Leading Edge 2021 Issue 2

IN THIS ISSUE ... A New Era in Pancreatic Elastase Testing 2-3 Increased Test Volumes in Your Lab? Avoid Capacity Issues 11 Complementing Laboratory Calprotectin Monitoring with Patient Self-Testing 4-5 Mycology 2021 - Rapid Aspergillus GM Testing 12 Investigating Gastrointestinal Disease in Gorillas 6-7 IMMY - Evolving in Response to the Pandemic 13 A Flexible FIT - Ensuring Services are relevant throughout COVID-19 8-9 Lupus Anticoagulant - Testing and Diagnosis 14-15 IBD Therapeutic Drug Monitoring - Be in Control of Your TAT 10 For a Perfect FIT switch to the NEW PillowPac2 Mailing Solution 16 2021 Issue 2 Alpha Laboratories Ltd. Diagnostics Turbo Charge Your Faecal Testing Calprotectin & Elastase from the Same Sample

2 2021 ISSUE 2 The latest NHS England performance figures show that nearly 3,000 people have been waiting almost two years for a procedure, whilst 400,000 have been waiting over a year. These numbers are a stark reminder that as we learn to live with COVID-19, the pressure faced by the NHS in tackling the enormous backlog, is unprecedented. However, the NHS has demonstrated a willingness to innovate during the pandemic, making use of new technologies to facilitate new pathways and new ways of working, to develop extra capacity and aid recovery. Alpha Laboratories has been working continuously with various Trusts to help support improved efficiencies. This issue of Leading Edge highlights several solutions that can improve work flows and enhance capacity. The new fPELA assay now enables pancreatic testing from the same patient sample as that used for calprotectin, on high throughput clinical chemistry analysers. In addition the new BioSystems BA200 offers a stand-alone platform for faecal testing if you need to free up your main analysers. We have reported during the pandemic how many Trusts have adopted the use of calprotectin home testing for monitoring IBD patients. On pages 4-5 you can read how some continue to find this complementary to laboratory testing. Diagnostic technologies such as faecal immunochemical testing (FIT) can triage patients and fast track the most in need. See pages 8-9. Alongside this, tailored patient sample collection and return logistics have been enhancing compliance and increasing test uptake. For some light relief read about Jock the gorilla on page 6! Launched in summer 2020, the new BÜHLMANN fPELA turbidimetric immunoassay for faecal pancreatic elastase, complements the popular calprotectin fCAL turbo assay, that is widely used across the UK. Using the same CALEX faecal extraction device as the calprotectin assays and running on main-stream clinical chemistry analysers, the fPELA is set to improve workflow and turnaround times, in a similar manner to the fCAL turbo. Rachel Navin and Sarah Rogers are both Senior Biomedical Scientists at York hospital, the largest hospital within the York and Scarborough Teaching Hospitals NHS Trust. Here they report on their experience of introducing the BÜHLMANN fPELA into their routine testing. “We currently test around 2,000 faecal elastase samples a year, which works out to about 40 per week. These samples are primarily from York, but we do also test for some other local hospitals. Primarily requests for pancreatic elastase come from gastroenterology and Cystic Fibrosis patients, for whom it is used for both diagnosis and monitoring of pancreatic insufficiency. Previously we were running the Schebo ELISA assay, initially manually, but in recent years it has been run on the Dynex DS2 ELISA processor provided by Alpha laboratories to run the BÜHLMANN fCAL ELISA. With the Schebo method we were freezing the samples on receipt, due to stability concerns, and then running the assay once a week. We are looking to switch the BÜHLMANN fCAL ELISA assay to the fCAL turbo on our existing Roche platforms. This means the DS2 will be decommissioned, so we needed to look for an alternative option for the elastase assay as we didn’t want to go back to manual testing. In the past we have had a few issues with the Schebo assay and had already investigated switching to alternative ELISA assays. These assays also required the use of the DS2 so were not considered this time. A New Era in Pancreatic Elastase Testing by Rachel Navin and Sarah Rogers, Senior Biomedical Scientists at York Hospital Sarah Rogers (left), Rachel Navin (right) with their colleague Hannah Eccles (centre) in their laboratory at York Hospital.

Find out more at: www.alphalabs.co.uk/fpela 3 New Method: SGH Comp. site: York Allowable di erence ±10% Passing-Bablok t (y=-1.293 + 0.9756 x) 500 450 400 350 300 250 200 150 100 50 0 0 50 100 150 200 250 300 350 400 450 500 Figure 1. Comparison of results of faecal samples tested with the fPELA assay at both York Hospital and Scunthorpe General Hospital. Like many hospitals we are tight on space, so there is no capacity for additional equipment which means we needed to investigate what was possible with our existing platforms – the BÜHLMANN fPELA was the obvious place to start as there was a protocol available for the Roche c702. Setting the assay up on the analyser was reasonably straight forward. The only limitation is that as a third-party assay we can only have one set of reagents loaded per assay. So, we are double filling the reagent packs which reduces the number of times that we need to replace the reagent. This approach also helps with the amount of shots per kit, because you reduce the dead volume impact. We already use the CALEX extraction devices for our calprotectin samples. This was an advantage as the team was already familiar with processing them. We have found that around 10% of samples request both calprotectin and elastase, so we only need to do one extraction for both assays. Previously we requested that separate samples were provided for elastase and calprotectin due to the different stability recommendations of each assay. It is possible that moving forward more samples will require both assays performed, because they can come as a single request. During the evaluation we did a sample swap with PathLinks, Scunthorpe General Hospital that was also evaluating the fPELA, and the results were within 10% of each other, so we were satisfied with that. [Figure 1] With the new service we are preparing the samples daily, storing them in the fridge and then running the assay twice a week – this will give a much better turnaround time on the results for our clinicians. We have been live with the assay for a few months now, and the service is running very smoothly. ■BÜHLMANN fPELA® turbo Runs on main stream clinical chemistry analysers for a simplified workflow and rapid results ■CALEX® sample extraction Utilises the same sample preparation device as the fCAL turbo calprotectin assay. ■Revolutionise your elastase workflow Perform two tests from a single extraction ■Time to first result: 10 minutes ■Dynamic range: 10 - 5000µg/g ■Extraction: CALEX ■Kit size: ~100 tests New BÜHLMANN fPELA® turbo Faecal Pancreatic Elastase Assay We would certainly recommend the BÜHLMANN fPELA to other hospitals considering the assay – the workflow and direct reporting has made things so much easier, and it would certainly be good to have other users to compare results to on the EQA.”

4 LEADING EDGE - 2021-2 The mean calprotectin concentration, measured from the tests that were completed, was 509 µg/g. The IBDoc system is customisable to an individual patient level which enabled the hospital to apply its local cut-off values to the results (red/amber/green traffic light system) that were obtained: 0 - 250 µg/g = Normal 250 - 500 µg/g = Moderate >500 µg/g = High The categorisations of the results according to the local defined cut-off values were then as follows: These values then prompted the following actions based on the IBDoc: ■ 36.7% of patients required no change in management ■ 31.7% of patients had their management modified based on the IBDoc results and subsequent clinical correlation. ■ 31.7% required further assessment Following use of the IBDoc during COVID, a survey was sent out to the patients. From those who responded, 95% indicated that they would be willing/comfortable using the IBDoc in the future. 85% said they preferred it to the standard clinical attendance laboratory test, so patient acceptance was high. Most of the studies/publications available on patient self-testing have been based on the adult population. So, this was interesting feedback from a different set of patients who were aged from just under 5 years old to just over 18 years old. This very positive feedback is even more surprising because the patients did not get access to the numerical result or the traffic light indication in the App. This was the clinic’s choice to reduce anxiety with unsupported results but is normally the feature adults like best. COVID has caused many changes in our day to day lives, with freedom and services intermittently restricted as the infection rates surge and abate. This pattern has also been evident in our healthcare system as we have previously reported to you. A UK on-line survey in 2020 of 125 hospitals (Kennedy et al. Frontline Gastroenterology1) showed that 35% of hospitals reported all IBD related endoscopy had been cancelled, but most reported a significant reduction in availability. At the same time 27% of locations reported no access to faecal calprotectin whilst a further 32% reported reduced access. This was for a variety of reasons, including concerns over infectivity of COVID from stool samples, lack of access to cabinets for safe handling, increased workload from COVID, staff shortages in labs and calprotectin being defined as a non-critical assay by the RCPath, IBMS, ACP and ACB. This left many gastroenterologists without the critical tools they normally employed to manage their IBD patients. During this time, many hospitals implemented new systems to support their patients in a rather stressful time. Introducing IBDoc Calprotectin Patient Self-Testing The Royal Hospital for Children in Glasgow was one of the hospitals that introduced the IBDoc calprotectin patient self-test during this time. The team there has recently published a paper about their experience (Jere et al. BMJ2). From this publication we can see that the majority of patients who used the IBDoc were being routinely monitored or were being monitoring for response to a new therapy: Complementing Laboratory Calprotectin Monitoring with Patient Self-Testing The reasons listed for preferring the IBDoc home test over the traditional lab test were: University Hospitals Birmingham NHS Trust also implemented the IBDoc with some of their IBD patients recently, in response to COVID. In a recent poster from ECCO 2021, Edwards et al.3 presented an improved level of compliance with calprotectin testing using the IBDoc compared with the traditional laboratory method. This enables the clinical team to better support the patients appropriately: The majority of calprotectin testing will always be laboratory based tests for the differentiation of IBD from IBS. This is largely due to economic factors. However, customised patient monitoring and involvement for IBD positive patients, with remote tests and symptom checking, is becoming more widely adopted. Digital Technology NHSX is promoting digital technology to help improve patient pathways in a number of focus areas, and has recently published some digital playbooks for gastroenterology including the IBDoc (www.nhsx.nhs.uk/key-tools-and-info/ digital-playbooks/) Publications that show improved patient management and testing compliance, with quicker results, will help technology become more widely adopted as the normal standard of care. This should lead to rapid initiation of appropriate treatment plans, resulting in better patient outcomes as well as cost savings.

www.alphalabs.co.uk 5 References 1. Kennedy NA, et al. Organisational changes and challenges for inflammatory bowel disease services in the UK during the COVID-19 pandemic. Frontline Gastroenterology 2020;0:1–8. doi:10.1136/flgastro-2020-101520 2. Jere M, Garrick V, Curtis L, et al. Point-of-care faecal calprotectin testing in patients with paediatric inflammatory bowel disease during the COVID-19 pandemic. BMJ Open Gastro 2021;8:e000631. doi:10.1136/bmjgast-2021-000631 3. D Edwards, M Ibrahim, R Cooney, R Boulton, P518 Compliance with Faecal calprotectin home testing as standard during COVID-19 pandemic compared to laboratory based testing preCOVID, Journal of Crohn’s and Colitis, Volume 15, Issue Supplement_1, May 2021, Pages S496–S497, https://doi.org/10.1093/ecco-jcc/ jjab076.640 For more information on IBDoc please visit: www.calprotectin.co.uk/ibdoc To discuss implementation for your patients please email: digestivedx@alphalabs.co.uk Name Date of Sample 107AIE 00000024 2021.05.31 M / F Date of Birth LOT HOW to Pl 1. Preparation Write your NAME and Date of Birth on the Green Plastic Bag and Device. Carefully and slowly twist and pull out the Stick Part from Main BODY. 107AIE 00000024 2021.05.31 Name Date of Sample 2021.05.31 Date of Birth Date of Sample Name Date of Birth Date of Sample Name Date of Birth Date of Sampling (DD/MM/YYYY) NAME Mr Ms Date of Birth (DD/MM/YYYY) / / / / T: 02380 483000 E: digestivedx@alphalabs.co.uk Maximise Compliance to Boost your FIT Service Benefit the Complete FIT Patient Pathway with Simple, Hygienic Sample Collection Improves patient uptake and compliance  Reduces sample rejections in the lab  Speeds up sample processing  Reduces turn-around time, enabling better patient management  Tailored instructions ensure reliability of your FIT Service  Ensures all required documentation is completed and included with the sample  Reduces administrative burden on the lab, allowing better work flow  All pathway steps are clearly identified and managed effectively For more information on Faecal Immunochemical Testing (FIT) and our bespoke Patient Pack service, please visit: www.faecal-immunochemical-test.co.uk

6 LEADING EDGE - 2021-2 Bristol Zoo Gardens is a conservation and education charity founded by Henry Riley, a local physician and is the fifth oldest zoo in the world. It first opened its doors on 11th July 1836 and has since helped to save 175 species from extinction through breeding programmes and has established over 30 field conservation and research projects globally. Charlotte Day, one of the resident vets at the zoo tells us about a recent study they conducted with Jock, their 32 stone male silverback gorilla. “Jock has had symptoms of gastrointestinal disease for quite a while with vague symptoms such as losing weight, being lethargic and having intermittent diarrhoea. We have tested him for various parasites but haven’t been able to get to the bottom of what is causing his symptoms and so we wanted a noninvasive way of finding out if he possibly had an inflammatory bowel disease (IBD). The problem with gorillas is that to do any investigations we need to give them a general anaesthetic. As you can imagine they wouldn’t co-operate with procedures such as an endoscopy. General anaesthetic presents considerable risk and is a major procedure. Jock also isn’t a young gorilla and has other underlying medical issues, so we really don’t want to anaesthetise him unless it is absolutely necessary. Calprotectin? I was aware that calprotectin testing is used in humans to assess for IBD but didn’t really have any data about its use for assessment in veterinary practice. Researching online I came across the BÜHLMANN Quantum Blue® faecal calprotectin test. This seemed ideal for our purposes because a lot of laboratories won’t take faecal samples from non-human primates due to the risk of zoonotic infection. Being able to perform the assay ourselves looked like the perfect solution and it seemed relatively straight forward. Because we didn’t really have any data on faecal calprotectin in gorillas we decided to test all of them and compare the results to Jock to see if there was a difference in their faecal calprotectin concentrations. Obtaining faecal samples from gorillas Normally, if we want to test a faecal sample from an animal then the vets will put a request in to the keepers to organise this. However, most of the animals are housed in groups, so identifying who has produced a specific sample is not always easy. The keepers can’t go in whilst the gorillas are in the enclosure; they need to wait until the gorillas are moved into a separate section and then they can go and collect the samples. Fortunately, the gorillas have all been trained to go into individual pens for eating so that they can have tailored diets. So, we can easily feed them edible food dyes to identifying which faeces belong to which gorilla. However, on consultation with Alpha Laboratories it was realised that this was not a good approach because the assay relies on the development of a coloured line in the lateral flow cassette and the dye might influence the result. For this reason we also excluded beetroot from the gorillas’ diet whilst we were doing the testing, just in case. Investigating Gastrointestinal Disease in Gorillas by Charlotte Day, Veterinary Resident, Bristol Zoo Gardens Jock, the silverback gorilla, and his fibrous diet.

www.alphalabs.co.uk 7 In the end, to avoid any risk of interference with the test, we decided to just wait and collect samples from the feeding dens where each gorilla was isolated, so that we could guarantee which faecal sample was from which animal. Sample Extraction Once we had the samples collected, we could begin the testing. We viewed the CALEX (sample extraction device) video on the website on how to deal with the various sample types. We found this really helpful. But, we quickly realised that gorilla faeces is nothing like human faeces – there really isn’t much ‘nutella’ portion. Our Gorillas have a mainly vegetable-based diet, but they eat lots of leaves and branches, so the faecal samples produced (excluding the episodes of diarrhoea) are extremely fibrous and were virtually impossible to obtain any soft material from without loads of fibres. After further discussion we modified the technique to sieve the sample through a tea strainer to remove the fibrous material, but that wasn’t an easy process. It took nearly a full pot of faeces to obtain sufficient soft material that we could then load onto the CALEX for extraction. Extended Range Quantum Blue fCAL We used the extended range BÜHLMANN Quantum Blue assay (LF-CALE25) which has a lower limit of 30µg/g. None of the samples we tested from the other gorillas came above this. But, Jock’s samples gave values of around the mid 70’s µg/g. This isn’t high compared to human levels, but may be significant as it was more than double the value in the ‘normal’ gorillas. To obtain a definitive diagnosis of IBD we would need to perform colonoscopy/biopsy, which we will look into doing as part of Jock’s next planned health check under general anaesthesia. The captive population for gorillas is quite small, but I am investigating the possibility of getting samples from other institutions across Europe, from animals with similar IBD symptoms. This will help acquire more data to correlate the results and hopefully validate with gut biopsies, for definitive confirmation, but that is a longer-term project. It would also be interesting to look at some of the smaller monkeys with marmoset wasting syndrome. There have been some publications using calprotectin to investigate this previously, before further invasive investigations are carried out. Sample processing for the smaller monkeys should also be easier as they eat less woody material. The project to look at faecal calprotectin concentrations within our population of gorillas has certainly been worthwhile. However, it did come with some unexpected challenges in the difficulty of actually extracting the samples compared to human faeces. Although the study was not conclusive, it does indicate that further evaluation would be beneficial, and at least we know how to modify the technique next time. Find out more about Quantum Blue® fCAL at www.calprotectin.co.uk Are you still using a guaiac method for faecal occult blood (FOB) detection? Qualitative faecal immunochemical tests (FIT) can be just as easy as traditional guaiac methods for near patient testing or when the requirement for a fast turnaround impedes the use of a quantitative FIT service. The DIAQUICK FOB cassette offers the specificity of a FIT in a simple yes/no manual test format: No Dietary Assay Interference It is common for guaiac-based methods to recommend adherence to a special diet in the days prior to testing. This is to avoid interference from peroxidases or animal haemoglobin, but is a distinct draw back when you need to test in an acute setting. There are no dietary restrictions when using the DIAQUICK FOB lateral flow assays, as these use antibodies that specifically bind human haemoglobin (Hb), with a sensitivity of 5µg Hb/g faeces. Specific, Sensitive, Simple Easy to perform ■ Result in 5 minutes ■ Specific for human Hb ■ Sensitivity 5µg Hb/g faeces ■ No dietary preparation required For more information on the DIAQUICK FOB Cassette, visit alphalabs.co.uk/ Z01101CE Detect Human Occult Blood in Faeces with the DIAQUICK FOB Cassette Immunochromatographic Lateral Flow Assay Is it time you moved on from gFOBT?

8 LEADING EDGE - 2021-2 A Flexible FIT Ensuring Services are Relevant Throughout the COVID-19 Pandemic The faecal immunochemical test (FIT) is used to identify microscopic traces of haemoglobin in faeces which is a common indicator of significant bowel disease (SBD). Primarily used in colorectal cancer (CRC) referral pathways, FIT has been in routine use across the UK for several years, aiding the assessment of symptomatic patients referred from primary care. It has also been adopted as the testing method within the national bowel screening programmes. The COVID-19 pandemic caused widespread challenges to the health service and many routine diagnostics were disrupted. As a result, the applications for FIT diversified leading to its implementation in a range of pathways; from secondary care triaging to bowel surveillance, to Vague Symptoms Pathways (VSP). The proven diagnostic efficacy, and the patient-centric nature of the associated FIT-KITs (a pack containing everything the patient needs to take and return their sample), has allowed FIT to progress naturally into these pathways. This is helping ensure patients are wellmanaged and resource is allocated effectively during the ongoing peaks and troughs of the pandemic. Benefits of FIT In July 2017, the National Institute of Health and Care Excellence (NICE) published its diagnostic guidance, DG30 , on the use of FIT in primary care, to help guide referral for patients with suspected colorectal cancer (CRC). As a result, the demand for FIT soared, and primary care pathways were set-up across the UK to help support the referral process. Towards the end of 2019, health services were seeing real advantages following the implementation of FIT: endoscopy waiting lists were reducing, and procedure waiting times were decreasing, resulting in better patient management. FIT was also being used more frequently in other pathways, not just primary care referral: Vague Symptoms Pathways (VSP) and Rapid Diagnostic Pathways (RDP) have been using FIT as a convenient method to gauge bowel health in individuals who may not otherwise fall into the DG30, or NG12 , pathways. Moreover, FIT has been shown to identify not only CRC, but a range of other significant bowel diseases (SBD), including inflammatory bowel disease (IBD), and high-risk adenoma (HRA) , which furthers the scope for the application of FIT in lower-GI diagnostics. Challenges of the Pandemic The advent of COVID-19 caused unprecedented disruption to a huge number of diagnostic services, threatening to undermine the work achieved so far with FIT implementation. During the initial stages of the pandemic, the risk of COVID-transmission through faecal samples was unknown, and as all non-urgent procedures were halted, the endoscopy waiting lists increased drastically. FIT demand dropped substantially as testing was halted to allow risk-assessments and restructuring to cope with the additional strains on the NHS. Access to GPs and healthcare settings were restricted, and individuals were more reluctant to discuss symptoms with their GP for fear of having to attend the practice in person. From June 2020, laboratory analysis of FIT samples began to ramp-up, yet the pathways originally bringing in the FIT samples had changed. One of the most obvious changes was the increase in the number of samples from secondary care. Patient Triage Patients awaiting further investigation following a referral were facing extended waiting times: and, as with many SBD cases, typically the earlier the diagnosis, the better the long-term prognosis. A higher concentration of faecal haemoglobin (f-Hb) is associated with more severe disease3, and therefore FIT is used to help triage patients, in conjunction with clinical suspicion, to manage the scarce endoscopy resource. It has allowed the patients with the most severe symptoms (and therefore those most at risk of severe disease) to be prioritised accordingly or assessed via other channels. Additionally, in the absence of f-Hb, the risk of severe disease is low, and these patients may often be better managed via a less invasive referral route, as colonoscopies are not without risk. Increased Test Uptake FIT and the associated FIT-KITs, have been well aligned with changes to patient’s healthseeking behaviours, increasing uptake of the test and improving sample quality. By giving patients contact-free access to a home-based sample collection kit, whether it be a COVID-19 test or a FIT-KIT, patients are increasingly familiar with following instructions, collecting samples, and returning them – even engaging more with follow-up and results. By reducing the fearfactor associated with faecal testing, and making the kits as user-friendly as possible, more people are engaging with the diagnostic pathway, which in turn increases the value of the test to the healthcare service. Name Date of Sample 107AIE 00000024 2021.05.31 M / F Date of Birth LOT Secondary care triaging Bowel surveillance 2m 2m

Find out more at: www.alphalabs.co.uk/fpela 9 Further Expansion To further expand the use of FIT, healthcare decision makers are looking beyond the original DG30 and NG12 guidelines and starting to assess the value of FIT in the younger population. With the incidence of CRC on the rise in the under 50s, the test must prove valuable in yet another cohort, and early studies are showing promising results . This is yet further evidence that with well-structured pathways, and appropriate efficacy studies, it is possible for FIT to be of even more value to lower-GI diagnostics. is important to use any diagnostic test with a full understanding of its limitations. Ensuring adequate safety netting is one of the most important aspects to any diagnostic service: and although FIT has a high negative predictive value for CRC (>98%) there is still a risk that cancer (or SBD) is missed. The key to further expanding FIT application is to ensure it is done safely and efficiently: monitoring patient outcomes, and ensuring the capacity challenges are resolved, not just displaced to another service. Overall, the diversification of FIT applications has been accelerated by COVID-19. By remaining cognisant of its limitations, and creating robust safety netting procedures, FIT applications will continue to diversify over the coming months. Applications in primary and secondary care, VSP and RDC, and expanding to the younger cohort, shows the true value of FIT may yet to be fully appreciated, and it is anticipated that the pathway changes will become routine and continue to help improve patient care, and resource management in the NHS for years to come. References / Sources: 1 National Institute for Health and Care Excellence (2017) Quantitative faecal immunochemical tests to guide referral for colorectal cancer in primary care. Diagnostics guidance [DG30]. [online]. Available at https://www.nice.org.uk/guidance/ dg30 (Accessed 15 July 2021) 2 National Institute for Health and Care Excellence (2021) Suspected cancer: recognition and referral NICE guideline [NG12]. [online]. Available at https://www.nice.org.uk/guidance/ng12 (Accessed 15 July 2021) 3 Strachan, J. A. and Mowat, C. (2021) The use of faecal haemoglobin in deciding which patients presenting to primary care require further investigation (and how quickly) – the FIT approach. [Online], The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine (eJIFCC). Vol. 32, No. 1, pp. 52-60. Available at https:// www.faecal-immunochemical-test.co.uk/ wp/wp-content/uploads/2021/03/ejifcc2021-FIT-Strachan-and-Mowat.pdf (Accessed 15 July 2021) 4 D’Souza, N., Monahan, K., Benton, S. C., Wilde, L., Abulafi, M., The NICE FIT Steering Group. (2021). Finding the needle in the haystack; the diagnostic accuracy of the faecal immunochemical test for colorectal cancer in younger symptomatic patients. [Online]. Colorectal Disease. Available at https://onlinelibrary.wiley.com/ doi/10.1111/codi.15786?af=R (Accessed 15 July 2021) However, it Q. A.  Q. A.  Q. A.  Q. A.  Vague Symptoms Pathways (VSP)

10 LEADING EDGE - 2021-2 IBD Therapeutic Drug Monitoring - Be in Control of Your TAT Adopt a Proactive Approach to Therapeutic Drug Monitoring for IBD Patients A recent UK national survey by Nigam et al., published in Frontline Gastroenterology 2021, investigated gastros’ attitudes towards therapeutic drug monitoring (TDM) of anti-TNF therapy in their inflammatory bowel disease patients. 85% of respondents said they would proactively monitor on an annual basis if the barriers were removed. The primary barrier cited was the time lag in receiving results. Rapid Testing Using the BÜHLMANN Quantum Blue system, results can be available within an hour. This enables real-time dose adjustment for infliximab and adalimumab, facilitating optimisation of treatment, minimising loss of response and side effects and saving valuable healthcare resources. Proactive Monitoring Proactive anti-TNF drug and anti-drug antibody monitoring can improve clinical outcomes through the maintenance of levels within therapeutic windows. This prevents sub-therapeutic levels which may enable low level inflammation that can cause tissue damage or trigger a flare. It also means supra-therapeutic levels can be de-escalated, minimising side effects and saving costs. Clarissa Rentsch at Alfred Health, Melbourne, Australia “This rapid test strategy has the potential to reduce patient risks and improve patient outcomes without negative cost implications” Watch the Presentation from ECCO https://youtu.be/TizubO07C1M Maria Pia Costa Santos from Hospital Beatriz Angelo, Loures, Portugal “Point of care infliximab trough levels were easy to implement into a daily practice setting. The therapeutic window was achieved in only a third of patients, in the remaining patients an immediate treatment adjustment was possible enabling a cost saving” Watch the Presentation from ECCO https://youtu.be/QNPMkaq-LD8 Quantum Blue® Reader ■ Quantitative results: - Infliximab 0.4 - 20µg/ml (linear up to 180µg/ml) - Adalimumab 1.3 - 35µg/ml ■ Anti-drug antibody assays available ■ Excellent correlation with the WHO infliximab standard ■ Simple bench top reader - Touch screen data entry - LIMs enabled for easy data entry and reporting ■ Ideal for use in POC: - No need to batch samples - Individually packaged single use tests to maintain quality until use - Small pack sizes available Reference Nigam GB, Nayeemuddin S, Kontopantelis E, et al. UK National Survey of Gastroenterologists’ attitudes and barriers toward therapeutic drug monitoring of anti-TNF therapy in inflammatory bowel disease. Frontline Gastroenterology 2021;12:22-29. For more information on Quantum Blue for TDM or to arrange a demonstration, please visit: www.calprotectin.co.uk/TDM

www.alphalabs.co.uk 11 Increased Test Volumes in Your Lab? Avoid Capacity Issues With current demands, many laboratories are experiencing capacity issues on their main clinical chemistry analysers Now you can free up space on your main clinical chemistry analysers by moving faecal calprotectin and elastase assays to the standalone BioSystems BA200 random access analyser. This bench top instrument offers an excellent alternative to the main stream analysers for faecal testing, with comparable performance and efficiency. ■ Available as a capital purchase or on a reagent rental agreement ■ CE marked protocols for the BÜHLMANN fCAL® turbo (faecal calprotectin) and fPELA® turbo (faecal elastase) assays ■ Direct loading of the CALEX extraction devices (one extraction for both tests) v ■ Time to first result is 10 minutes (200 tests per hour) ■ Built in bar code reader ■ LIMS enabled ■ Excellent correlation of results to other analysers BioSystems BA200 Analyser Standalone analyser offers an excellent alternative to the mainstream analysers for faecal testing, with comparable performance and efficiency. For more information, visit www.alphalabs.co.uk/83200 Method Comparisons with Mainstream Analyser

12 LEADING EDGE - 2021-2 Rapid Aspergillus GM Testing Jessica Price of Public Health Wales, Mycology Reference Laboratory presented data evaluating the use of the IMMY sõna Aspergillus Galactomannan (GM) lateral flow assay (LFA) with serum samples to aid diagnosis of invasive aspergillosis (IA)1. The retrospective study, using the GM LFA together with the Cube Reader to provide a GM index (GMI), tested samples from 136 patients most of whom were being treated for haematological malignancy. The study generated good overall qualitative agreement between the GM LFA and an established GM enzyme immunoassay (EIA), 89.0%. With the GM LFA demonstrating a sensitivity and specificity of 96.9% and 98% respectively. Quantitatively, GMIs generated by the GM LFA were significantly higher than those produced by the GM EIA. In conclusion, the GM LFA was found to provide a rapid alternative to the current GM EIA, which could improve time to result and improve accessibility for GM testing at non-specialist centres facilitating appropriate patient management. And The Future Holds... We are looking forward to more updates on fungal disease diagnosis and management this Autumn, as we plan to attend the 10th Trends in Medical Mycology2 meeting in Aberdeen, and of course at Mycology 20223 next March. 1. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC7269407/ 2. https://www.timm2021.org/ 3. https://mycolovvvgyconference.co.uk/ The joint British Society for Medical Mycology (BSMM) and Fungal Update meeting originally planned for March 2020, like many conferences following the outbreak of the SARS-CoV-2 pandemic was sadly postponed. Evolving into a virtual conference, Mycology 2021, the meeting was held in June this year providing a welcome opportunity to hear, and learn, from numerous opinion leaders on the challenges of diagnosing and treating Invasive Fungal Diseases. As may be expected, COVID-19 associated fungal infection (CAFI) was a prominent theme. Shared case studies from the COVID pandemic front line throughout Europe, also including a presentation from India, were a valuable resource to understand and compare the patient management and diagnostic strategies employed at different centres. It was fascinating to listen to insights into evolving diagnostic and patient management pathways, and awareness of the need for antifungal stewardship. Invasive Aspergillus Biomarkers Aspergillus species was a hot topic, not only for COVID-19 associated pulmonary aspergillosis (CAPA) but also for other high risk patient groups such as haemato-oncology and solid organ transplant. The diagnostic importance of biomarkers, such as Galactomannan (GM) & β-D-glucan (BDG), in serum and bronchoalveolar lavage (BAL) was highlighted. Introduction of rapid tests for such biomarkers would remove the need to batch samples and enable non-specialist centres to test in house, therefore providing faster turnaround times as part of their diagnostic strategies. A30 minute test time AHigh sensitivity and specificity ASerum and BAL specimens ADedicated assay reader APos/Neg and index value display ASimplified procedure For more information on the sõna Aspergillus Galactomannan Lateral Flow Assay (Asp GM LFA) immunochromatographic test system, please visit: www.alphalabs.co.uk/af2003 SÕNA ASPERGILLUS GALACTOMANNAN Lateral Flow Assay

www.alphalabs.co.uk 13 IMMY-Evolving in Response to the Pandemic Saving Lives One Diagnostic at a Time IMMY, a diagnostic manufacturer based in Norman, Oklahoma, USA, has had a singular focus since 1979: “Saving Lives One Diagnostic at a Time”. Until last spring, that vision was solely centred around creating diagnostics to be utilised close to the patient in clinics, hospitals, and labs across the world for diagnosing rare, invasive fungal diseases. With the onset of the pandemic, in early 2020, the necessity for pivotal changes in operations was clear, knowing that IMMY had the expertise and manpower to be a fighting force against COVID-19. The process was different, but the mission still rang true: “Saving Lives One Diagnostic at a Time”. So, IMMY got to work transitioning its workforce from developing new fungal diagnostics and began devising a method for COVID testing that would be faster and more efficient than the current, timeconsuming options. In March of 2020, as the pandemic started to take form in the U.S., IMMY officially founded IMMYLabs LLC to lend a hand in the fight against COVID-19. In less than a weeks’ time IMMYLabs became a CLIA certified laboratory capable of receiving and processing PCR samples. With the help of PCR machinery from the University of Oklahoma, IMMYLabs began receiving samples delivered to its lab for COVID-19 PCR testing. It’s goal was to get accurate results back to patients in less than two business days. After realising the desperate need for high-volume testing, IMMYLabs developed a highly efficient drive through system designed to test thousands of patients each day. Patients would sign up for a test on a secure, online portal created by IMMY’s internal IT team, show up to a drive through location that offered no-contact check-in, and would be swabbed within minutes of their check-in time. At the height of Oklahoma’s testing needs, IMMYLabs ran over 31,000 COVID-19 tests in a single week, returning results in an average of 25 hours. By July of 2021, IMMYLabs had administered over 300,000 PCR COVID-19 tests to citizens of Oklahoma. As the COVID-19 vaccine was being rolled out, there was an immediate surge in demand for vaccine appointments and not nearly enough locations administering them to keep up with said demand. IMMYLabs rose to the challenge again and developed an efficient, fast system for vaccinating Oklahomans on a mass scale. Again, with the use of an internally developed software, IMMYLabs allowed for patients to sign up quickly and easily for a vaccination appointment online. Locations all over the state were in need of vaccination services, so IMMYLabs made sure to develop their system so that it could be mobilised. IMMYLabs has been an essential piece in the battle against COVID-19 in Oklahoma and has potentially saved the lives of hundreds of thousands of Oklahomans by making testing and vaccination readily available. The state-wide effort to move back to normalcy has been greatly expedited by the services provided by IMMYLabs. The pandemic has brought many changes to IMMY, but one thing remains the same: the unwavering goal to always prioritise “Saving Lives One Diagnostic (or Vaccine) at a Time”. Read the full story online: www.alphalabs.co.uk/immy-covid

LEADING EDGE - 2021-2 14 Two Tests According to recommendations from the International Society on Thrombosis and Haemostasis, laboratory detection of LA screening should be performed using two tests, based on different principles. If one of the two screening tests comes back positive for LA, a mixing study is performed. If the result of the mixing study is prolonged, a confirmatory test showing PL dependence should be performed. Testing Pathway LA detection is based on PL-dependent coagulation tests, which complicate the methodology and hamper its interpretation because of interference, for instance by anticoagulant therapy and some acute phase response proteins. Testing for LA should focus on individuals that present with symptoms of APS and asymptomatic testing is discouraged. 1) Screening Test – Screening is completed using a dRVVT assay, such as CRYOcheck™ LA check, and an aPTT assay with a low PL concentration with silica as an activator. If both tests come back negative, no further testing will be completed on the patient. If one or both tests are positive, with positive regarded to be a clotting time that is prolonged beyond the locally established cut-off, a mixing test will be completed. This is part of the recommended first line testing from ISTH. 2) Mixing Test – The patient sample is mixed with pooled normal plasma. Pooled normal plasma for mixing studies can be prepared in-house, or a commercially available lyophilised or frozen pooled normal plasma may be used, such as CRYOcheck™ Pooled Normal Plasma. The mixed sample (1:1 ratio) is then re-tested. If the addition of pooled normal plasma corrected the aPTT, the patient is negative for LA and will be investigated for other causes of symptoms, such as factor deficiencies or inhibitors. If the mixed sample does not correct, a confirmatory test will then be completed. 3) Confirmatory Test – This is performed using Bilayer or Hexagonal (II) phase phospholipids with increased levels of PL showing a shortening of the clot time (PNP). Antiphospholipid syndrome (APS) is an autoimmune disorder characterised by the presence of antibodies directed at phospholipids and plasma proteins that bind to the phospholipid, causing a hypercoagulable state. The risk factors for APS include acquired infections such as HIV/Aids, Hepatitis C and Lyme disease. Also, a number of other autoimmune diseases and the use of various medications. Gender is also significant with APS found more commonly in women than men. There are four types of classification of antiphospholipid antibodies (APA): Anti-β2GP1, Anti-cardiolipin (aCL), Anti-prothrombin (aPT) and Lupus Anticoagulant (LA). Lupus Anticoagulant LA is thought to be present in 1-2% of the general population. It consists of antibodies that inhibit phospholipid (PL)-dependant coagulation in vitro. These antibodies are directed against a phospholipid binding protein, usually a β2-GP1. When β2-GP1 is bound by antibodies this results in enhanced PL binding, which then causes a prolongation of in vitro clotting times. The presence of LA indicates a greater association with unexplained thrombosis, recurrent foetal loss and is strongly associated with autoimmune disorders such as Systemic Lupus Erythematosus (SLE). The antibodies interfere with the prolonged phospholipid-dependent tests in vitro in coagulation such as APTT and PTT. Antiphospholipid Syndrome Lupus Anticoagulant Testing and Diagnosis

www.alphalabs.co.uk 15 CRYOcheck™ LA Sure is used following CRYOcheck™ LA check in the screening phase. It has a high phospholipid concentration that neutralises LA and therefore demonstrates the correction needed to report positive LA results with confidence. Alternatively, a platelet lysate, such as CRYOcheck™ Platelet Lysate can be used as a source of phospholipids, intended for use in the platelet neutralization procedure (PNP), used to detect lupus anticoagulants (LA). In either of these methods, if the clot time is corrected; meaning that the confirmatory test is positive, ISTH recommends that a retest be completed in 12 weeks. This is to allow rule out of a possible transient disorder as opposed to an autoantibody disorder. Hexagonal Phase Phospholipids Hexagonal phase phospholipids have been shown to have a superior immunogenic response to LA when compared to bilayer or lamellar phospholipids arrangements. Additionally, an integrated assay “weak” LA that prolongs clotting times above a patient’s baseline, but not above the RI, are more likely to be detected. In this situation, non-agreement between screen and confirm components of the test may reveal LA where a APTT based screening test alone would not. This provides a testing algorithm with easy interpretation of positive results and less ambiguity around negative results. Integrated Screen and Confirm The CRYOcheck™ Hex LA kit satisfies all three testing criteria from CLSI and ISTH for LA diagnosis (Screening, Confirmatory, and Mixing tests). It is an integrated (screen and confirm) silica-based APTT assay and has been designed to work on many common automated coagulation analysers. The Hex LA kit gives a simple, fast method for LA detection as part of a LA test panel. This allows the reagents to be loaded faster and report LA results with confidence. Fresh is Best The Precision BioLogic CRYOcheck™ range of products are all fresh frozen plasmas, required to be frozen at -80C. The products are easy to prepare. Simply thaw in a water bath for a few minutes and the products are ready to use. Unlike lyophilised products, they do not need to be reconstituted - not only does this save time, but it also eliminates reconstitution errors. Cost Savings With a shelf life of 2-3 years from the date of manufacture, paired with the different pack sizes that are available, there is something to suit any lab’s needs, with a lower risk of products going out of date before use. They are platform independent - they can be used on any analyser with any combination of reagents. This provides a simple, fast method for LA detection as part of an LA test panel, adding up to a dramatic time savings by allowing for quicker reagent loading and ensuring the ability to report LA results with confidence. References www.southtees.nhs.uk/services/pathology/tests/ lupus-anticoagulant/ www.labtestsonline.org.uk/tests/lupusanticoagulant www.islh.org/web/downloads/2020-LAC-guidanceJTH-16859413.pdf For more information on Lupus and the extensive range of Precision Biologic kits and Control/Reference plasmas we have available, please visit www.alphalabs.co.uk/lupus

40 Parham Drive, Eastleigh, Hampshire, SO50 4NU, UK Tel: 023 8048 3000 | Email: sales@alphalabs.co.uk Web: www.alphalabs.co.uk Registered in England 1215816 Coming Soon: Improve workflow with the bespoke, automated envelope opening solution designed for PillowPac2. For the Perfect FIT: Switch to the NEW Mailing Solution For more information Visit: www.alphalabs.co.uk/SHU-04-2 or email: marketing@alphalabs.co.uk Providing patients with convenient, easy to use sample collection and return methods helps improve test uptake and compliance, whilst ensuring quality samples for the laboratory. Any logistics solution also needs to be cost effective and provide efficient processing for the laboratory to create the best workflow. ■Minimise postage costs - Flat-pack outbound format - Royal Mail approved sleek, strong design ■Safe sample transportation - Robust card-based mailing pack - Integrated absorbent layer to capture any leakage - Full-width, extra-strong adhesive on the closure flap ■Size: 102mm Wide x 173mm Long (142mm when closed) ■Thickness: 1.35mm when flat – 16mm when popped ■Absorbent Capacity: 2.5ml ■Weight: 13g (empty) ■Box Quantity: 1000 The new PillowPac2 compliant sample return envelope is specifically designed for Faecal Immunochemical Test (FIT) sample collection devices.