlaboratory medicine, to “get out more” – tostep out of the silo. This comment was oftenreiterated at the conclusion of NHSImprovement projects. Again from the CarterReview, the consequences of patients gainingdirect access to their results from April 2015made the topic of this meeting highlyrelevant. A third reason was a broaderconsideration of the reasons for the slow, andhighly variable, rate of adoption of new testsas illustrated in the NHS Atlas of Variation inDiagnostic Services. To the latter one can addthe myriad of clinical audits, benchmarkingand publication activities related to whatmight be broadly described as inappropriatetesting, including: 1. tests not requested, 2. unnecessary tests requested, 3. results notreceived, and 4. results not acted upon –appropriately or at all. I was trying to put allof this into the broader context of the DarziReview and the foundation of healthcare andthe NHS in the future – patient experience,safety and effectiveness. I went to thismeeting, therefore, to better understand howone might assess patient and staff interactionwith the laboratory medicine services and usethis information to transform their experienceand enhance the benefits to patients and staff– as well as for providers and commissioners.

Stories and Numbers Please . . . The focus of the meeting was learning aboutthe importance of the inter-relationshipbetween staff and patient experience, and thefirst session posed the question “How do we

make sense of experience and why?”. Thescene was set by Professor Trisha Greenhalghin a talk entitled “Not stories or number, butstories and numbers”. She made the point thatevidence of good practice comprises bothnarrative (story) qualitative evidence frompatient and staff experiences and quantitativeevidence from, e.g., clinical trials andcollection of key performance indicator data,etc. In the hierarchy of evidence qualitativeevidence is the lowest quality, in part becauseof the variability of its accuracy for any givenevent. However, quantitative data also haslimitations, e.g., the degree of relevance toindividual clinical (patient) situations as well asthe differences between research (trial) androutine environments. Even in this first talk itwas possible to see the relevance forlaboratory medicine – the test result alone ismeaningless.In the second talk Andrea Sutcliffe, Chief

Inspector for Social Care at the Care QualityCommission, in her talk “Behind every numberis a human story”, described her use of theMum Test (is it good enough for my mother?)to assess patient experience. This translates to– is it 1. well-led, 2. effective, 3. responsive topatients’ needs, 4. safe, and 5. caring? The core of the approach is “listen, understandand act”. The parallel with laboratoryaccreditation is obvious – albeit with a broaderpatient and clinical focus, but also with qualityimprovement and translational research inlaboratory medicine.

Stories to Make the PointThe second session explored the power ofnarrative to generate understanding, in whichSara Ryan from the Health ExperiencesResearch Group in Oxford, talked about theimportance of identifying those patients

Transforming Staff and PatientExperience With Stories, Case Histories and NumbersChris Price, Oxford



whose views may not always be heard (seehealthtalk.org for more information), givingsome poignant examples. Dr Michael Easton,an academic GP from Imperial Collage, Londondescribed training doctors on how to listen. A number of questions crossed my mind at thispoint. 1. How can the laboratory help GPsfaced with patients armed with their results?2. As more point of care tests becomeavailable, how will GPs integrate them intotheir practice? 3. Can performing a test as partof the consultation increase patientempowerment?Professor Nick Black from the London School

of Hygiene and Tropical Medicine introduced asession on the value of numbers and their usesto drive improvements. He emphasised theimportance of patient experience, safety andeffectiveness (aka Darzi) in the context of thedomains of the current NHS OutcomesFramework as the main accountabilitymechanism between NHS England and theMinister of State for Health. The 2014/5domains are:

� Preventing people from dyingprematurely.

� Enhancing quality of life for people withlong term conditions.

� Helping people to recover from episodesof ill health or following injury.

� Ensuring that people have a positiveexperience of care.

� Treating and caring for people in a safeenvironment and protecting them fromavoidable harm.

The potential opportunity for laboratorymedicine is obvious. Mike Davidge from NHSElect described how to use data in campaigns,the methodology being similar to qualityimprovement methodologies – in this case“decide the aim, chose the measures, definethe measures, collect the data, analyse andpresent the data and then review themeasures, with the last three actions being thebasis for ongoing cycles. This could be a usefulapproach to promote change - in technologyadoption and benchmarking activities. The final presentation in this session was fromDan Wellings on the Friends and Family Test.

This tool is intended to gain insight intopatient experiences through the medium ofwhether patients would recommend theservices they have experienced to friends andfamily. Clearly the core of this is qualitativeresearch, as well as having a quantitativeelement. It is obvious that this will beimportant for laboratory medicine aslaboratories get closer to patients.

Team Approaches KeyThe afternoon session began with a choice ofworkshops covering Schwartz Rounds,experience-based co-design, benefits oflistening to patients and the role of patientleaders. Schwartz Rounds are multidisciplinarymeetings to review experience; do laboratorymedicine professionals attend these meetings?Research into the effectiveness of SchwartzRounds shows the positive impact that theyhave on individuals, teams, patient outcomesand organisational culture andimplementation of new programmes etc. As patients begin to have direct access to their results, these rounds could become veryimportant to the outward facing laboratorymedicine service. The session on experience-based co-design describedsuccessful approaches to patient experienceprojects and emphasised the importance of ateam approach to projects, and which could bean important adjunct in the design of outcomestudies of new laboratory investigations. The workshops were followed by a number ofcase studies illustrating points made in theearlier sessions of the day.Was this a useful day? Most definitely and as

a “quantitative researcher” it was valuable togain a better appreciation of the use of“qualitative research”, the common themebeing the need to be aware of robustmethodology, as well as the importance ofcritical appraisal and communication skills. As we begin to think more about value-basedhealthcare and the contribution of laboratorymedicine to this philosophy, and the moredirect links between the laboratory andindividual patients, the learnings from the daywere appreciated. �

Crossword | 25

The Colley ChristmasCracker 2014We must look back in ACB News some time and see when this Crossword first appeared! Anyway, never mindabout the past, this is the future! Once you have completed the crossword pass this page through thephotocopier to make a PDF. Then, email it to [email protected] by Monday 29th December. Every correctsolution will receive a suitable reward. Next month we are back to our normal crossword along with someuseful laboratory tips.

The grid is symmetrical in both dimensions. Clues are arranged in alphabetical order

of their solutions.

1 Vinegary hermit misses end of stories (6)2 A sweet child has desire to be back in committee

on organ failure (5,6,6)3 Farewell in lead diode (5)4 Father is not shut up in gas (2)5 Short short is husky (4)6 Part of large vessel for fizzy drink (4)7 Rod sounds grave (6)8 Do this to butter to explain (7)9 Bar balances (13)10 Palindromic omission from four (3)11 Baited, gross with complication (6) 12 Sort of exit without end bores (5)13 Curtailed fourteen to give space (2)14 French fin (2)15 Company car (6)16 Element of Union (2)17 Headless needlewoman and sheep, right in jug (4)18 Cut out tax (6)19 Former lover colours, when Midge's gone out of

existence (7)20 Eastern snowman for rude Roman (5)21 For example, I’m in reverse to donate in Aberdeen (3)22 This should sell well if it's the last (3,4)23 This audible desire produces a phalanx (7)24 I would have roughly been a princess (3)25 Burned in, a mix of units (5) 26 Technology from back end of twenty (2)27 Behold Californian metal ? (2)28 Variable skill is hidden (6)29 Recline briefly, for about a third of a mile (2)

30 Of more importance as a Prime Minister (5)31 Mother, female, has disease (6)32 Scorer for monitoring malignancy (6)33 Female document? (2)34 Odd grimace, two thirds silent letter (2)35 Negative drama (2)36 Sound, when back in sublime Sion's realm (5)37 Sounds painful when bird is detailed (2)38 Lever of the foot (5)39 Generate fifty-eight with cleverness; give me the

bird (6)40 Sanctimonious letter (2)41 Gangster follow case of the feet (5)42 Poet gives right hand for European, not eastern,

gets starch (7)43 One of numerous roots (5)44 This testing done by a jerk? (6)45 Learn about the kidney (5)46 Edible root used for duties (4)47 Does this spin both ways ? (5)48 Are you metallic ? (2)49 Kaolines mixed with tablets are unlikely to cure (5,3,5)50 Immediate blood test blemish (4)51 Confused masters of consciousness (7)52 Appreciate container containing Hydrogen (5)53 Tail-less bird can have tea, at a push (5)54 Rings confused fracas (4)55 Corporation belonging to us shows growth (6)56 Inconvenient loss of guardianship approaching (4)57 You’ve arrived, sounds like waste. (4)58 Sort of accustom to pass this (5)


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