Leading Edge 2024 Issue 1

Leading Edge An Alpha Laboratories Ltd. Publication 2024 - Issue 1 Experience the Next Level CALEX® Workflow Revolution Page 2 Confirming Consistency Across the Healthcare Network: A Comparative Analysis of BÜHLMANN Faecal Calprotectin Assays Page 4 Serum Calprotectin Analysis: ELISA vs. Turbidimetric Assays Page 6 NICE DG56 vs. NICE DG30: Updates to FIT Guidance Page 8 Introducing Tasso+ An Innovative Patient Centric Capillary Blood Collection Device Page 10 IMMY sõna Aspergillus Lateral Flow Assay Improve your Laboratory Efficiency for Diagnosis of Invasive Aspergillosis Page 12 Revolutionising Liquid Biopsy: Unveiling Nucleic Acid BCT Tubes Page 14

Experience the Next Level CALEX® Workflow Revolution Amanda Appleton, Senior Product Manager, Alpha Laboratories Ltd. In 2014, the CALEX Cap transformed faecal calprotectin extraction workflows in laboratories. Now, with CALEX faecal calprotectin collection kits, patients can prepare and return their own samples, eliminating the need for traditional stool samples. The lab receives a ready-to-use CALEX, streamlining the testing process. This revolutionary shift maximises laboratory resources, reshaping calprotectin testing workflows significantly. CALEX Cap is suitable for air and land transportation according to IATA 650 (UN3373) regulations. This allows the option to outsource pre-analytics to the patient’s home, increasing safety for laboratories and revolutionising speed, efficiency and cost savings in the stool testing workflow. With the CALEX Faecal Calprotectin Collection Kit it is possible to keep stool samples away from the laboratory and measure faecal calprotectin and Pancreatic elastase from ready-touse extracts using the high quality BÜHLMANN assays. Patient Friendly Kits Each kit is discretely packaged in a business style envelope with a CALEX extraction device with patient specific instructions for use leaflet (IFU) and an integral label (name, DOB and sample collection date). A clear grip seal bag is also included, for return of the CALEX and the request form back to the laboratory or GP. The IFU is written in lay terms and has guidance on taking the sample, simple to follow instructions with diagrams, and a link to a video to support the correct usage of the CALEX with different sample consistencies. The kits come in boxes of 20 and are stored at ambient temperature. Shelf life on receipt is generally 12 – 18 months, so that kits can be sent out to clinics and primary care in quantities, and conditions, that will minimise wastage. The boxes have a dispensing tally on the front to help maintain the correct level of stock within individual locations. Hospitals can order the kits through Alpha Laboratories and send them to clinics and primary care using their existing van delivery/sample collection services. Alternatively, the boxes of kits can be sent directly to individual locations using The Alpha Portal – A new ordering and stock control platform from Alpha Laboratories. Sample Stability Calprotectin Stability One of the biggest issues with calprotectin testing is the variable rates of degradation that occur within the stool sample. This was demonstrated in a stability study1, showing individual samples to have significantly different rates of degradation. The overall conclusion from this publication, and the widely accepted premise, is that calprotectin is stable at ambient in a stool sample for three days. Within the data, however, whilst some samples are relatively stable, others lose between 30 – 50% of detectable calprotectin in that time period. 2 Leading Edge

For more information please visit: www.alphalabs.co.uk/CALEX-pack Stability within CALEX Once the sample is in the CALEX it is stable at ambient for 7 days, giving sufficient time for the return of the sample by the patient to the laboratory. This reduces the variable degradation seen in the untreated stool samples, enablingmore consistent reporting. If the lab doesn’t want to test the CALEX immediately upon receipt, if stored at 2-8C, it is stable for 15 days. Using the CALEX gives more consistent results and the flexibility for laboratories to follow practices that best suit their work load. Consistent Results The result obtained from the patient using the CALEX, compared to sending in a stool sample into the lab for extraction will be different. This has long been the case with use of the IBDoc® calprotectin home test, for IBD positive patients, compared to the lab result. The calprotectin results are generally higher with the patient prepared sample compared to the lab prepared sample. This is to be expected with the CALEX as well, as was shown in the article from H. Bruce et al2. This highlights the impact of the immediate stabilisation of the calprotectin in the buffer compared to the variable degradation of the calprotectin in a stool pot whilst in transit to the lab. However, the general interpretation doesn’t alter greatly as is shown in the table below from the same publication: Compliance and Acceptance Compliance, or more accurately the cost of non-compliance, is another big consideration when considering the introduction of patient calprotectin extraction kits. Lanarkshire NHS introduced CALEX to patients during COVID because of a lack of access to extraction hoods for sample preparation within the laboratory. They conducted an audit that we reported in the 2022 Leading Edge issue 13 and they found a 95% compliance: Of the samples that were returned to the laboratory, 94% Analysis of CALEX Tubes Returned July-Dec 2021 94% Samples analysed 3% Unlabelled 2% Low fluid level 1% Other 95% Return rate were able to be analysed, (3% were unlabelled, 2% had low fluid level and 1% were spoiled). Considering this was using a trial kit and process, these results are extremely encouraging. Giving the CALEX to patients to prepare and send back to the laboratory worked well for the laboratory and a subsequent survey by Dr A Hart that was published at UKMedLab 20234 confirmed that there was a high level of acceptance around using the CALEX and that patients found it easy to use: Patients also seemed confident that they had prepared the CALEX correctly and where they had previous experience of using the stool pot, actually preferred using the CALEX. There are a large number of hospitals looking to implement the CALEX to patients process to gain efficiencies. Having a ready to use, UKCA marked, standardised patient pack available with clear instructions will make this significantly easier than laboratories having to prepare kits themselves. References: 1. Lasson et al. (Journal of Crohns & Colitis 2014): The Intra-Individual Variability of Faecal Calprotectin: A Prospective Study In Patients With Active Ulcerative Colitis 2. H. Bruce et al2 (Annuals of Clinical Biochemistry 2023): Comparison of faecal calprotectin using two collection & extraction strategies for the BUHLMANN CALEX cap 3. Jacqui McGuire et al: Outsourcing Calprotectin stool pre-analytics to the patients home 4. Dr A Hart, UKMedLab 2023: Evaluating the service user experience of CALEX® cap devices as a faecal sample collection method for calprotectin testing: a local audit www.alphalabs.co.uk © 2024 Copyright Alpha Laboratories Ltd. 3

Confirming Consistency Across the Healthcare Network A Comparative Analysis of BÜHLMANN Faecal Calprotectin Assays Barsa Manandhar, Junior Product Manager, Alpha Laboratories Ltd. Due to the good correlation of faecal calprotectin concentrations with endoscopic and histological disease activity, most IBD diagnosis and treatment guidelines recommend its use as an aid in diagnosis and monitoring of the disease course. This non-invasive method offers a more patient-friendly, costeffective, and efficient alternative to traditional endoscopy. As leaders in the field, BÜHLMANN has progressively introduced a range of faecal calprotectin assays, utilising different technologies. These include traditional enzyme-linked immunosorbent assays (ELISA), particleenhanced turbidimetric high throughput assays (PETIA), and rapid lateral flow immunoassays (LFA). The LFAs can be interpreted through conventional tabletop readers or, as technology has developed, through everyday smartphone applications. These leverage the phone’s camera to calculate quantitative results, marking a significant advancement in monitoring capabilities within the field. Standardisation All the BÜHLMANN assays are standardised with the same degree of metrological rigour, giving consistent data and allowing harmony of cut-off concentrations across the various platforms. This allows laboratories to change technology as their calprotectin request volumes increase and testing to occur in different areas of the healthcare network. A recent poster presented by Reinhard, C et al at the United European Gastroenterology Week highlights the comparative clinical performance demonstrated by four different faecal calprotectin assays: BÜHLMANN fCAL® ELISA, BÜHLMANN fCAL® turbo, Quantum Blue® fCAL IBDoc (iPhone 11) IBDoc (Samsung S7) QB fCAL fCAL ELISA fCAL turbo Sensitivity at 80µg/g 90.8% 90.8% 90.8% 90.8% 90.8% Specificity at 160µg/g 71.2% 82.7% 71.2% 67.3% 71.2% Sensitivity at 100µg/g 86.6% 88.2% 88.2% 88.2% 85.5% Specificity at 300µg/g 84.6% 82.7% 84.6% 84.6% 86.5% Table 1: Sensitivity and specificity for IBS/IBD differentiation (80/160 μg/g) and IBD monitoring cut-off (100/300 μg/g) of the different BÜHLMANN faecal calprotectin methods. For more information please visit: www.calprotectin.co.uk extended lateral flow assay (QB fCAL), and the smartphone based IBDoc® Calprotectin home test1. One hundred and twenty-eight raw stool samples from patients with signs and symptoms suggesting intestinal inflammation and who underwent endoscopic evaluation to determine if patients had IBD or IBS were used in this study. The results demonstrated an excellent accuracy across all BÜHLMANN faecal calprotectin assays: The comparability of smartphone-based home testing indicates the advancement in the technology for the accessibility and convenience of faecal calprotectin monitoring. This ability not only streamlines the testing process, but also supports self-management in IBD patients. This evaluation demonstrates the reliability and versatility of BÜHLMANN faecal calprotectin assays, irrespective of the method, technology, or location employed – whether in a laboratory, point-of-care (POC) clinic, or at home by the patient. The high comparability and excellent clinical performance allow for the safe interchangeability of these methods across the healthcare network. This provides flexibility for healthcare professionals to choose the most suitable approach tailored to individual patient requirements. Figure 1: BÜHLMANN Quantum® Blue vs fCAL® turbo vs fCAL® ELISA vs IBDoc References: 1. Reinhard, C et al. United European Gastroenterology Week: Clinical performance of four fecal calprotectin assays from smartphone-based home test to high throughput central lab methods 4 Leading Edge

2007 The first BÜHLMANN assay, fCAL ELISA, is launched in the UK to enable calprotectin testing is with assay protocol 10-600 μg/g 2009 Quantum Blue fCAL range was first introduced for laboratories with low sample throughput or for use in pointof-care setting, e.g. IBD clinics, or on wards 2010 High range assay protocol is released for fCAL ELISA giving results up to 1800 μg/g, enabling monitoring of IBD patients 2011 Quantum Blue fCAL high range (100-1800 μg/g) became available, ideal for monitoring positive IBD patients 2012 Double plate fCAL ELISA format for higher throughput lab testing made available 2013 Quantum Blue fCAL extended range (30-1000µg/g) was introduced, with results used to aid the diagnosis and monitoring of IBD patients with a single kit format 2014 fCAL ELISA WEX format and CALEX extraction device were launched. Designed for compatibility with the BÜHLMANN assay and offering a significantly improved workflow unlike the more traditional extraction method 2015 IBDoc Calprotectin home test, the first CE marked home test for patients with IBD, became available. The extended range cassette (30-1000µg/g) is used in the IBDoc 2016 BÜHLMANN fCAL turbo is launched in the UK for high throughput calprotectin testing on mainstream analysers. This is the fastest calprotectin assay on the market giving results in just 10 minutes 2017 CALEX Cap is improved in precision and now even closer to the goldstandard weighing method 2020 Launch of the 3rd generation Quantum Blue Reader. This reader is more POC friendly with touch screen, barcode reader or LIMs connection for data entry 2024 Our newest addition, CALEX faecal calprotectin collection kits. These kits streamline the calprotectin testing process and maximise valuable resources in the laboratory, reshaping calprotectin testing workflows Calprotectin Testing - Timeline www.alphalabs.co.uk © 2024 Copyright Alpha Laboratories Ltd. 5

In the Autumn of 2023, technical specialists from BÜHLMANN visited Great Ormond Street Children’s Hospital (GOSH) to collaboratively establish a protocol for integrating the new BÜHLMANN sCAL turbo into their Ortho Vitros analyser. This move aimed to facilitate the transition of the immunology team from the conventional ELISA method to the advanced PETIA assay for serum calprotectin. Casting our minds back to 20161, the Immunology Laboratory at Great Ormond Street Hospital, with Clinical Scientist Elizabeth Ralph, embraced the sCAL ELISA assay for routine testing. This assay, designed for serum calprotectin, played a pivotal role in supporting the diagnosis and management of Juvenile Idiopathic Arthritis (JIA), a challenging autoimmune condition affecting approximately 1 in 1000 children under the age of 16. Early detection in JIA is important as swift identification allows for timely administration of anti-inflammatory medications, crucial for minimising joint destruction. The partnership with Professor Lucy Wedderburn’s research group enhanced their method, pinpointing a specific group of JIA patients who are more likely to benefit from treatment with methotrexate2. Having successfully validated the BÜHLMANN serum MRP 8/14 ELISA kit for clinical use, the team at Great Ormond Street Hospital has been providing valuable support to rheumatologists at GOSH and analysing samples from hospitals across the country. The introduction of the new BÜHLMANN sCAL turbo presents an opportunity to enhance efficiency. Currently, the team is meticulously comparing the new assay and validating the transition from the ELISA method. The collaborative efforts of Clara Moniz and Meikel Eichmann from BÜHLMANN, along with Joe Cranny from Ortho, are supporting this critical phase. Serum Calprotectin Analysis: ELISA vs. Turbidimetric Assays Amanda Appleton, Senior Product Manager, Alpha Laboratories Ltd. From the left: Gerta Bikacu, Hani Rtabi, Arnold Awuah, Fari Tahami and Annabelle Mai 6 Leading Edge

The BÜHLMANN sCAL turbo, compatible with mainstream clinical chemistry analysers such as Roche, Beckman, and Abbott, boasts a swift time to the first result at 10 minutes, with subsequent results available every few seconds thereafter, contingent on the analyser’s cycle time. Initial results on the Vitros analyser are promising, displaying the anticipated linearity and precision (see Figure 1), and comparisons with results from the Mindray BS480 at BÜHLMANN have been conducted (see Figure 2). While the lab has undertaken preliminary sample comparisons between the ELISA and sCAL turbo methods, further investigations are scheduled for the upcoming year to establish appropriate cut-offs for the new standardisation. References: 1. Leading Edge Summer 2016 - on request from Alpha Laboratories 2. Moncrieffe H, et al. A subgroup of juvenile idiopathic arthritis patients who respond well to methotrexate are identified by the serum biomarker MRP8/14 protein. Rheumatology (Oxford). 2013 Aug;52(8):1467-76. BÜHLMANN sCAL turbo Performance Figure 1: Linearity Serum Calprotectin in the Inflammatory Response When calprotectin is released from white cells, it initiates a strong inflammatory response and rapidly forms a tetrameric format in conjunction with metal ions (calcium, zinc, magnesium). There is as much calprotectin in white cells as there is haemoglobin in red cells, accounting for around 60% of the soluble protein content. In conditions which provoke an inflammatory response the level of calprotectin in the blood can increase significantly. Although it is a non-specific marker, it can be used to aide diagnosis and determine the severity of certain conditions in conjunction with the other clinical evidence. The diagnostic advantage of calprotectin detection over other disease markers is that it is stored in the cell and released immediately in response to local situations. In contrast, other markers may be released by downstream pathways or need to be synthesised leading to delays in detection. If you would like more information on serum calprotectin testing from BÜHLMANN (lateral flow POC, laboratory ELISA or the new sCAL® turbo assay) then please visit the website: www.alphalabs.co.uk/serum-calprotectin or ask your local Key Account Manager for more information. Figure 2 : Ortho Vitros V the Mindray BS480 www.alphalabs.co.uk © 2024 Copyright Alpha Laboratories Ltd. 7

NICE DG56 vs. NICE DG30 Updates to FIT Guidance In August 2023 NICE published updated guidance on ‘Quantitative faecal immunochemical testing (FIT)’ to guide colorectal cancer pathway referral in primary care. This update expands and clarifies the previous recommendations, based on the extensive clinical evidence that has accumulated since DG30 was originally published, back in July 2017. What are the main changes? DG30 set the foundation for improving the primary care pathway for colorectal cancer, by utilising FIT in place of the guaiac faecal occult blood tests (gFOBt) for initial testing, following presentation with related symptoms. DG30 provided an overview of the diagnosis and care pathways at the time. This included referrals based on gFOBt outcomes, and identified the main problem to be addressed. DG56 has been able to utilise the huge base of clinical efficacy data and evidence, amassed since July 2017, to confirm the diagnostic accuracy of FIT, which has successfully resulted in the reduction of unnecessary colonoscopies. Additionally, with COVID-19 permanently changing the way patients engage with healthcare, FIT too has been adapted to this changed environment, to better serve the diagnostic pathway. Kayleigh Roberts, Senior Product Manager FIT, Alpha Laboratories Ltd. Original DG30 Recommendations DG30 recommended that FIT was adopted in primary care to guide referrals for suspected colorectal cancer in people without rectal bleeding who have unexplained symptoms, but who did not meet the criteria for a suspected cancer pathway (NICE NG12). Historically, the guaiac test has had low compliance and return rates and was susceptible to user errors both at initial sampling and when reading results in the lab. Utilisation of FIT meant that low-risk symptomatic patients could be triaged more effectively, addressing both clinical and cost concerns. DG56 Expanded Recommendations DG56 has expanded its recommendations to include a wider cohort of patients and symptoms. Thus, high-risk patients that wouldn’t have been offered FIT under DG30 will now be offered a FIT in conjunction with their colonoscopy referral. DG56 also states that FIT should be offered even if a patient has previously had a negative FIT result through the NHS Bowel Cancer Screening Programme, due to the differences between the threshold criteria. It also emphasises that safety netting should be put in place if a patient has a negative FIT result. This aims to prevent patients from being lost on the primary care pathway, by ensuring suitable follow-up reviews are conducted and alternative diagnostic tests are performed as necessary. The threshold for referral to a suspected cancer pathway remains unchanged at 10 micrograms of haemoglobin (Hb) per gram of faeces. DG56 reiterates that economic models still suggest a 8 Leading Edge

threshold of 10 micrograms Hb / gram of faeces is more cost effective than lower thresholds, and also addresses concerns that higher thresholds could reduce physician confidence in the test. Following the publication of DG56, NICE released a news article stating: What does this mean for FIT? With a wider scope of patients being recommended for FIT there will be measurable benefits to gastroenterology clinics and Trusts due to: • Earlier detection and treatment of serious bowel disease, including low-risk and high-risk adenomas, diverticulitis, as well as colorectal cancer. • Improved triaging of symptomatic patients, allowing efficient allocation of resource, and a reduction of people on extended waiting lists for colonoscopies. • Reduced likelihood of complications during colonoscopies as FIT provides quantitative results that indicate potential seriousness of the problem. Alongside these benefits also comes a greater requirement for the easy and efficient distribution of FIT kits to GP sites and patients across the UK, as well as improved workflows. In the same way that patients need safety netting, the operational aspects of providing the FIT service may require review to ensure that testing can be provided to all patients, as needed, without delay. DG56 recognises that “certain groups may need tailored resources or additional clinical or carer support to enable them to use FIT”. Therefore, it may be appropriate to perform an assessment of local sociodemographic needs to maximise inclusivity and ensure patients can complete the sample collection process to minimise pre-analytical variation. How does Alpha Laboratories support NICE DG56? Alpha Laboratories offers a number of bespoke solutions to accommodate the DG56 requirements and ensure that high levels of service can be provided, and patient usability and compliance can be improved. As DG56 alludes above, one size does not FIT all when taking a patient-centred approach to healthcare. Therefore Alpha Laboratories offers customisable “FIT-KIT” patient packs, that can be tailored based on the requirements of different sites across the UK. Customisable elements of FIT-KITs include language, font or instructions on IFU’s, sample return methods, or the inclusion of Fe-Col® faeces collection papers. A recent initiative, The Alpha Portal (TAP), direct ordering and stock control platform, is also now available to help reduce logistical burden, and support the traceable distribution of FITKITs to any UK location by enabling users to order additional kits via an online portal, and view: • Pictures and descriptions of kit contents, including custom pack items. • Real-time stock availability. • Current LOT numbers and expiry dates. • Usage reports – enabling quick and easy oversight of ordering frequency and demand. Additionally, Alpha Laboratories recognises the importance of on-going advice and support, training, and logistical cooperation. As part of the support services available, our dedicated specialists are on-hand to assist with technical and operational queries, help with workflow analysis, and facilitate discussions with key opinion leaders to ensure the best quality of care can continuously be provided to patients. Our recommendations can help around 100,000 people avoid having a colonoscopy […]. Contact us to discuss how we can further support your FIT service: digestivedx@alphalabs.co.uk Scan the QR code to see how the FIT-KIT works. To sign up, or for more information please contact: fit-kit@alphalabs.co.uk www.alphalabs.co.uk © 2024 Copyright Alpha Laboratories Ltd. 9

Raising the standards for capillary blood collection, Tasso+ is a micro-sampling device, providing a userfriendly and virtually painless alternative to lancets. It improves the clinical integrity and quality of blood, sampled by patients from the comfort of their homes. Patient Engagement Regular blood testing can enhance the monitoring of health conditions, with proactive reporting of symptoms, disease progression and treatment efficacy, overall improving patient outcomes. However, fostering active engagement from patients can be challenging so empowering them to sample effectively from the comfort of their home is a positive step. With convenience for patients and healthcare providers, it offers a time and cost-effective approach to streamlining clinical pathways. Sampling venous blood within patient homes requires a visit from a trained phlebotomist or nurse, which can be costly and time-consuming. Fortunately, capillary blood specimens can be collected from a patient’s own home, with lancets often used to prick their finger and ‘milk’ drops of blood into a collection tube. Sample Standardisation Under clear guidance, many patients can collect adequate volumes of capillary blood for analysis via this method. However, sample standardisation remains a major challenge with finger prick kits. They rely on clear communication of instructions for sampling success, such as ‘soaking hands in warm water’ and ‘wiping away the first drop of blood’, to patients from a wide range of demographics. Understanding these steps is crucial for collecting high-quality samples, yet specimen viability solely depends on patients accurately following these instructions. Addressing these challenges, Tasso+ is intuitively designed with wide scale usability in mind, allowing patients to easily sample high-grade, laboratory viable capillary blood specimens, at home. After warming and cleaning their arm, users simply adhere the device to their arm and press down on the button to begin capillary blood collection. Tasso’s patient-centric design eliminates many user difficulties associated with finger prick sampling, such as correct lancet placement, wiping away the first blood drop and directing blood drops into collection tubes. It enables high-quality samples to be simply and conveniently collected by the patient, with reduced apprehension. Patient Study Affirming the positive impact of Tasso on the user experience, a randomised control study assessed the accuracy and tolerability of capillary blood self-sampling methods in rheumatoid arthritis patients1. All patients had venous blood drawn by a phlebotomist andwere then subsequently split into groups, receiving either a Tasso+, or a finger prick blood collection kit for self-sampling, referred to as upper arm (UA) or Finger Prick (FP) groups respectively. Patients allocated Tasso kits, reported experiencing less pain compared with having venous blood taken and were more likely to promote capillary blood sampling to other patients, demonstrating their favourability towards capillary sampling using Tasso. Furthermore, when examining the reliability of capillary blood sampling compared with venous draw samples, excellent agreement was observed for all analytes when assessing inflammatory markers and autoantibody levels in patients. Overall, this study promotes the feasibility of remote capillary blood sampling to obtain accurate results for patients and suggests a higher patient acceptance when using the Tasso+ micro-sampling device. Introducing Tasso+ An Innovative Patient Centric Capillary Blood Collection Device Enhancing the Clinical Value of Home Sampling Chloe Bishop, Product Manager, Alpha Laboratories Ltd. 10 Leading Edge

For more information please visit: www.alphalabs.co.uk/tasso Applications As a patient-centric, ‘at home’ selfsampling device, Tasso+ has the potential to streamline patient diagnostic pathways, with prospective applications in remote health monitoring and population screening programmes. With laboratory collaboration, Tasso+ has been validated for an extensive range of standard analytes for cardiovascular health, kidney functions, heart performance, and hormone levels, as well as HbA1c for diabetes monitoring. Tasso+ is compatible with all BD microtainers®, which can be used on analysers, such as the Cobas c111, DCA Vantage, Afinion 2 and Quo-Test. Monitoring Patients with Diabetes Untreated diabetes has severe health implications and wider socio-economic impacts, with complications such as cardiovascular disease, strokes, amputations, and blindness debilitating for patients, reducing quality of life. As a blood test, HbA1c indicates average blood sugar levels over the past 3 months, providing a useful biomarker for patients managing their diabetes. Diabetes UK recommend patients test their HbA1c status 4 times a year, to monitor disease progression and treatment efficacy2. Patients living in remote regions, in full-time employment or with reduced mobility, highly benefit from the convenience of home sampling, condensing the number of GP appointments required for diagnosis and monitoring of their diabetes. The simplicity, ease of use and minimised pain offered by Tasso+ encourages repeated home testing, enhancing patient engagement. Overall, remote testing services provide a platform for reaching equality in healthcare, by reducing the social impact on patients managing their diabetes. Cardiovascular Disease Screening A quarter of all deaths in the UK are attributed to cardiovascular disease (CVD). CVD is denounced as the largest cause of premature mortality in economically deprived regions, and overall, the second largest killer in the UK, affecting the lives of 6.4 million individuals. Consequently, early detection and treatment of CVD is one of the most significant strategies for helping patients live longer and healthier lives. Cholesterol levels are a major risk factor related to CVD, with increased testing a key longterm strategy for the NHS. The ability to sample cholesterol at home expands the potential reach of screening services to targeted populations. With rollout of this programme targeting populations aged 40-75 who are often less familiar with self-sampling blood, wide-scale usability is essential. Therefore, Tasso+, as a user-friendly intuitive device, is ideal for facilitating participation, enhancing return rates and reducing self-sampling errors, providing accurate results for patients, laboratory scientists and physicians alike. User Experience of Capillary Blood Collection Methods - Tasso (Upper Arm) versus Finger Prick Data courtesy of Knitza et al.1 References: 1. Knitza, Johannes et al. “Accuracy and tolerability of self-sampling of capillary blood for analysis of inflammation and autoantibodies in rheumatoid arthritis patients-results from a randomized controlled trial.” Arthritis research & therapy vol. 24,1 125. 25 May. 2022, doi:10.1186/s13075-022-02809-7 2.“What is hba1c?” Diabetes UK. doi: https://www.diabetes.org.uk/ guide-to-diabetes/managing-your-diabetes/hba1c 3.“Evaluation of Tasso+ Blood Self-Collection for Clinical Diagnostic Assessment of Various Biomarkers”. ClinicalTrials.gov, August. 2023, doi: https://clinicaltrials.gov/study/NCT05852925 4.Dubé, Karine et al. “Participant experiences using novel homebased blood collection device for viral load testing in HIV cure trials with analytical treatment interruptions.” HIV research & clinical practice vol. 23,1 (2022): 76-90. 5. Vivian G. Oehler, Olga Sala-Torra, Qian Vicky Wu, Lan Beppu, Emily Welch, Erwin Berthier, Jerald P. Radich; Minimally Invasive Blood Sampling for BCR::ABL1 transcript Monitoring. Blood 2022; 140 (Supplement 1): 3883–3884. doi: https://doi.org/10.1182/ blood-2022-167799 Conclusion Advancements in at home sampling accelerates the potential to streamline patient pathways, by reducing the resource burden on phlebotomists, enhancing proactive monitoring and treatment of health conditions. Challenges towards the implementation of remote testing loom, such as navigating laboratory workflow transitions and streamlining data management. Fully remote trials pertaining to the clinical efficiencies of self-collection using Tasso are ongoing3. Nevertheless, the feasibility of patients regularly using Tasso+ for health monitoring is continuously being demonstrated in a variety of demographics, providing a beneficial solution for the shifting landscape of remote sampling provisions in healthcare4,5. www.alphalabs.co.uk © 2024 Copyright Alpha Laboratories Ltd. 11

Traditional ELISA Testing Testing for Invasive Aspergillosis is often performed by automated Enzyme ImmunoAssays (EIA), as this provides high throughput and economy of scale in reagent and staffing costs. Bronchoalveolar Lavage (BAL) fluid or serum samples can be batched and tested for the presence of Galactomannan (GM) on automated systems (such as the Dynex DS2®), in a 96well plate format. Optimal efficiency and economy of scale is achieved when a full 96-well plate is processed, as relatively fewer controls are run. However, reduced efficiency is achieved when fewer 8-well strips are processed at a time, and processing of incomplete strips causes important increases in test costs, as wells (i.e. tests) are wasted. Delays in Diagnosis Clearly, optimal processing of samples requires sufficient samples to fill strips or plates, which isn’t always the case in many laboratories. Batching of samples allows optimisation of laboratory efficiency but can cause delays in testing, which has important clinical impact. Moreover, laboratories that send samples to external laboratories for GM testing incur significant delays in result reporting. Importantly though, patients with invasive fungal infections require rapid and appropriate therapy. Hence, detection and identification of the causative organism should be achieved as quickly as possible. Rapid Testing One strategy to expedite GM testing is to test BAL and serum samples on a STAT basis, although, as discussed, this can lead to important cost implications for the laboratory if using an EIA. For laboratories processing lower numbers of specimens, a solution to this problem is to employ a Lateral Flow Assay (LFA) such as the IMMY sōna Aspergillus Galactomannan LFA (IMMY; Norman, USA). The IMMY sōna Aspergillus Galactomannan LFA has been suggested as a diagnostic tool in the 2020 ECMM CAPAIAA-ICU management algorithm guidelines1. Multiple studies have also demonstrated equivalent or even greater clinical performance of the assay than that of EIAs [Table 1]. IMMY sōna Aspergillus Lateral Flow Assay Improve your Laboratory Efficiency for Diagnosis of Invasive Aspergillosis Nick Parham, Senior Product Manager, Alpha Laboratories Ltd. Performance of IMMY ASP LFA Specimen Sensitivity Specificity NPV vs. Proven IA2 Serum & BAL 100% 95.5% vs. Probable IA2 Serum & BAL 87.5% 96.2% vs. Proven IPA3 BAL 91% 92% 99% vs. EORTC/MSG4 Serum 91% 91% vs. 2008 EORTC/MSG5 BAL 88% 81% 94% vs. EORTC excluding GM5 BAL 100% 81% 96% vs. AspICU5 BAL 94% 81% 97% vs. modified AspICU5 BAL 87% 81% 94% vs. modified AspICU excluding GM5 BAL 97% 81% 98% Table 1 : Good agreement to existing product, better agreement to EORTC (true disease status) 12 Leading Edge

Clinical Performance White PL., et al.6 evaluated the clinical performance of the IMMY sōna Aspergillus Lateral Flow Assay (AGM LFA) in serum samples from cases classified as proven/probable/chronic IA/ IFD (n=32) using EORTC/MSG criteria and control patients with no evidence of IFD (n=100). In serum samples, the AGM LFA was found to correctly generate a positive result for 97% of patients with IA, and a negative result for 98% of patients without IA. The PPV shows that among patients with a positive AGM LFA result, the probability that they truly have IA is 94%. NPV shows that among patients with a negative AGM LFA result, the probability that they do not have IA is 99%. Mercier T, et al.3 examined the diagnostic performance of the IMMY sōna Aspergillus Lateral Flow Assay in BAL samples from haematology patients classified as proven IPA (n=11) using EORTC/MSG criteria and control patients with no evidence of IPA (n=117). In BAL samples, the AGM LFA correctly generated a positive result for 91% of patients with IA, and a negative result for 92% of patients without IA. The NPV shows that among patients with a negative AGM LFA result, the probability that they do not have IA is 99%. With the IMMY sōna Aspergillus Lateral Flow Assay, results are produced in 45 minutes as opposed to 3½ hours with EIAs, which provides a rapid turnaround time (TAT) and reporting of results to clinicians, who can then manage their patients appropriately. Confirmatory Testing For laboratories processing sufficient samples to be able to use EIAs efficiently, there is still a case for using an LFA. This is because positive GM EIA results often require confirmatory testing, which is generally done immediately as further delays in result reporting, due to batching of these samples, cannot be accepted. If this is done with an EIA, testing efficiency is usually reduced due to incomplete filling of test strips. Also, TAT is extended as around 3½ hours are required to run the assay. As such, use of the IMMY sōna Aspergillus Lateral Flow Assay for immediate confirmatory testing of ASP GM EIA-positive samples improves laboratory efficiency, TAT, and facilitates expeditious treatment of patients. Further, due to its two unique monoclonal antibodies, the IMMY sōna Aspergillus Lateral Flow Assay provides additional specificity that can reduce the occurrence of false-positive results. For more information please visit: www.alphalabs.co.uk/aspergillus Sensitivity Specificity PPV NPV 97% 98% 94% 99% Sensitivity Specificity NPV 91% 92% 99% References: 1. ECMM. COVID-19/Influenza-Associated Pulmonary Aspergillosis – Management. 2020 2. Jani K, McMillen T, Morjaria S, Babady NE. Performance of the sōna Aspergillus Galactomannan Lateral Flow Assay in a Cancer Patient Population. J Clin Microbiol. 2021; JCM0059821. 3. Mercier T, et al. Lateral flow assays for diagnosing invasive pulmonary aspergillosis in adult hematology patients: A comparative multicenter study. Med Mycol. 2019. 4. Serin I, Dogu MH. Serum Aspergillus galactomannan lateral flow assay for the diagnosis of invasive aspergillosis: A single-centre study. Mycoses. 2021;64(6):678-683. 5. Mercier T, et al. Point of care aspergillus testing in intensive care patients. Crit Care. 2020. 6. White PL, Price JS, Posso R, Cutlan-Vaughan M, Vale L, Backx M. Evaluation of the Performance of the IMMY sona Aspergillus Galactomannan Lateral Flow Assay When Testing Serum to Aid in Diagnosis of Invasive Aspergillosis. J Clin Microbiol. 2020;58(6):e00053-20. www.alphalabs.co.uk © 2024 Copyright Alpha Laboratories Ltd. 13

Introducing Nucleic Acid BCT While traditional storage methods, like EDTA tubes, offer brief sample integrity, they fall short in long-term room temperature storage. The new Nucleic Acid BCT™ (NA-BCT) from Streck, is a novel blood collection tube. It is a game-changer in preserving nucleic acid concentrations, maintaining cfDNA, cfRNA and EV particle levels at draw-time concentrations for up to 7 days at room temperature. This empowers laboratories to shift focus from degradation concerns to data analysis. Limit Haemolysis Whereas non-stabilising tubes, such as EDTA, or even current tubes intended for cfDNA usage, suffer from storage timedependent increases in haemolysis and related decreases in recoverable plasma volume, NA-BCT is designed to limit both [Figure 1]. This is accomplished via an optimised stabilisation solution that maintains the integrity of erythrocytes and WBCs. Blood samples stabilised in NA-BCT have decreased haemolysis compared to equivalent samples stored in other stabilisation tubes or EDTA and better maintain draw-time plasma volume during room temperature sample storage (Figure 1 B, C). This is critical for those assays containing a plasma volume requirement for their analyte extraction workflows. At the same time, retention of draw-time plasma volume directly results in increased extractable analyte yield (e.g., cfDNA yield). Maintain Draw-time Plasma cfDNA Levels Total nucleic acid was isolated from plasma using the QIAamp® Circulating Nucleic Acid Kit (Qiagen) according to the manufacturer’s “3 mL Plasma” protocol, with the exception that the 60 °C incubation was extended to 60 minutes (Figure 2A). Resultant cfDNA concentration was measured using the Qubit™ dsDNA HS Assay according to kit-included instructions (Thermo-Fisher). Sample quality was assayed using Cell-Free DNA ScreenTape analysis following the manufacturer’s protocol (Agilent Technologies). While blood collected into non-stabilising EDTA tubes demonstrates robust time-dependent increases in plasma DNA levels, equivalent donor samples collected into the NA-BCT maintain draw-time plasma cfDNA concentration for up to 7 days when stored at room temperature (Figure 2B). Further, Day-7 cfDNA size and calculated %cfDNA remain similar to draw time for blood collected into Nucleic Acid BCT™, but not donor-matched EDTA [Figure 2 C, D]. Together, these data demonstrate that NA-BCT maintains the draw-time characteristics and concentration of plasma cfDNA for up to 7 days of ambient storage. Revolutionising Liquid Biopsy Unveiling Nucleic Acid BCT Tubes Nick Parham, Senior Product Manager, Alpha Laboratories Ltd. Human blood is a treasure trove of genetic information, hosting crucial details within circulating cellfree DNA (cfDNA) and cell-free RNA (cfRNA). Leveraging the simplicity of a blood draw, liquid biopsy emerges as a powerful tool, unravelling insights from cancer predisposition to the aftermath of traumatic brain injuries. The Crucial Role of Draw-Time Analysis In the realm of liquid biopsy, timing is everything. Diseases linked to elevated circulating cfDNA and cfRNA demand precise analysis, necessitating a choice: immediate evaluation or the adoption of a stabilisation tube. Stabilising blood samples, ensures an accurate reflection of what is in the patient’s circulation. Without stabilisation, samples deteriorate, releasing genomic DNA (gDNA), extracellular vesicles (EVs), and EV-associated cfRNA due to white and red blood cell breakdown. This degradation introduces non-specific increases in analytes, clouding the original sample’s analysis. Figure 1. Nucleic Acid BCT™ (NA-BCT) maintains draw-time plasma characteristics. (A) Blood was collected from self-declared healthy donors into EDTA or NA-BCT. Plasma was isolated immediately after draw (Draw) or after 7 days (Day-7) of ambient temperature storage using a generic double spin centrifugation protocol and immediately frozen at -80 °C. (B) Haemolysis of blood samples collected into EDTA or NABCT immediately after draw or after 7 days of ambient temperature storage. (C) Plasma volume is maintained to near draw-time levels in NA-BCT. 14 Leading Edge

For more information please visit: www.alphalabs.co.uk/NABCT Maintain draw-time EV concentration When samples were collected into NABCT, draw-time EV concentration was maintained for up to 7 days at ambient temperature storage. In contrast, EV concentrations increased markedly at days 3 and 7 for equivalent samples collected in EDTA (Figure 3). Maintain draw-time cfRNA concentration To qualitatively compare cfRNA between samples collected in EDTA or NA-BCT, the Bioanalyzer RNA Pico Assay was used per kit included instructions (Agilent). Samples collected into the Nucleic Acid BCT maintained cfRNA concentration for up to 7 days, whereas cfRNA levels increased substantially with time for samples collected into EDTA (Figure 4). Further, samples collected in the Nucleic Acid BCT maintained a drawtime cfRNA size profile for up to 7 days of ambient temperature storage. These data demonstrate that Nucleic Acid BCTs effectively maintain draw-time cfRNA concentration during blood sample storage. Streck Nucleic Acid BCT stabilises all plasma nucleic acids (cfDNA and cfRNA) and extracellular vesicles for up to 7 days at room temperature. This tube is ideal for labs seeking to reduce haemolysis in their samples, maximise plasma yield, and maintain draw-time concentrations of cfDNA, extracellular vesicles, and cfRNA. NA-BCT is a powerful addition to the liquid biopsy toolkit allowing for combined interrogation of both cfDNA (mutation profiling) and cfRNA (transcriptome analysis and expressed fusion gene detection) in addition to downstream analysis of EVs. However, the advantages extend far beyond precise data. NA-BCT liberates laboratories from cold storage constraints, slashing shipping and handling costs. It is perfect for groups relying on offsite laboratories, it extends storage time without compromising analysis. Moreover, it amplifies laboratory efficiency, allowing batches of samples to be processed weekly, contrasting with the immediate attention demanded by traditional tubes. References Nicholas George, Ph.D., Lisa Bartron, MB(ASCP), and Jordan LaRue Nucleic Acid BCT™ maintains draw-time concentration of cell-free DNA, extracellular vesicles, and associated cell-free RNA www.streck.com/wp-content/uploads/2023/06/880237-NABCT-TechNote.pdf Figure 2. Plasma cfDNA levels are stabilised by Nucleic Acid BCT™ for up to 7 days of ambient storage. (A) Workflow of cfDNA collection and analysis. Cellfree DNA isolated from plasma was assayed for concentration, size and purity using a combination of Qubit™ dsDNA HS Assay, Cell-Free DNA ScreenTape analysis, and Bio-Rad ddPCR. Cell-free DNA concentration (B), size (C), and purity (D) in plasma collected into EDTA or Nucleic Acid BCT™ immediately after draw (Draw) or after 3 (Day-3) or 7 days (Day-7) of ambient temperature storage. [DNA] and %cfDNA are graphed as mean ± STDEV for 6 donors. The single donor electropherogram shown in (C) is representative of what is normally observed for all donors. Figure 3. Concentration of EVs from plasma collected into EDTA or Nucleic Acid BCT immediately after draw (Draw) or after 3 (Day-3) or 7 days (Day-7) of ambient temperature storage. n=6 self-declared healthy donors. Figure 4. cfRNA concentration in plasma collected into EDTA or NA-BCT immediately after draw (Draw) or after 3 (Day-3) or 7 days (D ay-7) of ambient temperature storage. www.alphalabs.co.uk © 2024 Copyright Alpha Laboratories Ltd. 15

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 Zinc Use with Serum, plasma or seminal fluid Measuring range 5-2000µg/dL Standard included On board stability 30 days No deproteinisation step Direct Colorimetric Assay NIST Standardisation Choice of kit sizes Copper Use with Serum or plasma Measuring range 3-500µg/dL Standard included On board stability 45 days No deproteinisation step Direct Colorimetric Assay NIST Standardisation Copper for Urine Measuring range 3-20µg/dL Standard included No deproteinisation step Direct Colorimetric Assay NIST Standardisation Direct and Total Bilirubin Use Vandate Oxidation Assays with Confidence An New Elution Solution No interference from Haemoglobin up to 500mg/dL No interference from Ascorbic Acid up to 50mg/dL Direct Bilirubin: linear to 20mg/dL (342µmol/L) Total Bilirubin: linear up to 40mg/dL (684µmol/L) Ready-to-use liquid stable reagents Open-vial stability 30 days at 2-8C Standardised to SRM916a (NIST) Some traditional assays for trace metals include a pre-treatment step to deproteinise samples prior to analysis. Sentinel Diagnostics offer assays for zinc, copper that eliminate this step improving workflow. Improving Workflow of Trace Metals Zinc and Copper - Direct Colorimetric Assays Without a Deproteinisation Step For more information please visit: www.alphalabs.co.uk The ALBA Elution Kit is for use in the acid elution of antibodies from intact red blood cells for further detection and identification. The kit offers the same high quality and expert support that you expect from ALBA by Quotient, as well as other key features such as: Distinct pH change reactions Room temperature storage Validated with various methods and enhancement techniques User-friendly instructions Minimal product waste thanks to recyclable cardboard packaging