The Bulletin of the Royal College of Pathologists

Number 191 July 2020

SPECIAL EDITION: Pathology and COVID-19 The role of genomics in shaping the response Cytology and the pandemic Experiences of NHS Nightingale Death certification Establishing convalescent plasma therapy Caring for the deceased Testing in the devolved nations Our COVID-19 seminars

Also in this issue: The Royal College of Pathologists Haematology workforce challenges Pathology: the science behind the cure Going digital: training and exams Kate Gould: an appreciation The Royal College of Pathologists CONTENTS Pathology: the science behind the cure July 2020 NUMBER 191

EDITORIALS 114 INTERNATIONAL 150 From the Editor 114 Challenges for pathology laboratories during From the President 115 the pandemic: the view from Australia 150 PATHOLOGY AND COVID-19 117 Reorganisation of mobile blood collections in the age of social distancing 152 A new plague year 117 The role of viral genomics in shaping the TRAINING 154 response to the pandemic 118 FRCPath examinations during the COVID Nightingale tales 121 pandemic 154 The journey from Oxford medical school to Digital pathology and safe workplace the world’s largest ICU 124 station awareness 157 Cytology and the pandemic 125 Creating e-learning modules for undergraduate Establishing convalescent plasma as an medical students 159 effective therapy 126 Digital pathology validation for trainees: 160 Healthcare scientists in pathology: the CLINICAL EFFECTIVENESS 162 challenges of responding to the virus 128 What does patient safety in pathology Death certification: lessons learned within mean to me? 162 the hospital setting 130 Antibiotic prescribing following a positive Caring for deceased patients at the NHS Clostridioides difficile result 163 Nightingale mortuary 131 PEOPLE 166 A chaplaincy view from a multi-faith university hospital community 133 Appreciation: Professor Frances Kate Gould 166 Appreciation: Dr Denis Raymond Stanworth 167 COLLEGE NEWS 134 Appreciation: Dr Michael Gerald Rinsler 168 The RCPath Learning Programme: Appreciation: Professor Mohammed Sami the COVID-19 pandemic 134 Shousha 169 Moving to the new College premises 135 Archive of eminent pathologist Sir Lionel RCPath Consulting 137 Whitby deposited at Downing College 170 ON THE AGENDA 138 Deaths reported to Council 172 Challenges for the haematology workforce 138 Consultants: new appointment offers 172 Tackling haematology scientific workforce REVIEWS 174 challenges 140 The Royal College of Pathologists Book reviews 174 6 Alie Street, London E1 8QT The journey to pathology 3.0: more on New report calls for collaboration to ‘bricks’ and ‘clicks’ 141 improve cancer diagnostics 176 T: 020 7451 6700 E: [email protected] SHARING OUR SUBJECT 144 Charming snakes: a seminar on reptiles 177 www.rcpath.org School’s out but the Schools Science Highlighting chemical pathology Conference must go on 144 and metabolic medicine overseas 178 President Professor Jo Martin Vice Presidents Dr Rachael Liebmann REGIONAL 146 Letter: Reporting of race in autopsy reports 179 Dr Tim Littlewood COVID-19 and the devolved nations 146 On the cover: An illustration Professor Shelley Heard of the COVID-19 virus. Registrar Dr Lance Sandle Highlighting UK workforce concerns 148 Assistant Registrar Dr Esther Youd Treasurer Dr Andrew Boon CEO Daniel Ross Bulletin Editor Dr Shubha Allard Disclaimer: Authors’ views are personal and are not indicative of College policy, except when College Officers write in their official capacity. Errors or admissions are the responsibility of the Production Editor Stacy Baxter authors alone. Advertisements are paid for by external agencies and do not indicate endorsement or otherwise by the College. Editorial & Digital Manager Rob Hucker www.rcpath.org Number 191 July 2020 113 EDITORIALS

EDITORIALS From the President

Change all around us the skills for interpretation and quality control, and From the Editor It has been a time of enormous change for everyone, the key infrastructure and data connectivity that all over the world. We have changed what we do we need, rather than just numbers of tests being Welcome to our first digital College Bulletin! The impressive, with greater inclusion and engage- and how we do it, including the services in which performed. We have the support of 22 organisa- theme, understandably, is COVID-19 – a topic ment. While travel is curtailed we can certainly we work, in an incredibly short period of time and tions and the strategy has been very well received that has totally refashioned how we conduct our still push boundaries and reach out to colleagues at a rapid pace with considerable personal effort. by our stakeholders. We have had excellent media working and personal lives. Out of adversity and to work together. The pandemic resulted in a We have done this at a time when there has been coverage and interest and support from politicians. significant personal loss has come some good, with fundamental rethink of working arrangements in huge change in our own circumstances in the face Feedback from the government has been positive the pandemic being the unlikely enabler of inno- many countries so that we can share lessons (p150 of personal loss or significant difficulties. Thank and we are determined to ensure it informs policy Professor Jo Martin vation and novel ideas. Contrary to my initial fears and p152), even if significantly lower numbers of you for all you continue to do for our patients and development in the UK. Do have a look at it if you that authors would be unable to contribute, this is COVID-19 cases were encountered than in the UK. for our profession. We really value your skills, your have not had a chance so far. It’s a strong message an extraordinary ‘bumper’ edition and I have been The strengthening of IT with remote working effort and your enormous dedication. in a clear format. delighted by the immense breadth of the contribu- and greater interconnectivity will hopefully also We have also made significant and large-scale The College has been heavily involved in the Dr Shubha Allard tions received. help support greater digitisation of pathology changes at the College. You will have seen the speed development and championing of an innovative The introduction to the theme by David Jenkins and transformation of services across organisa- with which we have been responding to the need crowdsourcing platform ‘Testing Methods 2020’. (p117) eloquently captures the essence of key tional boundaries (p141). However, the workforce for information-specific guidance across a whole This has posed specific challenges for the commu- events and milestones as the pandemic unfolded. remains our greatest resource, with a progressive range of issues during the epidemic. This has been nity of pathologists, laboratory professionals and A heady mix of articles on COVID-19 covers approach needed to the development of medical achieved by the efforts of our Specialty Advisory industry related to COVID-19. Examples have molecular science and the role of whole genome and scientific staff. Clearly there are major chal- Committees and Chairs and our Communications included extraction-free rtPCR methods, alterna- sequencing in mapping global progression (p118), lenges ahead and much still to do (p138 and p140). directorate, with exceptional responsiveness to tives to swab methods and multiplexing. A new finishing with the challenges of supporting the The increasing focus on diversity and inequality professional needs. Some of the other changes were challenge has also just been launched on ‘greener bereaved in a multi-faith university chaplaincy is timely and we must surely now pursue this already planned, but have now been accelerated by testing’ that is being championed by Dr Esther (p133). Along the way we hear about the significant dialogue across our specialties. I do look forward the advent of COVID-19 – a digital Bulletin being Youd, our Assistant Registrar, who is also our achievements of setting up a new pathology service to hearing thoughts and comments on reporting of one of these. The era of posted journals is being RCPath Trustee Board sustainability champion. (virtually overnight) to support the emergency race at autopsy (p179). Is it time to review practice superseded by the era of digital media. This is good This has suggestions on plastic-free swabs, and we field Nightingale hospital at the Excel site (pp121 and recommend change? for both the finances and the environment, and are looking forward to ways in which we might be and p131), addressing the increased demands for I have been really pleased with the increasing especially good during the epidemic. I do know able to reduce our plastic usage for the transport of death certification in adverse circumstances (p30) number of books coming our way and the ready that there will be nostalgia for the paper format for samples. Do get involved to help spread great ideas together with the impressive contribution of many volunteers willing to review these, hopefully some, but I hope that you will enjoy this version and new ways of working! healthcare scientists across a breadth of specialties igniting your interest in the topics covered. We equally. As we move into the next phase of dealing (p128). hope to maintain this trend and are happy to with the epidemic, and as we try to build back up The need for high-quality research to support receive your suggestions and input. Virtual meetings and education to some form of normality in our health services, the introduction of any new therapies, however We must sadly remember colleagues we have We have moved to online meetings for all our I am acutely aware that many of the problems persuasive retrospective surveys and anecdotal use lost and acknowledge their significant achieve- committees, Council and Trustee Board and will around lack of workforce, especially in transfu- may seem, is emphasised in an article (p126) on the ments (ppp166–169), including Kate Gould, who continue with the virtual format for the vast sion and histopathology, are still there. With the UK’s approach to COVID-19 convalescent plasma. held many College roles and was Chair of the majority of College activities, even after the lock- requirement to isolate for 14 days if ‘tracked and Conversely, the approach to the implementation of England Regional Council. down has been lifted. This approach is both traced’ I have highlighted the specific risks around testing rolled out across the many regions certainly As we emerge from the shadow of the pandemic, financially and environmentally beneficial. We transfusion staffing and have asked for all Chief raises many questions (p146), with lessons to be we can certainly build on experiences and define have run an excellent weekly series of short educa- Executives of Acute Trusts to urgently risk assess learned that will help inform future healthcare what is the ‘new normal’. Our vocabulary has tional COVID-19 webinars, all free to access. The their own service. During my pre-pandemic lab policy. perhaps been enriched but at the risk of clichés entire series so far is available on the website tours I saw several labs with only three people I think we should all be proud of our trainees creeping in, supporting rhetoric with a need for for review, and I would commend them to you. providing a 24-hour service. This is not sustainable. – from undergraduate volunteers stepping forth more explicit action. Do we feel it is timely to move All are instructive, and many are very thought into uncharted territories (p124) to evaluating on from the term ‘NHS Heroes’? Hard work and a provoking and entertaining! I have hugely enjoyed Digital Now aspects of digital pathology (p157), developing selfless approach to the day (and night) job need all of them, and they continue weekly. Check Yet more change is in development and has been virtual laboratory training (p159) and promoting not just plaudits, but well-resourced, structured the COVID-19 resources hub on the website and proceeding at pace during lockdown. This includes pathology more widely as a career (p144). The and inclusive healthcare policies. register. We are also developing our virtual educa- the design and scoping of a digital learning plat- trainee survey (p154) captures concerns around tional programmes to replace, or in some cases to form to support morphological learning – the cancelled College examinations – a first in the Dr Shubha Allard complement, events that have been deferred, with Digital Now project. The platform will help College’s history – but signifies opportunities to Bulletin Editor new themes being planned. provide graded learning materials in digital modernise going forward. format, to enhance learning for both trainees and The rapid development of remote seminars COVID-19 testing current practitioners. Members will be able to with high-quality speakers (p134) has been highly Over the last month we have done a huge amount upload digital slides to the resource to help grow of work on the development and publication of the content and share great cases. I led a successful RETURN TO RETURN TO COVID-19 testing: a national strategy. We have bid to Health Education England for this and I am CONTENTS CONTENTS brought the focus back to the purpose of testing, very passionate about the possibilities of digitally

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supported morphology-based learning, with specialties. Trustee Board was divided on this, so excellent quality-assured content mapped to the we are asking you. Please do respond to the email curriculum. It will be available to all our members consultation. Any change to this would take effect PATHOLOGY AND COVID-19 across all nations, as well as registered trainees. following the term of my successor. Initial work will include the migration of existing suites of histopathology materials, but the plat- A new President Elect A new plague year form will be developed for our other specialties, With regards to my successor, I am delighted to too. I will continue to chair the project and work see Dr Michael Osborn take up office as Presi- r David Jenkins introduces the theme of COVID-19 for this edition of the Bulletin, with the clinical lead Dr Hasan Rizvi and a broad dent Elect. He will succeed me in November and I team, including trainees and the College’s Learning know he will do a great job. He will represent the capturing our collective experience and concerns. directorate. The project will deliver the platform College across all our 17 specialties and will do later this year, towards winter time. this excellently. I have worked with him closely in D We have continued to put a great deal of pres- meetings with the Chief Coroner and on cellular ‘it was a most surprising thing, to see those streets, infection in the UK.6 We became used to the daily sure on the commissioners of medical and scientific pathology work. Dr Osborn has served as Chair which were usually so thronged, now grown announcements of hundreds of COVID-19 deaths. training posts to place more people into pathology of the Death Investigations Committee and the It might be sobering to recall that the official desolate, and so few people to be seen in them’ training across many of our disciplines. We have Cellular Pathology Specialty Advisor Committee, death toll of the 2013–2016 Western Africa Ebola done all we can (and have done it well) to increase as well as leading work on the post-mortem portal – Daniel Defoe, A Journal of the Plague Year (1722) virus epidemic, seen rightly as an overwhelming recruitment into our profession. Following two for COVID-19 and writing many very helpful guid- humanitarian crisis, was 11,323. years of full recruitment into histopathology, there ance documents under extreme time pressure The detection of an outbreak of pneumonia caused The explosion in the spread of infection around can no longer be an excuse for not increasing the during this period. by an unknown pathogen in Wuhan, China, in the globe has been mirrored by the growth in publi- numbers of posts. You may have seen some of the As I come to the close of this piece, I am acutely December 2019 signalled the start of a cataclysm cations about the SARS-CoV-2 virus, COVID-19 and press on this, and we have included the issue in our aware that many of us have been operating flat out that has swept the world. Events have moved with consequences of infection. At the time of writing, strategy document, too. We will continue to press for many months. 13-hour days and working week- astonishing speed. The World Health Organisation there are 2,737 pre-print manuscripts on medRxiv, on this, and for full digital pathology rollout. ends have been the norm for me and for so many (WHO) China Country Office was notified of clus- 671 on bioRxiv and 12,563 articles addressing 1 other colleagues. We are tired. This epidemic will ters of cases of pneumonia on 31 December 2019, the infection listed on Medline. The rapid iden- Your input is needed continue for the foreseeable future, and it has the same day that a rapid response team was sent to tification and characterisation of SARS-CoV-2 Proposed changes to the charter, ordinances and already seen some regional resurgences. Do take Wuhan from the Chinese Centre for Disease Control within days of the initial reports of the first clin- bylaws are out for consultation and we would some time for yourselves and your loved ones as and Prevention in Beijing to assist local health ical cases is a remarkable achievement. However, 2 like to hear your views on these. Some of these soon as you can. You deserve a break. Please work authorities investigate the outbreak. Epidemiolog- it is becoming obvious that the rush to publish are simple (members are not all ‘he’!), others are with colleagues to plan in some downtime. It ical inquiries implicated the local seafood and wet by other authors has led to claims and conclu- to enhance good governance. The issue of those might not be sitting on a beach in an exotic loca- animal wholesale market as the origin of the infec- sions that just a month or two later are clearly not holding College diplomas being able to vote in tion, but it should at the very least include some tion, and this was closed on 1 January 2020. A novel sustainable. For example, as an early analysis of elections is also raised, which is very strongly time to catch up with rest and have some moments coronavirus, of probable bat origin, was isolated the genomic and protein structure of SARS-CoV-2 supported by our trainees and Trustee Board. of calm. from infected patients on 7 January and the genetic concluded, ‘these findings suggest that the new 2 There is a really important question for you sequence of this virus was published on 12 January. virus does not readily transmit between humans to consider in the communication about rota- My very best wishes and grateful thanks to you all. The recognition that this virus could be transmitted and should theoretically not [be] able to cause very tion of Presidents through the specialties. There from person to person and that it caused severe or serious human infection’.7 is a balance here between an entirely democratic Professor Jo Martin fatal disease in a high proportion of patients created Many other questionable beliefs have been process where any Fellow can stand, and the President mounting global apprehension as the infection promulgated, including the fiction that 5G data feeling that the presidency should rotate between spread first through China, then to other countries networks weaken immune systems and increase in Asia and subsequently to every part of the world. susceptibility to COVID-19.8 Arguably more The speed at which the infection swept across dangerous was a belief that was fundamental to the globe is highlighted by the rapidly changing initial UK public health policy – that COVID-19 position taken by the WHO. On 29 February, Dr infection would produce long-lasting protective Michael Ryan, executive director of the WHO immunity that would bring the outbreak under 3 Health Emergencies Programme said, ‘If we say control. At the time of writing, the prospect of there is a pandemic of coronavirus we are essen- long-term immunity is not certain and precedents tially accepting every human on the planet will be from other coronaviruses are not encouraging.9 exposed to that virus and the data does not support To say that the NHS managed to cope with the that as yet.’ A global pandemic was declared by outbreak, even by the skin of its teeth, is a misrep- 4 WHO on 11 March. resentation. There was poor preparedness for the The first two cases diagnosed in the UK were pandemic despite the opportunity to learn from 5 announced on 31 January 2020. The pair, Chinese Exercise Cygnus.10 Many patients were denied nationals, were probably already infected when intensive care and the possibility of survival, they entered the UK. The first identified case of however small. The delivery of personal protective infection acquired in the UK was diagnosed on equipment was erratic and jeopardised the lives of 3 28 February. Almost certainly there were earlier front-line NHS staff. The stock of FFP3 respirators missed infections. that was delivered changed every week, making fit- Since the first UK COVID-19 death on 5 March, testing impractical. When it was carried out, some RETURN TO RETURN TO over 44,000 deaths have been attributed to the CONTENTS CONTENTS FFP3 devices had a 100% fit-test failure rate. Over

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120 NHS and social care workers have died of infec- prevention. The lack of availability of rapid SARS- mutational rate (approximately two nucleotide to be genetically related to SARS-CoV-2, particularly tion, a burden that has been especially heavy for CoV-2 testing capacity compounds the difficulties. substitutions/month4) is lower than other RNA in the RBD, but evidence is inadequate to support black and minority ethnic staff. While not all of At the time this Bulletin is published, the country viruses (such as influenza) due to inherent capacity this species as the intermediate host (Figure 1).15 these infections will have been acquired occupa- has started to experience fresh local outbreaks, and for proof reading. Virus nomenclature is not fully The cleavage site described above is notably absent tionally, there will remain the concern that some fears of a second wave of infection remain. What- established yet and is likely to be further refined. from both the closest bat and pangolin viruses, indi- of these deaths could have been avoided. ever the future holds, the articles in this edition Rambaut et al. recently proposed the naming of two cating that another, as yet unidentified, virus is the Now, after nearly two months of lockdown and will be a valuable record of a new plague year. major lineages (A and B) and several descendent direct progenitor of SARS-CoV-2. Current scien- deserted streets, the country appears to be past the lineages.5 tific thinking is that SARS-CoV-2 originated from peak of the outbreak. However, the need to restore References available on our website. multiple, naturally occurring recombination events inpatient care for non-COVID-19 patients while Use of genomics to understand the origins among viruses present in bats and other wildlife. It still admitting COVID-19 patients is the next chal- Dr David Jenkins and biological properties of SARS-CoV-2 is worth noting that our understanding of the range lenge; the risk of acquiring infection is now greater Consultant in Medical Microbiology Zoonotic transmission events resulted in human of coronaviruses in other species is limited, owing to inside hospitals than in the community and few and Virology, University Hospitals of Leicester Dr Tehmina Bharucha coronavirus outbreaks caused by SARS-CoV the lack of knowledge of sequence diversity. Many UK hospitals have anywhere near enough single NHS Trust in 2003 and MERS-CoV in 2012. The resulting questions remain about the origins of SARS-CoV-2 occupancy rooms to allow effective infection increased awareness of the pathogenic potential and where and how the virus became adapted for of coronaviruses led to an escalation of research efficient human-to-human transmission – genomic into animal reservoir hosts, and viral properties data will prove critical to unravelling this. that might govern their emergence and transmis- During the course of the pandemic, small sion in humans. Bats are a natural reservoir for a numbers of SARS-CoV-2 infections have been The role of viral genomics in shaping large number of coronaviruses, some of which may detected in wild and domestic animals, including have potential for cross-species transmission.6,7 cats, dogs, ferrets, mink, pangolins and big cats, Indeed, serological evidence from areas of rural some of which displayed respiratory symptoms. On the response to the pandemic China suggests that human spillover events occur several mink farms in the Netherlands, outbreaks at low frequency.8 Other animal species can act as of SARS-CoV-2 infection were reported, which hole genome sequencing with data sharing across a global community has intermediate hosts, enabling the species jump into were thought most likely to have resulted from been unprecedented and essential in informing the public health response Dr Daniel Bradshaw humans, as observed with dromedary camels for reverse zoonosis events. Additionally, two possible MERS-CoV and palm civets for SARS-CoV. cases of human infection acquired from mink have during the pandemic. W This pre-existing genomic surveillance has been reported by Dutch authorities. Pigs, chickens Advancements in genomic capability over the sequence data, which is important to encourage proven vital to our understanding of SARS-CoV-2. and ducks were not susceptible to experimental 16,17 past decade have resulted in significant improve- sharing of information. Comparative analysis identified SARS-CoV-2 as infection with SARS-CoV-2. The consequence ments to the speed and reliability of whole From the earliest stages of the outbreak, the UK a group 2B coronavirus. Similarities between the of exposure of livestock and companion animals to Dr Anika Singanayagam genome sequencing (WGS). WGS can be expected participated in a collaborative effort with laborato- receptor-binding domain (RBD) of SARS-CoV and infected humans is not known, i.e. which animal to make important real-time contributions to ries across Europe that was instrumental in securing SARS-CoV-2 indicate they use the same ACE2 species can become infected (symptomatically or scientific understanding and the public health early molecular diagnostic capability.3 Three assays receptor, supported by structural and biochem- subclinically) and whether they can be infectious 9,10 response to the coronavirus disease 2019 (COVID- were selected, targeting the RdRp, E and N genes, ical analyses. However, SARS-CoV-2 has a Furin to other animals or humans. Monitoring animals 19) pandemic, to a degree that was not feasible based on good matching to the first six publicly cleavage site in the spike glycoprotein that is not for infection forms part of the risk assessment for 11 during the SARS epidemic (2003) or H1N1 influ- available sequences. At this point, clinical isolates of found in SARS-CoV. Another bat coronavirus new reservoirs and transmission chains. enza pandemic (2009). The COVID-19 Genomics the novel virus were not available to international (RmYN02) isolated in Yunnan province in 2019 UK Consortium (COG-UK) was launched on public health bodies, and collective experience has a similar cleavage site in the spike protein, Bat CoVs= orange and red; pangolin CoV= green; 23 March 2020 to deliver large-scale and rapid working with SARS-CoV/Middle Eastern Respir- Professor Maria Zambon providing evidence that such insertion events 12 human SARS-CoV-2= light blue; SARS-CoV= dark blue WGS for SARS-CoV-2 across the UK. In this article, atory Syndrome Coronavirus (MERS-CoV) was can happen in nature. Polybasic cleavage sites we discuss the vital role that genomics has played critical in developing a diagnostic workflow. Detec- in avian influenza viruses were found to lead to a 13 so far and how WGS can be harnessed to shape the tion of two UK cases on 31 January 2020 provided Figure 1: Full genome highly pathogenic phenotype. However, under- ongoing response to COVID-19. our first clinical material, facilitating further assay tree of SARS-CoV-2 standing the significance of this cleavage site for validation. Sequencing of these isolates was rapidly related precursors. SARS-CoV-2 pathogenicity or transmissibility Dr Anna Jeffrey-Smith requires further work. Rapid sequencing contributed to early performed and deposited to GISAID on 3 February. From www.GISAID.org.2 Phylogenetic analysis suggests that the virus development of molecular diagnostic assays The authors from the originated in Wuhan in November/December Cases of pneumonia of unknown aetiology in Global genomic data deposited to the original and submitting 2019,4 although a preceding period of cryptic trans- Wuhan City, Hubei Province, China, were reported public domain laboratories of sequence mission in humans cannot yet be ruled out.14 High in December 2019. The causative agent was iden- As of 18 June 2020, 48,012 SARS-CoV-2 genomes data on which the viral loads were reported in environmental samples tified as a novel coronavirus on 7 January 2020, have been deposited to GISAID, including 21,433 analysis is based are later named Severe Acute Respiratory Syndrome sequences from the UK. High volumes of genomic from the Wuhan wet market, where a variety of gratefully acknowledged. 14 Coronavirus 2 (SARS-CoV-2). The unprecedented data are being rapidly generated. These data can animals were sold, but it is not yet known whether effort of Chinese scientists led to rapid publication provide important insight into the evolution and or which animal species initiated the first human of the first SARS-CoV-2 genome1 on www.virolog- epidemiology of the pandemic, be used to evaluate infections. A bat coronavirus isolated in Yunnan ical.org on 10 January 2020, followed quickly by a control strategies (drugs, vaccines) and aid in the province in 2013 (RaTG13) was found to have the further five sequences deposited to www.GISAID. refinement of diagnostic assays. greatest overall sequence similarity (~96%) to SARS- org (Global Initiative on Sharing All Influenza SARS-CoV-2 is a large RNA virus (~30kb) with CoV-2, although there are differences in the RBD 11 RETURN TO Data).2 This is an open access database that fully potential for genetic recombination, point muta- RETURN TO that indicate it is not the direct progenitor. Coro- CONTENTS recognises the contribution of those depositing tion and some replication error correction. The CONTENTS naviruses isolated from pangolins were also found

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to infer transmission events is not straightforward. long as SARS-CoV-2 continues to circulate among Box 1: Public health, clinical and scientific areas to which whole genome sequencing may contribute Epidemiological metadata can add significant humans, genomics will play a vital role in shaping Diagnostics weight to genomic findings and may be essential in public health policy and aid in decision making. • Periodic comparisons of primers/probe sequences against circulating lineages to identify mismatches that might affect the ruling possible sources in or out. accuracy of molecular diagnostic assays; these can be further evaluated in the wet lab. Second, nucleotide mismatches in primer/ References available on our website. 25 • Investigate unexpected negative PCR results using WGS – for example, Artesi et al.23 recently described a low frequency probe binding regions have been described but variant that was associated with failure of the Roche Cobas E gene assay in a small number of cases. require further testing to assess for any effect on Dr Anika Singanayagam diagnostic assay performance and to understand Clinical Fellow and Specialist Registrar in Clinical the prevalence among UK isolates. Infectious Diseases and General Internal • Sequence virus from relevant body compartments across spectrum of clinical presentations (e.g. respiratory/gastrointestinal/ Third, as an RNA virus adapting to humans as Medicine, Public Health England and Imperial paediatric multisystem inflammatory syndrome) to assess for mutations associated with particular disease phenotypes. a novel host, SARS-CoV-2 can be expected to accu- College NHS Trust • Understand the distribution of clades between population subgroups (e.g. age, ethnicity, geography). mulate genetic change, some of which will confer selective advantage. Other changes may be dele- • Assess for genomic features that may associate with disease outcome or transmissibility. Dr Anna Jeffrey-Smith terious or have no biological effect. For example, Clinical Research Fellow in Virology and 26 Therapeutics and vaccines Korber et al. described the increasing frequency Infectious Diseases, Queen Mary University • Antiviral susceptibility testing – a possible role for sequencing the polymerase or protease genes in patients treated of a mutation (D614G) in the spike protein that of London and University College London, unsuccessfully with inhibitors of these viral proteins (e.g. remdesivir). the authors purported led to increased viral trans- seconded to Public Health England for the missibility. Functional assays are required before • Vaccine development − identification of conserved sequences within epitopes; investigation of vaccine escape mutants, COVID-19 response assertions can be made about the significance of e.g. S gene mutations. viral mutations, deletions or insertions for viral Dr Tehmina Bharucha Transmission and virus evolution transmissibility, disease outcome or therapeutic use. Specialist Registrar in Infectious Diseases and • Understand how UK strains fit in the global phylogenetic tree. Microbiology, Institute of Glycobiology, Oxford, Conclusions • Investigate whether UK outbreaks are due to external introductions or ongoing transmission within the community. and Virology Cell, Public Health England From the earliest stages of the emergence of SARS- • Identify transmission hotspots or diminishing lineages. CoV-2, genomics has proven critical to the public • Understand nosocomial transmission within UK hospitals and care settings. health response. The timely generation of whole Dr Daniel Bradshaw Consultant Virologist, Virus Reference • Investigate epidemiological clusters and outbreaks. genome sequences from the global community has contributed to the development of diagnostics, Department, Public Health England Virus biology understanding of transmission dynamics and anal- • Direct RNA sequencing of transcriptomes, e.g. MinION. ysis of the origins and evolution of the new virus. Professor Maria Zambon Rapid and open-access sharing of data has been Consultant Virologist and Head of Influenza and • Identification of genomic changes occurring cell passage, e.g. deletions in the spike protein cleavage site described unprecedented and played a critical role in the Respiratory Virology & Polio Reference Service, by Davidson et al.24 response. In the months and years to come, for as Public Health England • Use of reverse genetics and pseudotype viruses to assess the consequences of genomic changes (e.g. as described by Hoffman et al.9).

Viral sequencing to characterise transmission Developing genomic capability across the UK chains, clusters and outbreaks On 23 March 2020, the UK government announced Sequencing can be valuable to complement epide- a £20 million initiative to launch the COVID-19 Nightingale tales miological evidence of clusters and outbreaks. The Genomics UK Consortium (COG-UK). The consor- first COVID-19 case in the USA was detected on 21 tium involves expertise from the four UK public his article describes the incredible achievements in setting up pathology services January in Washington, in a traveller from Wuhan. health agencies, several academic institutions to support the Nightingale Hospital at the Excel site at very short notice. Five weeks later, a second positive individual in and collaborating organisations. Combined with this region with no travel history was identified epidemiological and clinical information, this T through testing of influenza surveillance samples. large-scale WGS aims to contribute directly to I write this on 6 May – the day that the Nightin- Setting the brief Sequencing revealed that the two isolates had iden- informing interventions and UK policy decisions. gale Hospital London discharged its last patients The scale of a 100-acre hospital was daunting. tical genomes except for three mutations and both As of 11 June 2020, 25,052 sequences have been and went into suspended animation in the sincere Arriving early, I was able to join the intensive treat- possessed a genetic variant present in only a small uploaded. A preliminary analysis of SARS-CoV-2 hope that it will not be needed again. ment unit (ITU) workstream meeting when the proportion (2 of 59 – 3.4%) of genomes published importation into the UK identified at least 1,356 clinical model for the hospital was explained to from China at the time. This indicated a low prob- independently introduced lineages, mainly from Dr Rachael Liebmann The initial call the ITU consultants who, like me, had been cold ability that the variant occurred by chance and, European countries, followed by local transmis- It was only back in late March when I was contacted called and asked to contribute if they could. This 22 combined with the geographical proximity, was sion in the UK. Real-time sequence analysis has by the Medical Director, Dr Alan McGlennan, was fascinating. There were obvious concerns used as evidence to suggest that community trans- potential to inform a wide range of applications, about setting up pathology support for the Night- that simultaneously they were already heavily 18 mission had occurred within the USA. Six of the detailed in Box 1. ingale Hospital. Only five minutes before I got involved in the ‘surge’ of ITU capacity in their first ten UK cases resulted from a cluster of cases his text I had heard the news about the first new own Trusts. Then we were all reminded that this 19 linked to travel to a ski chalet in France and three Caveats to interpreting genomic data field hospital to be set up to help the country deal was to be a field hospital. Not all specialist services clusters of local transmission in Singapore were Interpretation of the significance of genomic data with COVID-19 patients. It seemed surreal but of would be available on site and so patients with 20 identified early in the pandemic. Going forward, has its limitations and caution should be taken to course I was happy to help if I could. After a short COVID-19 and known co-morbidities could not genomic data will be key to supporting cluster and avoid overinterpretation of findings. First, the lower conversation I agreed to meet the other pathology be safely treated there. For example, if a sickle cell RETURN TO outbreak investigations such as those described in error rate of the coronavirus genome limits genetic RETURN TO workstream members the following morning. patient with COVID-19 was admitted to the Night- 21,22 CONTENTS care homes. diversity, meaning that purely using genomic data CONTENTS ingale London, how would the ITU team access

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centre. It quickly became clear to us that the prag- Retired College Fellows matic requirement was for point-of-care testing Anticipating digital connections, we had initially (POCT) in the wards, with specimen reception and asked for volunteers from among the retired emergency blood transfusion available on site, and College Fellowship across the UK to support result the wider repertoire of testing undertaken at the reporting and clinical advice from home. I was Royal London hospital in established laboratories hugely touched by the excellent response and the where training programmes, quality systems, etc. preparedness to countenance this remote form of were already well established. return to clinical practice. It was anticipated that when patient volumes at the Nightingale London Mortuary provision increased, the wonderfully supportive consultants We were all aware from recent experience in China from Barts Health NHS Trust would not be able and Italy that, despite maximal treatment, some cope with this additional workload on top of their of the patients would sadly not survive. Autopsy already heavy clinical commitments. However, it histology images shared on social media by Dr became clear as April progressed that the ‘surge’ in Esther Youd from her practice showed clearly NHS ITU capacity was ‘coping’ with the pandemic why that is the case. The CT images in which the in the UK and the Nightingale London was not lungs of the most severely ill COVID patients look filled to anything like its potential capacity. exactly like the liver recall the red and grey hepa- So, these retired RCPath volunteers were never The Nightingale from the Royal London hospital, but not wanting to Dr Rachael Liebmann appropriate advice? Therefore, the hospital needed tisation of yesteryear in the pneumonia pots in deployed. recreation room – take staff from stretched hospital services, we also with a team of Oxford strict acceptance criteria and all diagnostics at the our pathology museums. For the first few days the before and after. looked for volunteers. My fellow RCPath Vice Pres- medical student hospital were to be highly protocol-driven. pathology workstream was reassured that there Couriers rising to the challenge ident Dr Tim Littlewood offered to contact Oxford Nightingale volunteers. was separate mortuary planning. On day three it A significant issue for all pathology services is spec- medical students not yet deployed in the COVID ‘If this turns out to be the biggest white elephant the UK became clear this workstream had yet to be set up. imen transport. We were extraordinarily fortunate effort who lived within travelling distance of the has ever built, we will be delighted.’ Within an hour of finding this out, I had recruited that the TDL couriers who normally collect cervical another College Council member, Dr Mike Osborn, Excel site. Eleven medical students responded screening samples from all over Greater London and were brought on board. Initially, we thought Support from the Armed Forces consultant histopathologist, President of the Asso- were at a loose end during the time of the pandemic. pathology staff would be asked to take swabs from As well as biomedical scientists and pathology ciation of Anatomical Pathology Technology and This was because throughout the UK women were ward staff for COVID-19 RT-PCR testing and this managers, I was pleased to see fellow College now President Elect, to set up the mortuary work- either too scared of infection to attend their GP or was the anticipation until a separate occupational Council member Lt Col (Dr) Emma Hutley, the stream (see p131 for Dr Matthew Clarke’s article). found their GP practices were seeing only urgent health workstream was created with a drive-in staff Defence Consultant Advisor for Pathology, in the cases. These couriers, who normally work within testing facility at the Crick Institute. pathology workstream. It was clear that the service Pathology services set up and POCT GP opening hours, were asked to volunteer to had to be of equivalent quality to that anywhere The speed of building of the North and South support the Nightingale London 24/7. I am very Role of medical undergraduate volunteers else in the NHS. Emma, a consultant medical micro- ward areas, each able to house 2,000 patients, proud to say that the majority chose to support The clinical skills and knowledge of the students biologist with experience of setting up pathology was awe-inspiring. However, in my opinion, the the new field hospital. These fully-trained couriers were invaluable, but more highly prized still was services quickly in less than ideal circumstances, procurement, installation and verification of inte- with appropriately equipped motorbikes worked their ability to form an effective and efficient team. created a list of pathology tests as a potential reper- grated point-of-care testing devices, building of a 12-hour shifts to collect samples from the Night- They organised their own rota to provide 24/7 toire (see Table 1). When this had been approved safe pathology reception and setting up of IT links ingale centre, dropping off at the Royal London cover seamlessly. Each medical student was on by the ITU Clinical Lead, we got started with plan- with off-site hospital laboratories by my pathology Hospital laboratories every 30 minutes throughout duty for eight-hour stretches. It was important to ning the pathology service to meet the needs of the workstream colleagues, clinical scientists and the hospital’s life. Along with the specimen recep- make the room adjacent to the pathology reception hospital’s intubated COVID-19 patients. transfusion practitioners was equally impressive. tion staff, biomedical and clinical scientists and a little more pleasant for breaks during the long Those of us who were brought up on episodes By the time the first patients were admitted, the supervising consultants, these couriers ensured antisocial hours worked. Bringing in some wall- of M*A*S*H might have thought that the Armed area initially marked just with black tape near the timely pathology services for the field hospital’s paper I had leftover from home and bright table Forces have fully equipped hospitals and laborato- Eastern Entrance nine days previously had become critically ill patients. cloths, with the help of two of the medical labo- ries in cold storage ready to be erected in a series a well-stocked, functioning, signposted and fully ratory assistants, I was able to make this a fairly of khaki tents when required. This impression networked specimen reception with a blood fridge. Final reflection pleasant recreation room. was further supported by the nearby London City Key to clinical needs were the blood gas analysers Despite the tragic circumstances, the last six weeks This was work experience like no other, with Airport having become RAF Nightingale, with that needed to be put into place on the wards with have been some of the most exciting and liberating long hours, last-minute training sessions and heavy Chinook helicopters and C130 Hercules flying staff trained to use them. Special mention needs to of my time in pathology clinical management. The responsibilities. They were willing and able to take past and many in the conference centre dressed go to Jenny Lake who single-handedly set up, veri- normal timescales for change and service develop- on new challenges. As gaps in ward staff inductions in military uniform. While the military do have fied and quality assured the POCT gas analysers ment were abandoned as there was a real need for became apparent, they were happy to become part rapidly deployable laboratories, they are designed and implemented an induction training regimen speed! It was a privilege to be part of this project, of the induction and training faculty providing to support small, mobile military hospitals, not a within 48 hours. which was delivered with such momentum by a POCT and blood transfusion training (see p124 4,000 bed ITU as was being asked. The ability to set disparate group of people volunteering to work for Dr Charlie McKechnie and Thomas Hanton’s up robust, quality assured diagnostic pathology Staffing for pathology services towards a common goal. The goal was to allow as article). In normal circumstances I would take new services quickly is a much more complicated But how did we staff these services? Pathology many patients as possible to live to tell their own recruits out for dinner to help team building, but process than simply struggling with a mallet and teams were needed to book in samples, provide Nightingale tale. of course during COVID-19 lockdown, this was not tent pegs. Electronically, the Nightingale London on-site advice (and specimen rejection) and provide possible. I look forward to a reunion at some future would be linked to the Cerner system at the Royal Code Red emergency blood transfusion support if Dr Rachael Liebmann point and when that happens dinner is on me! RETURN TO London Hospital as part of Barts Health NHS Trust needed for intubated patients. We were able to call RETURN TO Vice President for Communications CONTENTS since this hospital was the closest to the Excel on some experienced medical laboratory assistants CONTENTS

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The journey from Oxford medical Cytology and the pandemic

school to the world’s largest ICU his article describes the major impact of the COVID-19 pandemic on cytopathology services across the UK. Many issues are similar to those faced edical undergraduates contributed a significant amount of time and effort T by other pathology disciplines, but some are unique to cytopathology. in helping with the efficient running of pathology services at the No one could have imagined the impact the This may contain fixatives other than 70% ethanol, Nightingale Excel Hospital. COVID-19 pandemic would have on society, and and most, if not all, labs have had to modify labo- M 3 the tragic toll on human life. As across pathology, ratory protocols to handle the collection and On the 30 March, we found ourselves – as part of ward staff. This was unsurprisingly one of many the cytology community has struggled with huge processing of samples. The previous ease of use of a group of clinical medical schools – at the Excel teething problems that arose. changes not only in our personal lives, but also in samples using liquid-based cytology preservatives conference centre. If the year had progressed as We accrued more responsibilities in addition working practices.1 and methodology has been made more problem- Dr Charlie McKechnie planned, we should have been on placements to processing blood samples, including managing atic with these additional requirements. across Oxfordshire and working in a hospital on blood for transfusion and teaching incoming staff. Cytology samples the Solomon Islands. Instead, we were in a huge The irony of social distancing in spaces adorned In common with other areas of pathology, cyto- Cervical cytology conference centre being rapidly transformed into with photos of the previously packed venue was pathology services have experienced a significant Departments that offer cervical cytology have seen a 4,000-bed field hospital. Following the closure of not lost on us. The teaching faculty were looking reduction in demand during the pandemic. Never- a huge reduction in demand. All four UK countries our medical school a week before, we received an to train up to 1,000 people a day in intensive care theless, diagnostic cytology remains central to did pause non-urgent routine call/recall invita- email from Dr Tim Littlewood and Dr Rachael Lieb- skills, including the use of blood gas machines. cancer diagnosis, and laboratories are still receiving tions, but this was not done uniformly. Women mann asking for students to help with staff testing The trainees ranged from flight attendants to expe- bronchoscopy specimens, pleural and peritoneal have experienced local variations in the availa- at the newly announced NHS Nightingale. rienced intensive care consultants who months fluids/washings, and urine and cerebrospinal fluid bility of screening, although this was not driven Soon after meeting Rachael, we found out that before could have been our examiners. Working samples. As many cytology samples are received by the laboratories. Professional bodies including testing clinical staff was no longer the priority at the Nightingale was a new experience for fresh and considered potentially hazardous, cyto- the College produced guidance agreed by NHS for us since this was being carried out by others. everyone. This shared experience of unfamiliarity pathology laboratories are used to handling England and NHS Improvement (NHS EI), but Instead, we were needed to set up the pathology led to a uniquely supportive and cooperative team samples in compliance with the control of infec- this exposed a lack of agreement and unified lab at the Nightingale. Flexibility was certainly a environment. This was no doubt as a result of the Thomas Hanton tion guidance. However, all procedures have had action between those responsible for testing and key learning point in our experience at the Night- ever-present Wellbeing team providing support in to be revisited in the light of COVID-19 guidance.2 screening in England. The reduction in routine ingale. We were told to expect the hospital to be this stressful intensive care setting. And feeding us Many cytopathology samples are derived from workload during the pandemic has allowed labora- filled within a number of weeks. With that in chocolate instead of salad. fine needle aspiration (FNA). The pandemic has tories to largely clear backlogs that had developed mind, we completed our pathology reception During our time at the Nightingale we were brought into sharp focus the need for safe handling following the introduction of the primary HPV training – this would ordinarily take six weeks but encouraged to attend clinical governance meetings of potentially infective (from all causes) aspirated cervical screening program. we did it in just three days thanks to the lab staff at to feed back any problems we had encountered. material, particularly with respect to appropriate With the rapid introduction of COVID-19 the Royal London Hospital. This involved learning This provided a unique insight into the strategy personal protective equipment (PPE) and a safe testing, cervical screening providers and commis- to process samples for biochemistry, haematology, and outlook of the hospital from a regional and working environment. Although cytopathologist- sioners were not always fully involved in decisions coagulation, blood transfusion, microbiology and national perspective. One problem we encountered and radiologist-performed FNA have been limited on prioritisation of use of platforms that can virology testing. During our training, we learnt was having to reject blood transfusion samples to urgent referrals, it has been important to find safe be used for both tests. The Roche Cobas plat- that an intensive care patient will have 42 samples because the relevant form hadn’t been submitted ways of continuing FNA services, given its valuable forms proved ideal for early implementation of collected per week. Doing some quick maths, we with them. The next day reminder signs were seen role as a triage and diagnostic tool for suspected COVID-19 testing and have in some laboratories realised that for 4,000 patients, this would mean throughout the hospital. malignant lesions, including lymph nodes, breast been refocused on this. The ability to run both we would have to process 24,000 samples per day. Fortunately, London fared better than was lumps and subcutaneous deposits. FNA of acces- tests on the same platform or even within the same This would be perhaps more than the 11 medical expected, and at the time of writing the Nightingale sible metastatic sites have been used as a surrogate laboratory seems to vary between centres. Prac- students could handle – at this rate we would have is on standby, ready to respond if needed. Working at for biopsy of the primary site. Trans-oral FNA has tical use of the Hologic Aptima test platforms for to roster the whole clinical school. the Nightingale has been rewarding and formative been reported instead of tonsillar/palatal biopsy COVID-19 testing has been slower to implement. The first patient arrived in our second week in ways that are hard to convey in writing. During to help keep operating theatres free for emergency Problems with test capacity and reagent supply at the hospital. Dr Charlie McKechnie received the six weeks at the Nightingale, Charlie became a surgery. P16 and HPV-ISH on cell blocks from have been highlighted. At the time of writing, the the first set of bloods on the night shift, not long doctor – he could never have anticipated that in his primary and metastatic site FNA have been used NHS in England has been focused on restarting before receiving a call from the ward staff. The first job out of medical school he would help manage in new oropharyngeal cancers awaiting definitive non-COVID services and recommencing cervical point-of-care testing machines were failing to run a new department in the middle of a pandemic. treatment. Once routine work resumes, there will screening services, including restarting routine samples and we were due to receive training on From the warmth of staff working in the boule- be a significant backlog, particularly with respect invitations. It is essential that protected capacity maintenance for these machines at 9am the next vard to witnessing the mammoth task of setting up to endobronchial/endoscopic ultrasounds (EBUS/ for HPV testing is ensured before sample taking morning. Understanding that patient safety was at a functioning hospital, our time at the Nightingale EUS), thyroid and head and neck FNA, for which returns to normal levels. risk, Charlie rang the on-site maintenance phone will undoubtedly shape our future careers. cytopathologists should be prepared. After such massive screening programme number, which unfortunately was also due to be The WHO has recommended that all cytology disruption, it seems doubtful that laboratories set up the following morning. He escalated this Dr Charlie McKechnie samples are immersed in at least 70% alcohol, will meet many of the programme quality stand- to Dr Liebmann, who sent out a national alert for Foundation Year Doctor, Oxford University which has been shown to inactivate coronavi- ards. Commissioners in England, and Screening guidance, no doubt disturbing many people’s sleep Hospitals ruses. As such, the ability to offer EBUS rapid Quality Assurance services, are taking a pragmatic to help him. The machines were fixed remotely, a onsite evaluation or immediate reporting has been approach. However, aspects of quality assurance, backup courier system was set up, and within two Thomas Hanton RETURN TO RETURN TO compromised. Many samples nowadays are taken including incident reporting, remain very much as days we were teaching point-of-care testing to the Fifth Year Medical Student, University of Oxford CONTENTS CONTENTS into a liquid preservative (liquid-based cytology). normal.

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Impact on working practices to use web-based tools and material has accelerated Convalescent plasma treatment, containing diagnosed with COVID-19 and the benefits of For pathology laboratory and medical staff, the the implementation of digital pathology.4 The first high levels of polyclonal antibody, has been used preventative treatment for people at high risk of impact of COVID-19 has meant reduced onsite College specialist webinar was in cytopathology, to treat severe viral pneumonia during previous getting COVID-19. staffing levels, more working from home, addi- held jointly with the British Association for Cyto- pandemics. In fact, it has been used intermit- tional PPE, social distancing measures and remote pathology, and attracted 300 participants. Others tently for over a century, including patients treated Outline of current UK trials multidisciplinary team meeting input, most of are being developed and this must be the model during the era of the Spanish influenza pandemic In the UK, NHS Blood and Transplant is leading two which has been rapidly implemented. The huge going forward. When actual meetings restart, we in the early 20th century.3 Although all the studies large trials of convalescent plasma. This represents dependency on IT has become evident, and the must not abandon online teaching, given its great described at that time had significant method- a new programme of work funded by the Depart- NHS IT infrastructure has struggled at times to flexibility and ease of access. ological flaws and none were randomised, they ment for Health and Social Care. The strategy is to deliver. Many of the patterns of work introduced The effect of COVID-19 restrictions on in-lab suggested a reduction in mortality.3 build up a collection of plasma from convalescent may continue as part of the ‘new normal’. It is also training has been felt acutely in the staff-heavy Recently, convalescent plasma has been used to donors to provide enough plasma not only for two likely that there will be changes in clinical path- cellular pathology disciplines. Social distancing treat H1N1 influenza and, more relevantly, SARS- large-scale randomised controlled trials to assess ways and clinical ways of working. The use and has negatively impacted day-to-day supervision, Professor David J Roberts CoV infections in 2003. In one systematic review the efficacy and safety of convalescent plasma, but delivery of cytopathology may never fully revert to with less one-to-one double-headed microscope there was evidence of some considerable benefit, also to provide enough plasma to treat hospitalised pre-COVID ways and, in some aspects, this will be teaching. Some have found innovative solutions especially if convalescent plasma was given earlier and/or intensive care patients with COVID-19 if for the better. such as extending double-headed microscopes or in the course of the disease (within the first 14 days the randomised controlled trials do show efficacy. the use of cameras on consultant microscopes to of symptoms).4 The design of the study has required assessment Education and training show images via IT systems. of the titre of antiviral antibodies using a series of The opening slide Significant changes have occurred in education The COVID-19 pandemic has changed the world recently developed assays, including neutralising to the College’s first and training. Conferences and meetings have in a few short weeks. Much that was taken for antibody of live SARS-CoV-2 invasion in tissue specialist webinar ceased, and examinations suspended. It is difficult granted prior to it will not happen again for at least culture cell, neutralisation of pseudo-typed virus on cytology. to see these returning in 2020. The immediate need a long while. However, many of the changes intro- bearing the spike protein from SARS-CoV-2 that duced in cytopathology – indeed across pathology contains the ligand for the host ACE2 receptor, and medicine – are positive ones, and should not be and immunological assays of antibodies against forgotten or abandoned. There is also much we can different formulations of spike protein.7 Convales- learn about the collective response to the pandemic, cent plasma for clinical trials will only use plasma and what we can implement for the future. that has antibodies in the upper third of the range of antiviral antibodies. References available on our website. REMAP-CAP Dr Paul Cross The first trial, REMAP-CAP, is for treatment of Chair of the Cytopathology Sub-Committee community-acquired pneumonia in intensive care. This international trial is randomising patients Dr Ashish Chandra across the UK to several different treatments to Dr Louise Smart assess whether they are beneficial to critically ill adults with COVID-19. One of these randomi- Dr Karin Denton sations is comparing convalescent plasma with Members of the Cytopathology Sub-Committee Patients who have had Convalescent plasma has already been used COVID-19 can donate in observational studies of patients with severe standard care. plasma that can be COVID-19. However, a systematic review of the Patients who have recently been admitted to used as a therapy for evidence has shown that limited conclusions about intensive care are receiving two doses of conva- new patients the effectiveness and safety of convalescent plasma lescent plasma to assess whether this decreases Establishing convalescent plasma at different stages in people with COVID-19 can be drawn from these the risk of remaining on a ventilator or dying due of the disease. studies.5 There have been only eight uncontrolled to COVID-19. Furthermore, any potential harms studies published, with a total of 32 participants. caused by this treatment are also being assessed. as an effective therapy Some of these series are consistent with increased The plan is to randomise up to 2,000 participants viral clearance and recovery from the disease. to this trial. This is an adaptive trial and if there is evidence that convalescent plasma improves igh-quality research is essential in underpinning the clinical use of COVID-19 A recent report of 5,000 patients treated with convalescent plasma in the USA suggested that outcomes for critically ill patients, the trial will convalescent plasma and this article describes the UK randomised controlled convalescent plasma is safe, with no obvious cases be stopped and all patients admitted to intensive trials underway. of antibody-dependent enhancement of disease. care will be given convalescent plasma. The trial is H currently open at 50 hospitals around the country However, without data on control patients, there is Rationale for using convalescent plasma antiviral therapy that is proven to reduce insufficient evidence to determine whether conva- and there are plans to open it at more than 100 The global pandemic of the new coronavirus SARS- mortality, although many putative antiviral and lescent plasma is really both safe and effective in intensive care units nationwide. CoV-2 has not just medical but also historical anti-inflammatory regimens are being tested in 6 Dr Lise Estcourt the treatment of COVID-19. significance. In many parts of the world, the expo- large randomised clinical trials. However, the most More rigorous assessment of the role of conva- RECOVERY nential epidemic curve of cases has overwhelmed promising specific antiviral therapy is also one of lescent plasma is underway. At the last count, 22 The second trial is a UK-wide trial of convalescent hospital services. The primary pulmonary viral the oldest: tpatients who have had COVID-19 can randomised trials around the world had been plasma in all hospitalised patients with COVID-19 infection has required stepped supportive care donate plasma that can be used as a therapy for registered on trial registries.5 Two living system- and this started in May. Patients in the RECOVERY with oxygen and, if needed, mechanical venti- new patients at different stages of the disease. atic reviews of convalescent plasma will assess trial receive the same treatment, two doses of RETURN TO 1,2 RETURN TO CONTENTS lation. However, there is currently no specific CONTENTS the benefits of treating people who have been convalescent plasma, as in the REMAP-CAP trial.

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The RECOVERY trial will assess whether conva- put in place to control the epidemic, it is almost addition to extended molecular and serological skills to support the COVID-19 response, a compre- lescent plasma decreases the risk of death or the inevitable that the multiplication of the virus will COVID-19 testing. It is vital that ongoing scientific hensive document has been produced by NHS need for mechanical ventilation for anyone who is increase and it seems likely that there will be a long diagnostic and treatment services continue to be England to assist trusts and other organisations in hospitalised with COVID-19. It will include people tail of cases and quite probably a resurgence of the maintained for urgent and emergency care path- the deployment of scientists in the surge response with COVID-19 of any age, including neonates, infection in the coming months. This will allow ways, including cancer and acute cardiac events. and beyond to COVID-19. who are unwell enough to be admitted to hospital. completion of the trials and we hope definition of In addition to ensuring that normal pathology A four-country document entitled Health- The plan is to randomise up to 5,000 participants to possibly the first, effective therapy for COVID-19. services continue, scientists in laboratories are care Science Workforce Augmentation in response to this trial and open the trial at more than 200 hospi- coordinating testing for C-reactive proteins, which COVID-19 is due to be published as this report is tals around the UK. References available on our website. is proving useful in evaluating prognosis and being written. This document addresses how final It is inevitable that completing any trials of monitoring the clinical condition in patients with year clinical scientists and biomedical scientists therapy in a pandemic is a race against time. Dr Lise Estcourt COVID-19, and for ferritin, which has been found will progress onto the temporary HCPC registers These trials have proven no exception. While the Consultant Haematologist, NHS Blood to be elevated in approximately 60% of hospital- to create additional workforce capacity to respond convalescent plasma arms of the REMAP-CAP and and Transplant, Oxford ised patients with COVID-19 and may be associated to COVID-19. These registers will also be open RECOVERY trials will be actively recruiting by with increasing severity in this group. Scientists in to allow re-registration of clinical scientists and the end of the May, the number of patients with Professor David J Roberts some laboratories have introduced IL-6 into the biomedical scientists who have left the register COVID-19 admitted to hospitals and intensive care Consultant Haematologist, NHS Blood COVID-19 testing panel to further track the inflam- over the last three years and will facilitate clinical units has fallen substantially after several weeks and Transplant, Oxford matory progress of the disease. scientists currently employed in non-clinical roles, of lockdown. Although many measures are being Many genetics, molecular pathology and micro- either in provider organisations or other sectors, to biology/virology laboratories have repurposed return to frontline care. This is supported by the their scientists and their equipment to run PCR frequently asked questions section on the HCPC testing to help with COVID-19 testing. Pathology website. scientists around the country are working with Healthcare scientists in pathology: the academic scientific colleagues in contributing to Rehabilitation and the new normal many different types of clinical trials, including Finally, it is becoming clear that when this initial crucial studies to evaluate novel and reliable diag- COVID-19 surge declines there will be a require- challenges of responding to the virus nostic tests for antibody detection.1 ment to support patients in the community and In addition to working in their own depart- social care who have had COVID-19 and have been he Head of the National School of Healthcare Science highlights the key ments, NHS pathology scientists are helping to discharged from hospital, in addition to adapting contribution of scientists across many disciplines and the part they played train either life scientists who are returning to services to work with those at risk of acquiring work or final year STP trainees and other life scien- COVID-19 infection. In this respect, the skills of during the pandemic. T tist students who are volunteering to work in pathology scientists in providing continuously Healthcare scientists working in the NHS number patient-facing experience and detailed anatom- Trust laboratories or in the new Lighthouse labo- accurate testing and point-of-care testing will be over 50,000 and constitute 5–7% of the NHS work- ical knowledge to perform COVID-19 swabs. The ratories by providing them with the laboratory key as will the skills of the rehabilitation engi- force. This workforce contains over 50 healthcare commissioning and rollout of the Nightingale skills and understanding of quality systems to neers, cardiac and respiratory scientists. science specialties divided into four major profes- hospitals across the country employed expert help them support expansion of COVID-19 testing. sional areas: pathology (life) scientists, many of leadership and skills from healthcare scientists in This detailed training ensures that these volunteer References available on our website. whom are either fellows of the College or come pathology, clinical engineering, respiratory physi- scientists can be placed appropriately for their skill under its auspices as trainees; physiological scien- ology, cardiac physiology and vascular science. sets, recognises their relevant competencies and Professor Berne Ferry tists; and medical physicists including the clinical coordinates their onboarding and induction into Head of the National School of Healthcare engineers and clinical bioinformaticians who span Pathology laboratories safe pathology scientific testing. Science all four professional areas. Scientists within all 29 pathology networks have While many scientists working in pathology set up well organised local initiatives to meet the Redeployment guidance and temporary may not often encounter acutely unwell patients challenge of delivering normal diagnostic services, registers for scientists during their careers, this is not the case for phys- as well as preparing and delivering COVID-19 In recognition of the importance of embedding and iological or physical scientists who are critical in testing. Issues such as competencies and experi- supporting the redeployment of healthcare scien- caring for patients with respiratory and cardiac ence required of staff, including previous RNA/ tists, including pathology scientists, in new and conditions or who work in theatres or intensive DNA extraction and PCR capability, Cat 3 and PPE expanded roles and applying their transferable care. These highly skilled respiratory, cardiac and capability have been collated and shared within critical care physiological scientists have proven networks. Equipment and consumable concerns key to working within multidisciplinary teams and discussions on evaluating and validating treating COVID-19 patients with severe respir- results of new COVID-19 assays are also continu- atory problems. They provide non-invasive and ously being shared within and between pathology mechanical ventilatory support and diagnosis and networks. monitoring of cardiac complications with rhythm management and echocardiography. Clinical Scientists working in pathology engineers are essential in ensuring that all equip- There are stories of many scientists working across ment, including ventilators, are safe to use, fit for various pathology disciplines stepping up to the purpose and are continually maintained. At many plate during this crisis. Throughout the pandemic RETURN TO Trusts, audiology scientists have been critical to these scientists are continuing to provide essen- RETURN TO CONTENTS the frontline of COVID-19 testing, utilising their tial monitoring and diagnosis of all patients in CONTENTS

128 July 2020 Number 191 The Bulletin of the Royal College of Pathologists www.rcpath.org Number 191 July 2020 129 PATHOLOGY AND COVID-19 PATHOLOGY AND COVID-19

framework). An important lesson was the value of aid the first steps in the bereavement process. The Death certification: lessons learned skilled bereavement support officers not only in questions are often unpredictable and sometimes providing administrative knowledge and support, surprising. However having scrutinised the death but especially in guiding the bereaved through the and with access to the clinical records, it is usually within the hospital setting registration process, which was even more chal- possible to satisfactorily address any lingering lenging given social distancing rules. Furthermore, queries. Other issues may be less easy to address but r Zoë Avila outlines challenges she experienced working as a lead doctor communication, teamwork and patience with the may require prompt action, e.g. unmet safeguarding in a death certification unit at a COVID-19 pandemic hospital and as a local registrar and crematorium were vital given concerns regarding a dependent relative or the some of the nuances of the new legislation. breathless relative on the phone (emotional upset medical examiner at a London teaching hospital. D Established London hospitals have taken versus COVID-19 desaturation). There have been key changes in the death certi- to give COVID-19 as a cause of death as opposed different approaches regarding the ME system Many families have expressed their huge appre- fication/registration process following the to simply ‘pneumonia’. Since false-negative swab during the pandemic, with some suspending its ciation of the care given and this is something I’ve introduction of emergency legislation in the Coro- results are not uncommon, if the clinical suspi- introduction to concentrate on core (legal) require- had the pleasure of feeding back to clinical teams. navirus Act (2020).1 This article aims to highlight cion of COVID-19 is high (for example with typical ments and others embracing it. I have observed However, it is not unsurprising that in establishing some of the lessons learned with respect to the symptoms, radiology, lymphopenia and clinical many advantages of the system during the what are effectively new ways of working in hospi- Medical Certificate of Cause of Death (MCCD) picture) then COVID-19 should be given in part pandemic. For example, MEs have been supporting tals, involving staff deployed to unfamiliar roles, completion for hospital deaths during this turbu- 1 if this is felt clinically to be the most probable junior doctors by encouraging them to take a break dealing with a new disease with pandemic-level lent period (with legal references applicable to direct cause of death even if the swab is negative. from the wards to talk through a death (with a staff–patient ratios, using different specialist equip- England and Wales). Conversely, if a person dies from another direct refreshment) for collaborative scrutiny, providing ment, and with added challenges such as personal Accurate and timely completion of a MCCD is natural cause but has a positive COVID-19 swab advice on legal changes, assisting the timely protective equipment, concerns regarding quality important in enabling the bereaved to promptly result, then strong consideration should be given completion of paperwork, and essentially taking of care have occasionally arisen. The use of inde- 7 register a death and informing national statis- as to whether COVID-19 was a significant contrib- over MCCD (and Cremation form 4 completion ) pendent doctors to scrutinise death for purposes of tics. During the pandemic, the Office for National uting factor (and enter this in part 2 as appropriate). at the peak of the pandemic. accurate MCCD completion and to ensure actions Statistics has published weekly mortality reports It is also important to enter co-morbidities that are taken in the appropriate manner to address on the number of MCCD that mention COVID-19. have significantly contributed to death (e.g obesity, Contact with bereaved families concerns from staff or families will help maintain Furthermore, all COVID-19-related hospital deaths hypertension, ischaemic heart disease, diabetes, One of the most rewarding but sometimes harrowing trust, drive improvements and aid tracking of the (regardless of swab result) need to be formally chronic renal failure and/or dementia in part 2). aspects has been explaining to relatives what has pandemic. reported as soon as possible to NHS England While COVID-19 is an acceptable natural cause been written on an MCCD and addressing any (NHSE) via the COVID-19 Patient Notification of death, there have been increasing concerns concerns they may have. It is here that the tragedy Acknowledgements: I would like to thank Dr John System (CPNS).2 This timely sharing of mortality regarding COVID-19 deaths in healthcare and of a death hits home, with not infrequent stories of du Parcq and Dr Nigel Kennea for their advice. data helps to track the pandemic, with the poten- other workers where it could be argued that multiple deaths within families due to COVID-19, or tial to guide public health policies.3 COVID-19 was contracted at work.5 In law, any other family members on ventilators. By taking time References available on our website. disease proposed on MCCD that may be ‘related to address what are often relatively straightforward Legislative changes to the deceased’s employment’ necessitates notifi- questions in relation to the MCCD (e.g ‘was it really Dr Zoë Avila One of the main changes brought about by the cation to the coroner.4 If there is reason to suspect COVID that killed them, doctor?’, ‘but what about Consultant Histopathologist, St George’s emergency legislation relates to who can sign that human failure contributed to the person that swab test?’) and broader questions in relation to University Hospitals NHS Foundation Trust, a MCCD, with any medical practitioner (with a being infected at work (for example due to a lack the death (e.g ‘was he/she comfortable?’), you may London and NHS Nightingale Hospital, London GMC registration) being able to do so providing of personal protective equipment), then this makes the following criteria are met: the death potentially ‘unnatural’ and the coroner should be informed. Even though the Senior • it is not practicable for the attending doctor to Coroner has issued guidance to coroners that an complete the MCCD inquest may not be the best format for the inves- Caring for deceased patients at the • you are able to give a cause of death to the best tigation of such deaths, this does not remove a of your knowledge and belief doctor’s obligation to notify the coroner.6 • a medical practitioner has seen the deceased NHS Nightingale mortuary either during their final illness (extended Death certification units and the ME system from 14 days to 28 days) or seen the body after In setting up a COVID-19 pandemic death certifi- athew Clarke describes the team approach to setting up the mortuary death (e.g at verification).1 cation unit, the primary aim was meeting the legal service at considerable speed at the NHS Nightingale Excel Hospital. It is therefore possible for doctors such as requirement to register deaths within five days3 and medical examiners (MEs) in exceptional circum- to enable the dignified storage and release of bodies M stances, to complete MCCDs without having from the mortuary (preventing ghastly images we’ve ‘A human being does not cease to exist at death. It Nightingale this had an added dimension of diffi- attended the deceased during their final illness or seen in other countries). Fortunately, we were not is a change, not destruction, that takes place.’ culty; deceased patients would be admitted to after death as long as notification to the coroner overwhelmed by the feared peak volume of deaths the mortuary in a body bag, which would not be Dr Matthew Clarke – Florence Nightingale is not indicated (the usual obligatory reasons still and even at an emergency field hospital it was possible opened for the duration of their stay and there- 4 apply ). to incorporate some of the beneficial aspects of the fore it was imperative to ensure we had all the On my arrival at the Nightingale Hospital, I joined ME system; namely, providing channels of commu- necessary identifiers to ensure the correct patient a team whose remit was to construct a mortuary to Cause of death nication for families to raise concerns after death was released to the correct family to avoid one of look after deceased patients as part of the compas- In hospital, the completion of MCCD is usually and providing independent scrutiny of all deaths the most serious never events that pathology can sionate care team. It is often forgotten that people RETURN TO straightforward. However, controversies have (ensuring appropriate notifications to the coroner RETURN TO encounter. CONTENTS arisen as to the level of diagnostic proof required and feeding into the hospital clinical governance CONTENTS who have died need looking after too, but at the

130 July 2020 Number 191 The Bulletin of the Royal College of Pathologists www.rcpath.org Number 191 July 2020 131 PATHOLOGY AND COVID-19 PATHOLOGY AND COVID-19

modification of a few of our SOPs and providing within the mortuary learnt a great deal. Showing further risk assessments to meet the expected that a fully functioning HTA-compliant mortuary criteria for compliance. and associated services can be created in such a short time frame will hopefully be a legacy of the And finally… NHS Nightingale mortuary and our team. People Thankfully, there were fewer admissions to the who have died need looking after too, and hope- Nightingale then initially feared – this should be fully we have shown other clinical teams and the celebrated and not criticised. As we entered May, it general public the vital role and skills that bereave- became clear that we had passed the peak of the infec- ment staff, anatomical pathology technologists, tion, with London intensive treatment units having pathologists and all members of the compassionate the capacity to cope with the decreasing numbers care team have to help ensure this. of hospital admissions. With the decision taken to service free of charge with an online system and go into standby mode (in case of a second peak), we Dr Matthew Clarke an alarm to alert if temperature arrears occurred. ensured that the deceased in our care were trans- Histopathology Clinical Fellow, Institute of Resource acquisition, such as body bags, disin- ferred to funeral directors with eventual closure. Cancer Research (ICR), Sutton, London fectant, PPE and scrubs, was a major priority but On reflection, this was one of the proudest expe- challenging in the face of a national shortage. riences of my career so far and everyone working Setting up an IT service with appropriate access for staff was vital and the mortuary had a specific drive that stored all our processes and a register.

Staffing, SOPs and training A chaplaincy view from a multi-faith The strong mortuary managerial team needed a large network of staff and a workforce plan was created based on escalating numbers of inpatients university hospital community to ensure that the mortuary was functioning 24 hours a day. The workforce included mortuary rank Boulton, retired haematologist and blood transfusion specialist, is now a support officers, who were responsible for the Quaker Faith Advisor for Southampton University’s Faith and Reflection Centre. receipt of deceased patients into the mortuary and subsequent release to funeral directors, and a team F He also has an immuno-haematology teaching commitment within the Faculty of of porters helping with transit from the ward to Medicine. He shares his experience of supporting a multi-faith chaplaincy community. the mortuary. Much needed staffing support was Top: the Nightingale Equipment and logistic challenges provided by Team Rubicon, an organisation that I finally realised the implications of the oncoming weekly county-wide audio tele-conference of faith mortuary. We needed to ensure there was adequate PPE provi- has a membership of former military, naval and pandemic with the first UK death (7 March), by leaders to help their bereaved families to cope, sion for mortuary staff and satisfactory cleaning of RAF staff. We would not have been able to function which time Italy had registered 47 deaths. A closer particularly with the needs of different faiths and Bottom: the the area to reduce transmission risk. Security was without this amazing team of volunteers. eye would have seen the ominous signs earlier as the much reduced funerals enforced by the lock- 1 mortuary team. of paramount importance – all doors were key card Identification of the deceased was a major we can’t say we were not warned, but ballot box- down. Cremation is encouraged, but while this is access only, all lifts were disabled and all poten- concern and a deceased transfer pack was created related events had taken our eyes off the ball. welcomed by Hindus, it is anathema for Muslims. tial visual access to the mortuary was removed. An to ensure all required information was passed As our main hospital made plans to receive as Catholics take comfort in priest-led ‘last-rites’, so appropriately placed screen ensured privacy of the from ward teams to mortuary staff. Several checks yet unknown numbers of seriously ill people (and families find it very hard when priestly attend- deceased’s transfer to the funeral directors. were carried out during the transfer process to the adjacent cemetery dug open graves), how did ance is curtailed, although many funeral directors There were many other logistical aspects that ensure prompt detection of inaccuracies, and this the rest of the university respond? and crematoriums provide live-streaming and tele- needed to be considered. Initially, we sourced fridge was supported by a daily mortuary register audit. Like other UK universities, we are a multi-faith recording facilities and, so long as attendance is units that were converted ISO containers with A series of 16 SOPs were created with associated community with a chaplaincy on the main campus. limited, families can have graveside funerals. capacity for either 16 or 32 deceased patients, with a forms, quick reference guides and risk assess- We work with support services for students, post- Although the much anticipated backlog of total capacity of 1,344. With a predicted maximum ments. This was more than any other department graduates (and accompanying families if from people awaiting funerals has not materialised, at capacity of 4,000 inpatients at the hospital, the in the hospital and a reflection of the number of overseas), academics, other staff and administrators. such times of stress, care for the bereaved remains mortuary would need to be able to cope with poten- processes needed for the efficient functioning of With the university campus closed, the chap- important for College members and Fellows. The tially receiving 80 deceased patients per day. There the mortuary. This was underpinned by a training laincy is a tele-resource for its community, just like country’s COVID-19 survivors, especially the were potential challenges with the speed with programme for all mortuary staff. the city’s now closed places of worship. Colleagues carers, deserve whatever services we can offer, which funeral directors could collect a patient, since in the chaplaincy of the main teaching hospital whatever their faith – or none. they were working at full capacity with limited Acquiring an HTA licence (two miles away) serve patients, staff and students, storage. Families were likely to encounter further The mortuary was initially set up with no post and the toll on them – including staff deaths – References available on our website. delays in being able to organise funerals during lock- mortems planned and therefore without a need has been profound. The chaplains accepted their down. We therefore needed the ability to convert to acquire an HTA licence. However, it became physical exclusion from patients’ bedsides with Frank Boulton the fridges to freezers should a patient be staying evident that some cases would need to be discussed grace but became very resourceful at ‘tele-coun- Retired Haematologist and Blood Transfusion with us for 30 days or more. with the coroner and transferred within seven selling’ patients and relatives through tablets and Specialist Following delivery, the fridges needed rapid days of the referral as required by law. It there- other devices (including bedside telephones) and validation and a temperature monitoring system. fore became apparent that we would need to apply providing reading materials and games. RETURN TO A company called Tutela kindly provided their for an HTA licence, which was acquired after RETURN TO The Hampshire County Coroner, through the CONTENTS CONTENTS Anglican Chaplain to the Police Force, arranged a

132 July 2020 Number 191 The Bulletin of the Royal College of Pathologists www.rcpath.org Number 191 July 2020 133 COLLEGE NEWS

COLLEGE NEWS Moving to the new College premises

his article gives the background as to why the College moved to its new premises The RCPath Learning Programme: T and highlights some of the financial issues involved. the COVID-19 pandemic From June 1970 until February 2015, 2 Carlton • layout of the building, which did not lend House Terrace was the home of the College. After itself to modern working, with the need for a he pandemic provided novel opportunities for innovation in education with a short term in temporary accommodation in more open-plan structure providing greater Prescot Street, the College moved into the lower flexibility and space the rapid development by the College of a well-attended series of remotely floors of its new permanent premises at 6 Alie • inability to satisfactorily accommodate staff, delivered expert talks on COVID-19. T Daniel Ross Street in November 2018, taking possession of the which had increased in number since 1970. full building by the end of April 2019. One year At the end of March Professor Peter Johnston, Chair ensured that the communications and logistics College trustees appointed property consult- later we can now reflect on why it was necessary to of the Scotland Regional Council, suggested to the have worked and that speakers are well prepped ants and lawyers to conduct the negotiations with move and how we may use this wonderful building RCPath Trustee Board that the College consider to deliver their session from the comfort of their the Crown Estate and were advised that a joint sale going forward. Professor Shelley Heard developing a webinar series for its members during sitting rooms. This could only have been achieved arrangement would be in the best interests of the the COVID-19 lockdown. This suggestion was well through the enormous cooperation and good- College. Why move from Carlton House Terrace? received and with great enthusiasm Professor Will will of the virology community, which saw the The Crown Estate sold 2 Carlton House Terrace Initial stages and financial considerations of the Irving, Professor of Virology at the University of value and importance of providing a directed and with a new 125-year lease for £65 million and as move Nottingham, Dr Kate Templeton, Consultant Clin- focused learning resource on COVID-19. the leaseholder the College received £28 million. The property at Carlton House Terrace was held on ical Scientist in Microbiology, Royal Infirmary, Aimed at providing ‘bite-size’ learning, the Remarkably, this was twice the Crown Estate’s a 99-year lease from 1969 with a peppercorn rent of Edinburgh, and Professor Shelley Heard, RCPath webinars take place from 7:00 to 7:30pm (through original opening offer. The College also saved £2,000 per annum fixed for the duration. The value Vice President for Learning, developed a webinar to 29 July) on Wednesday evenings. Participants approximately £1 million in dilapidations charges to the College of the lease was declining with each series in a very short timescale. The first of these need to register weekly on the RCPath website. through this deal. passing year. At the end of the term we would have webinars took place on 15 April. The webinars are recorded for those who are The property at 6 Alie Street was an off-market Dr Andy Boon had to hand the property back to the Crown Estate, This webinar attracted more than 250 regis- unable to attend or who wish to refer back to opportunity that the Trustee Board agreed would the freeholder, paying a substantial dilapidations trants and Dr Chris Coleman, Assistant Professor the information provided. Feedback from the be ideal owing to its development potential and charge, and either find alternative premises or of Infection Immunology at the University of programme so far has been excellent and the full this was successfully acquired despite competi- negotiate and pay for a new lease. The latter would Nottingham, spoke on SARS-CoV-2, the virus and programme, which covers PPE, testing, autopsies, tion with another bid in 2016. The timing of the Professor Will Irving have been prohibitively expensive as the Crown other coronaviruses. vaccines and much more, can be found on the project was optimum since Carlton House Terrace Estate operate on a fully commercial basis. The format of the webinar was established with website. was sold at the top value of the London super Accordingly, the College vacated the prem- Will Irving hosting and introducing the session and prime residential market, while Alie Street was ises when there were still 53 years remaining on Chris speaking for 15 minutes. Questions from the Professor Shelley Heard purchased before prices rose owing to the move of the lease and while we were still in a strong posi- Zoom audience were then received by our online Vice President for Learning, Royal College of the City eastwards. tion to negotiate with the Crown Estate on the facilitator, Richard Sams, Business Administration Pathologists early relinquishment to release value. Council’s Officer at the College, with Will assimilating these The next stage: rebuild vs refurbish? view, as the Trustees of the College at the time, was and putting them to Chris for his response. And so, Professor Will Irving The design team considered refurbishment of the that if a suitable freehold property could be found the format of the 17-session RCPath webinar series Professor of Virology, Nottingham University existing building, but this would have resulted in in Central London, close to good transport links, was piloted, tested and demonstrated its success in Dr David Cassidy a lecture theatre of 100 people and 85 desk spaces. refurbished to a high standard and with the costs of its first 30 minutes. The better option was to demolish and rebuild, a new property obtained from the College’s share Diane Gaston, Director of Communications allowing a lecture theatre for 210 people and of the proceeds of sale of 2 Carlton House Terrace, at the College, and her excellent directorate, have desk spaces for approximately 130 – surprisingly then this would be a good deal. In addition to these without much greater expense. Either way, the financial considerations, a move to an alternative, cost of the project was greater than the proceeds The College’s COVID-19 suitable freehold property could help address some received for the sale of Carlton House Terrace and webinars can be significant shortcomings of the Carlton House the Trustee Board agreed to take out a mortgage viewed on our website. Terrace venue, including: loan to fund the difference. • the main lecture theatre only being able to A new bespoke building was designed to our hold 100 people, when ideally the College requirements building, with expansion space that required a facility capable of accommodating could be let on commercial terms. This would 200–250 people reduce the reliance on membership subscriptions • lack of office facilities for honorary officers as the major source of income while enhancing and others who perform an enormous amount the profile of the College as a conference centre of work for the College, together with appro- for both public sector and commercial clients. priate space as requested by members, such as The success of this strategy depended on having a members’ lounge, small meeting rooms and market-leading facilities and services. RETURN TO RETURN TO refreshment facilities CONTENTS CONTENTS

134 July 2020 Number 191 The Bulletin of the Royal College of Pathologists www.rcpath.org Number 191 July 2020 135 COLLEGE NEWS COLLEGE NEWS

Advantages of the new premises In addition to the awards won, the College was 6 Alie Street balances the three distinct require- also a shortlisted finalist for the following: RCPath Consulting ments for a College building. First, space for • Building magazine’s project of the year. These members and trainees to use, which incorporates awards are the industry’s longest running and he clinical pathways and structure of the NHS are rapidly changing and the the library collection. Second, space for offices to most prestigious recognition of excellence, house the administrative staff, honorary officers College is well placed to give advice to NHS and private healthcare organisations which allow organisations across all aspects and other pathologists who undertake College through the consultancy services of RCPath Consulting. of building to have their achievements held roles. Third, space to hold College symposia, exam- T up as an example to the sector. inations and other meetings. Included in the latter RCPath Consulting, which operates as part of individual advisors will be involved infrequently, • the Concrete Society awards in the education is a suite of meeting rooms with capacity ranging RCPath Trading Ltd, a wholly owned subsid- the varied nature of the work that we are invited to category. This award concentrates on all new from 12 to 210 suitable for use by the College and iary of the College, was established eight years consider often means that highly specialist advice projects in the UK with concrete as the major also by external organisations. ago. It provides expertise across all of our special- is required. We are currently looking to expand our structural component. We have established the brand ‘Events @ No 6’ ties to NHS and private healthcare organisations current list of advisors to ensure that we have the • the Academic Venue Awards, for which the as our commercial quality conference centre to let Professor Tim Helliwell and national bodies that seek an independent right range of expertise to match the work. College was shortlisted as a finalist for the the rooms to paying guests when not in use by the and authoritative view on how best to deliver Most contracts have come from promotion of Best Sustainability Award. College, and in addition have an entire floor being pathology services to optimise patient care. We our work by College Fellows. We also promote marketed to tenants to generate further income. This demonstrates that 6 Alie Street is a very have carried out many reviews ranging from a the work of RCPath Consulting directly to service attractive building, meeting all the key aims and ‘sense check’ of policy documents, through to managers. If you know someone who might appre- Reflections after the first year objectives and day-to-day functions of the College reviews of the governance processes in specialist ciate our advice, please ask them to get in touch for As expected with a new build, there were some effectively and efficiently, as well as being an teams and whole departments, and considera- an informal discussion. teething troubles with the contractors having outstanding venue for future internal and external tions of the likely risks and benefits of network If you have experience in laboratory manage- resolved all but one or two of the last, but nonethe- events. proposals. Professor Tim Helliwell is the Clinical ment and governance and would like to make this less important, items. Lead for this work, with Richard Sams providing available through RCPath Consulting, you can The Events @ No 6 commercial conference Going forward administrative support within the College. view the person specification and application form centre business had established itself and was Demand in the London office market will change Advisers are senior members of the College on the College website. generating income close to the budgeted level, no as a result of the pandemic. We continue to actively and the Institute for Biomedical Science, who If you are already an advisor for RCPath mean feat from a standing start after less than 12 market the fifth floor, which is still available for are appointed following open advertisement and Consulting and would like to be considered for a months of trading. This was, of course, before 24 rent and comprises 4,402 square feet, although it interview. Advisers are paid for their time, and future role as Clinical Lead, please contact Richard March when we had to close the premises owing may now take us longer to find a tenant than envis- all profits from our work are gifted to the College. Sams. to COVID-19. aged. We have, however, let some small spaces to The panel of advisors covers most of the major Although the conference market will change three tenants and are generating rental income specialties and provides a wealth of experience in Professor Tim Helliwell as a result of the pandemic, trade will start to pick from this activity. laboratory leadership and management. Although Clinical Lead for RCPath Consulting up again and slowly build up in time. The venue is The original development loan taken out by the number of contracts each year is small, and well placed as a meetings venue when the market the College was £12 million. To subsequently get picks up, and has won the following awards: the best mortgage deal, Trustees agreed to pay £2.5 million of capital from College reserves in • the New London Award in the education cate- February 2020 to reduce the loan amount to £9.5 gory. This award recognises the very best in Deadline for CPD returns extended to 30 September 2020 million. The interest rate on the loan is 1.5% above architecture, planning and development, the Bank of England base rate. We also took the including both new and proposed projects The College recognises and appreciates the tremendous effort made by our members opportunity to further our sustainability commit- across all sectors of the built environment, during this extremely difficult period. ment by selling our direct share investments in selected by an international expert jury. fossil fuel companies (fortuitously, just before In order to alleviate the pressure of submitting within the normal deadline, we have • the Architizer A+Award for Architecture + their value plummeted). extended the 2019/2020 CPD returns deadline to 30 September 2020. Learning. These are international awards, 6 Alie Street is a great asset for the College. It celebrating the year’s best buildings and Collecting CPD credits will allow us to function as a modern College for spaces from concepts through to completed It is recognised that collecting CPD credits might be challenging during the COVID-19 many years to come, generate revenues to offset projects, spanning all sectors. The College outbreak; for example, attending meetings or activities with human interaction. the running costs of the College, and provide was recognised in the Architecture + Learning Reflective learning is a very good way to keep up to date, can be done at home and is welcoming space for fellows and trainees to use. category for design solutions that enhance encouraged by the GMC and the Academy of Royal Medical Colleges. For further information and full accounts, the learning process and address the changing please contact Daniel Ross or Andy Boon. Examples of reflective learning include: means of knowledge sharing. • reflecting on an incident that occurred in the workplace – where care was good • best newcomer in the Hire Space Awards. Daniel Ross or excellent or sub-optimal and harm could have or did occur This awards the best of the events industry Chief Executive by recognising and rewarding hard-working, • online learning resources – taking an online course innovative and forward-thinking venues and Dr Andy Boon • articles in journals or books – learning something new and reflecting event bookers from across the UK. Treasurer on what you learned • The Brick Development Association, Brick Development Award. The annual brick • TV / YouTube / video content Dr David Cassidy awards celebrate the best examples of clay Immediate Past Treasurer • group study and reflection via video conference or teleconference. RETURN TO bricks in the built environment. RETURN TO CONTENTS CONTENTS

136 July 2020 Number 191 The Bulletin of the Royal College of Pathologists www.rcpath.org Number 191 July 2020 137 ON THE AGENDA

Left: The College’s The haematology ON THE AGENDA laboratory workforce: challenges BRITISH SOCIETY FOR HAEMATOLOGY and solutions. WORKFORCE REPORT 2019 Challenges for the haematology The haematology laboratory workforce: Right: The challenges and solutions British Society for workforce Haematology’s A Meeting Pathology Demand briefing Workforce Report 2019. onathan Kell, on behalf of the College, and Beverley Hunt, on behalf of the British Introduction As part of the Royal College of Pathologists’ Meeting Pathology Demand series, we carried out a survey of the haematology laboratory workforce, to help determine whether there is the right Society for Haematology, give an overview of the haematology workforce challenges number of staff with the right skills in the right places to ensure safe and effective high-quality patient care and support. Like many pathologists, haematologists have a role in the direct management and treatment of patients as well as undertaking diagnostic work in the laboratory.

identified from the two recent surveys from their respective organisations. This briefing contains the findings of our survey, which was sent to clinical directors and heads of haematology departments across the UK between December 2018 and September 2019. In J particular, it focuses on the laboratory, rather than clinical, commitment of haematologists. The British Society of Haematology carried out its own review of the UK haematology clinical workforce Haematology, along with clinical biochemistry and unheeded by successive directors of deaneries, over a similar period and we welcome the results of that report. The results of our survey highlight the challenges facing haematology. We have made immunology, represents the epitome of the dual hospital management and the government. The recommendations for solutions to those challenges and set out the commitments the College is making to help alleviate the problems facing haematologists.

role of the medical pathologist as a patient-facing current reports show there has been a minimal What is haematology?

Dr Jonathan Kell Haematology involves the diagnosis and treatment of patients who have disorders of the blood and physician and laboratory specialist. Indeed, this increase in the number of consultant posts across bone marrow. While a large amount of a haematologist’s time is spent providing direct clinical care to patients, diagnostic work in the laboratory is also a significant part of the workload of many duality is one of the most commonly cited reasons the country with a marked reduction in trainee haematologists. It is crucial to the delivery of high-quality patient management and care. for trainees deciding on a career in haematology. It recruits. The BSH document states that there has certainly was for us: who else sees the patient, takes been a 9.4% reduction in applications to haema-

the diagnostic sample (bone marrow), reports the tology specialist training schemes and a 36% histology and/or sends off requests for complex reduction in applications to SHO level rotations, LISTENING LEARNING LEADING tests to a laboratory where one was involved in which include haematology. This is alarming and setting up and policing the very same assays, and frightening, but it is backed up by personal experi- experienced clinical interpretation of results and a time when it needs to be increasing. Laboratory then communicates the result to the patient and ence when we see vacant training positions in our communication of these results to other clinical tests are becoming more complex – haematologists executes the management plan? The majority own institutions increasing in the last two years services. Many haematologists have more clin- are exposed daily to multiparameter flow cytom- of consultant haematologists have a medical – something that was previously unknown. The ical responsibilities, for example now providing eter reports and there is a need to contribute and background and we remain dually accredited – vacancies are particularly prominent in certain (appropriate) oversight of acute management of interpret genetic results at multidisciplinary team MRCP and FRCPath – and our Specialist Training subspecialties such as paediatric haematology, venous thromboembolism services. There is also meetings – at a time when we are losing, or have Committee is hosted in the Royal College of where the pressure of work/life balance in those Professor Beverley Hunt added work from the use of direct oral anticoag- lost, senior clinical scientist experience. There has Physicians. who remain to struggle on is enormous. ulants (DOACs) since many units are initiating been a 4.3% reduction in band 7 scientific staff Consultant clinical scientists in haematology DOACs in patients for their area or providing and a 9.3% reduction at band 8, although band and transfusion science undertake the FRCPath Retirement advice to GPs. 5 has seen a 26% increase. Laboratory scientists examination either in haematology or transfusion There has been a consistent (and, unfortunately, As the population generally ages, the incidence are getting younger as the medical consultants science, respectively. They are currently fewer in inevitable) increase in the average age of haema- of haematological malignancy is increasing. Treat- are getting older. Experience and knowledge are number with a clear need for expansion. tologists, as highlighted in both surveys. The BSH ment advances mean that many of these older gained over a career and by good mentorship, not document suggests around 10% of consultant patients are now eligible for quite demanding subsumed by osmosis at an induction day. The Workforce challenges for haematology haematologists are likely to retire in the next five treatments where previously they may have only benefits of having good clinical leadership in the departments years, while the College publication reports that been on watch and wait programmes. The treat- laboratory appears to be dismissed by hospital Two recently published reports define new chal- around one in 20 consultants are now on retire and ment of chronic lymphocytic leukaemia is a good management, but is becoming acutely apparent as lenges facing the haematology workforce: the return programmes. It might be that many depart- example of this, with many patients now receiving many of our physician colleagues are struggling to Royal College of Pathologists published The haema- ments are already reliant on these ‘returners’ to fludarabine- or ibrutinib-based therapies and bene- understand the limitations of assays – not least for tology laboratory workforce: challenges and solutions continue operating, and it is hardly a well-planned fiting greatly from them. The number of clinic testing for SARS-CoV-2 at present. while the British Society for Haematology (BSH) vision of the future. We know of one Health Board visits is increasing annually, with the BSH report published its Workforce Report 2019. Both examine in Wales that has lost three of the four consultants suggesting an average haematology medical staff Training primarily the clinical side of the service. Unfortu- in one of their centres despite receiving several member now undertakes around 964 outpatient Much work still needs to be done to ensure there nately, they are both incomplete for a number of reports on the fragility of the service. The one patient consultations per year – that is about 23 is good training in thrombosis and haemostasis, reasons. First, both reports had difficulty in finding remaining is past retirement age. We fear for what per week for a 42-week year and does not count transfusion medicine and, particularly, in paedi- up-to-date information on the haematology scien- might happen when they retire later this year. day centre visits for chemotherapy or other assess- atric haematology. Perhaps the current crisis will tific workforce and were based on self-reported ments. Of course, the COVID-19 pandemic is afford the opportunity to have a good look at all responses to surveys. Nonetheless, they comple- Clinical versus laboratory services changing the way we are working, and we hope our services and to establish how many consultants ment each other and demonstrate a consistent The integration of clinical and laboratory services not to go back to the old way of doing clinics, but (with medical or clinical scientist background) are picture. remains one of the great attractions in haema- patients will still need to be reviewed in person or really needed, not just how many we have, and the tology. However, fewer specialty medical trainees virtually. number of trainees to ensure a sustainable work- Trainees are now getting deep exposure in the laboratories, This increased clinical workload, and reduction force. Some units are recognising that not all of the The College last published a haematology survey and the College workforce report highlights that in consultant numbers, is impacting on the labo- clinical work needs to be conducted by doctors, in 2008, which called for an urgent increase in many consultants are now having laboratory time ratory. The time consultant haematologists are and the growth of clinical nurse specialists reflects RETURN TO the number of medical trainees coming into the squeezed in favour of the clinical service. Many RETURN TO getting to spend in the lab addressing abnormal this. Others are increasingly utilising physician CONTENTS specialty. This call appears to have gone largely Trusts are overlooking the ever-increasing need for CONTENTS results and interpreting assays is being squeezed at associates and some units now have segments of

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the clinical services delivered by highly specialised unique place with our feet in both the laboratory and training of HCS routes need to be simplified. some of the workforce issues in haematology and pharmacists, for example running anticoagulation and the clinic. It would be a very grave loss to our To this end, Health Education England has set up transfusion science. services, including initiation of DOAC clinics. patients to have a purely clinical haematology a working group with membership including the service no longer interested in the bone marrow College, professional bodies (including the IBMS), Sheila JM O’Connor Conclusion and solutions pathology appearances, the limits of minimal the National School of Healthcare Science and Haematological Malignancy Diagnostic Service, The two reports highlight the imminent danger residual disease technology or understanding the employers who are working together to produce Leeds Teaching Hospitals Trust to haematology. Urgent action is needed now to complexity of antiphospholipid testing. We must a current and up-to-date approach to training increase haematology (and pathology) exposure strive to maintain the dual and integrated clinical and assessment with clear benchmarks for career Professor Berne Ferry in medical schools and to make our junior medical and laboratory aspects of our roles. progression. This will generate a larger pool of Head of School, National School of Healthcare training rotations more attractive so we can eligible staff for HSST, which would ameliorate Science continue to train the next generation(s). We need Dr Jonathan Kell to work with our scientist colleagues to develop Consultant Haematologist, Cardiff and Vale training schemes in haematology (and other) clin- University Health Board and Chair, Wales ical laboratories to develop our new young clinical Regional Council, Royal College of Pathologists scientists, such as through the Higher Specialist The journey to pathology 3.0: more Scientist Training (HSST) scheme. We need to Professor Beverley Hunt OBE develop advanced nursing and pharmacy roles Thrombosis & Haemophilia Centre, Guy’s on ‘bricks’ and ‘clicks’ with clinical independence. We need to harness & St Thomas’ NHS Foundation Trust and Chair the talent and expertise in specialty and associate of External Affairs Committee, British Society specialist (SAS) doctors and to develop their skills. for Haematology ranko Perunovic builds further on his vision for ‘Pathology 3.0’ with a Our people remain our greatest asset and only by post-pandemic emphasis on the digital pathology platform as a clear enabler developing them can we continue to exercise our B for the transformation of services. The current histopathology service model, and Chesterfield.1 Three critical enablers to jump- unchanged for decades owing to an absence of start this transformation are: technologically and operationally viable alterna- • migration to a digital pathology platform Tackling haematology scientific Dr Branko Perunovic tives, is becoming unviable due to the widening • a progressive approach to the development of gap between demand and capacity. The workload the medical and scientific workforce is growing in volume and complexity and cannot workforce challenges • adequate governance arrangements to enable be ‘absorbed’ through enhanced utilisation of the transformation across the current organisa- existing human and technological resources.1 tional boundaries. n urgent re-evaluation of our approach to haematology scientific education and There is a global shortage of histopathologists.2–4 workforce planning is needed to address severe gaps, under-resourcing and lack Finally, as with other pathology disciplines, A digital pathology platform histopathology services are fragmented across of career progression. The digital pathology platform is the key techno- A organisational boundaries. The inevitable conse- logical enabler of the transformation. The required The workforce issues in haematology are well There is a clear route for clinical scientists (CS) quences of this fragmentation are variation of technology is now mature and more affordable, described, and two recent reports (the British Society to undertake higher specialist scientist training clinical, operational and financial performance, with a range of established vendors.7,8 Although for Haematology’s Workforce Report 2019 and the (HSST) with the FRCPath exam as evidence of the inconsistent generalist and subspecialist there is still limited hands-on experience, digital Sheila JM O’Connor Royal College of Pathologists’ report The haema- competence, resulting in eligibility for consultant approach, underinvestment in technology and pathology is not now an alien or iconoclastic tology laboratory workforce: challenges and solutions) grade CS posts. However, given the examples in underdevelopment of workforce. Owing to this concept,9 and the pragmatic response by the profes- both consider the problems around recruitment both of the recent reports of increasing service gaps strategic debt, the specialty is behind with the sional bodies will accelerate adoption.10 and retention with an ageing population as well as that could be filled by CS, HSST numbers remain scaling-up of digital and molecular pathology5 and For me, the term ‘digital pathology platform’ ageing, experienced consultants. Yet these reports very low in each cohort. Haematology and transfu- developing a modern multiprofessional workforce. extends beyond ‘digital microscopy’ or ‘pathology predominantly considered medical haematology sion science HCS are usually biomedical scientists Hence, its capacity to deliver the current service PACS’. On a technological level it incorporates staffing and not its scientific workforce. (BMS) and entry to HSST currently requires HCPC and its human and technological capability to end-to-end digital transformation. It includes inter- Clinical haematology with complex therapy is registration as a CS. This means that highly trained endorse computational pathology, ‘multi-omics’, operability with a range of laboratory, hospital a busy specialty with little time available for labo- BMS need to undertake ‘equivalence’ to CS (remit integrated diagnostics and precision medicine is and cancer registry systems, including electronic ratory duties, leaving many laboratories lacking of the Academy of Healthcare Science [AHCS]) or neither sufficient nor strategically aligned at the requesting, whole pathway activity tracking, in clinical leadership. Healthcare scientists (HCS) an experiential route via the Institute of Biomed- system level. reporting assisted by synoptic, voice recognition (biomedical and clinical) are clearly part of the ical Science (IBMS). This equivalence route is a Nevertheless, the call for new solutions for the and clinical-grade computation pathology tools, solution to this impending workforce crisis. For significant extra burden of work for the BMS who emerging post-pandemic healthcare service should and video-assisted communication and supervi- too many years, laboratory science has been under- generally has to navigate the system, often with unlock the transformational drive within the sion (multidisciplinary team meetings [MDTMs], resourced and there has been a constant drive to little support and then with acceptance of equiva- profession. This article outlines my views on laying dissection, intraoperative frozen sections, training, have relatively low-grade staff run an automated lence being relatively subjective. the foundations for an effective, equitable, resilient etc.). In this context, a digital pathology platform service. This has resulted in the loss of skilled mid- Given the parallels in CS and BMS training, and future-proof histopathology service model – a should be regarded as a tool for improving team- career HCS owing to a lack of career progression, we need to re-think our approach to the educa- model best described as a distributed subspecialist work, communication and efficiency, sharing with most senior posts in laboratories dominated tion and training of all HCS as we cannot risk this network. As previously explained in the Bulletin,6 resources, balancing workload and leveraging tech- by managerial or quality roles rather than scien- valuable scientific resource because of barriers to some of its aspects have been prototyped in Shef- nology to enable new ways of working. In practical RETURN TO tific/academic roles. HSST and lack of career progression. Education RETURN TO field and through collaborative ventures with Hull CONTENTS CONTENTS terms, this means that any histopathologist will be

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Digital pathology First, some degree of consolidation of labora- quantifying performance activity for resource allo- offers opportunities tory processing is inevitable; we cannot ignore cation, by virtue of its design, ‘RCPath point’ lends to improve teamwork, the opportunity to leverage the economy of scale, itself well as the pathology currency for simpli- communication utilise the existing estates and other resources fying and building confidence around contractual and efficiency. prudently and standardise processes and equip- and financial arrangements and, ultimately, for ment. A digital platform will enable physical decreasing transactional costs. In that context, decoupling of specimen dissection, processing, ‘pathcoin’ is much needed to support scaling-up of reporting and participation in meetings. This is histopathology. intrinsic for supraregional ventures, and particu- Several reports by teams that have embedded larly attractive for niche subspecialties and digital pathology highlight the opportunity for domains of interest. productivity improvements15–19 and to be viable, We will need to address the laudable concerns of individual business cases will need to forecast at colleagues who are unfamiliar with this approach. least some of these, likely in the range of 15–20%, For the foreseeable future, each laboratory and over the current RCPath norms. To pre-empt hospital site will have to have suitable accom- potential anxieties within the profession, we need modation for consultants and trainees needed for to reason that it cannot be delivered from day one, reporting or dissection of cases that require direct without the optimal end-to-end digital platform or engagement. adjustment for the changes of workload profiles. It The idea of remote working has already will be critical to work closely with our users, regu- gained substantial currency during the COVID-19 lators and professional bodies to understand the pandemic, and some of the previous concerns future demand, pre-empt under-resourcing and will be less relevant. Remote working comprises keep the guidelines up to date. able to seamlessly view, report, comment, share, at different stages of people’s careers and that any a range of direct clinical, professional, academic Ronald Heifetz, a physician and Harvard lead- consult, hand over, supervise, present, teach/train forward-thinking employer will strive to support or educational activities. Reporting, supervising, ership scholar, said that ‘the single biggest failure and request additional information or additional its talent and scarcest resource. participation in meetings or SPA activity delivered of leadership is to treat adaptive challenges like work on any case from within the clinical network, Based on our experience, the logistics of the from a home office is only a special case. The oppor- technical problems’. With that in mind, limiting irrespective of the site where the work originated, transition and future service would be practically tunity for working from home has the potential our ambition to procuring digital pathology kit their physical location or the physical location of impossible without a digital platform. Further- to improve histopathologists’ work-life balance, and minor modification of organisational charts other colleagues. more, it cannot be done in a rush or approached decrease the environmental footprint and increase and processes to comply with governmental initi- as ‘one size fits all’. SSDT will need to have the capacity (by enabling consultants to offer addi- atives and improve performance would be the Workforce development autonomy and responsibility for developing and tional activity not achievable if work onsite was biggest mistake we could make. To safeguard the The rapidly expanding volume of knowledge is refining its principles, taking into account pecu- required). Needless to say, working from home will future, we need a comprehensive, strategic rethink challenging the ability and the opportunity of liarities of individual clinical pathways, the not remove the need to have face-to-face contacts of the way we organise and deliver histopathology individual histopathologists to keep up with the continuity and quality of the existing service, and with colleagues, users, trainees and laboratory services and how we utilise a digital platform and entire range. This trend is further accelerated by other realities. As a minimum, the colleagues who staff.12 Nevertheless, we need a robust governance emerging computational pathology to enable this the rapid developments in precision medicine5 and join an SSDT will need to demonstrate that they framework to address anxieties about a laissez- journey. is influencing the career and lifestyle aspirations participate in the national external quality assur- faire approach to onsite attendance and working of the contemporary workforce. One of the inevi- ance scheme for the subspecialty, and are engaged hours, abuse of equipment, or setting precedents References available on our website. table legacies of services being fragmented across and functioning members of the subspecialist team for other peer groups. the acute Trusts’ landscape, consultant shortages and participate in the relevant local and network Finally, RCPath’s guidelines for staffing and Dr Branko Perunovic and the logistic ceiling to sharing cases across the MDTMs. workload have evolved and become more accu- Clinical Director, Pathology Transformation geography in real time by the physical moving of rate in capturing safe and optimal workloads with Programme, South Yorkshire and Bassetlaw slides is a ‘generalist’ or ‘partly generalist’ model Governance the current state of technology and operational Shadow Integrated Care System in almost all but large regional cancer centres. A regional and supraregional footprint is design for most subspecialties.13,14 In addition to Duplication of work via mandatory ‘central’, becoming an industry standard for the modern subspecialist reviews further decreases the cumu- pathology service. To paraphrase Intel’s Andy lative reporting capacity of the system. Grove, ‘losing the ability to scale will ultimately A distributed subspecialist network model damage our capacity to innovate’. With that in proposes subspecialisation of the consultant work- mind, the proposed distributed subspecialist force and their consolidation into subspecialist network is conceptualised as a platform, hence diagnostic teams (SSDT). SSDT, comprising medi- inherently collaborative, scalable and potentially cally and, as we further progress, scientifically independent of the organisational models chosen qualified histopathologists, will report across the for each regional pathology network.11 However, current organisational boundaries and deliver an it will need a suitable governance framework to equitable service to the same standard of quality leverage technology, optimise talent manage- for the population within and beyond the region. ment and realise the collaborative and commercial The survey in SYB showed that the majority ventures within the healthcare sector or with of histopathologists prefer to practice as oligospe- academia and industry. The details are outside the RETURN TO cialists. The model also assumes significant scope of this article; instead, we will draw attention RETURN TO flexibility, acknowledging that individual profes- to three particular issues that have surfaced during CONTENTS sional and personal aspirations and objectives vary consultations. CONTENTS

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SHARING OUR SUBJECT School’s out but the Schools Hugh Platt Science Conference must go on Win £200 ublic engagement doesn’t stop during a pandemic. The annual RCPath Schools Foundation Science Conference went ahead with virtual workshops and selfie videos by P pathologists on sickle cell disorder. Essay Prize What is the Schools Science Conference? about their personal experience as individuals For nearly a decade, the College’s Public Engage- living with sickle cell disorder. 2020 Receive a ment team have been partnering with Science4U Students are invited to ask questions by Thadcha Retneswaran certi cate to provide fun-filled, interactive and educational commenting on the videos and replies will be at a College event pathology-themed workshops for their annual provided by the contributors. The workshop also Schools Science Conference. Now in its 17th year, incorporates quizzes to test students’ learning and the aim of the conference is to encourage students our ‘Make a Blood Cell’ activity. from less advantaged backgrounds from schools across London to study science. It is run entirely Science4U receive the Queen’s Award for by volunteers, including scientists and health Voluntary Service Enter by professionals from various disciplines across the On 2 June, Science4U received the Queen’s Award Get published NHS and private sector. Each year our members for Voluntary Service – the MBE for voluntary on our website and in the Bulletin have generously offered their time and expertise groups. Created in 2002 to celebrate the Queen’s 28 August to provide insight into the science of pathology Golden Jubilee, the Queen’s Award for Voluntary and highlight the numerous career opportunities Service recognises outstanding work by volunteer within the profession. groups benefiting their local communities. Are you an FY1 or FY2 doctor aspiring to become a pathologist? We are delighted that the Science4U team are This competition o ers a unique opportunity to boost your CV ahead of applying Delivering our workshop during the COVID-19 being recognised for all their hard work – it is very Find out more pandemic much deserved! Events like the School Science for your specialty training. Please address the topic: and enter: In early March, with the ongoing COVID-19 Conference are incredibly important for inspiring ‘Tiny test, huge impact’ – write an essay drawing on your experience of a patient pandemic, an imminent lockdown and closing today’s students to become tomorrow’s scientists, encounter which illustrates the impact a pathology result can have on a patient www.rcpath.org/ of schools, it became clear that it would not be especially for those students who might not other- and their family. essay-competitions possible for this year’s conference to go ahead wise be exposed to such opportunities. We’d like as planned. Determined to ensure that students to thank everyone who has contributed to all our didn’t miss out, Science4U opted to move the School Science Conference workshops to date. event online. We adapted our practical activities We look forward to collaborating with Science4U on genetic inheritance and sickle cell disorder into and our members to create many more interactive a virtual workshop called ‘Split Your Genes’. On 4 activities in the years to come. May, Science4U rolled this out to the schools that For more information on this year’s School had signed up for this year’s conference. Science Conference and the Queen’s Award, visit Taking the form of a narrated PowerPoint pres- science4u.info. entation, the workshop features seven engaging Save the date! selfie videos from five pathologists and two Sickle Thadcha Retneswaran Cell Society representatives. Dr Shubha Allard Communications Officer and Dr Cath Booth describe their work with NHS Get involved in our annual celebration of pathology and help Blood and Transplant (NHSBT) and explain how us highlight the important work of pathologists across our they help people with blood disorders and related specialties. conditions. Dr Rachael Carling and Dr Yvonne Daniel explain their roles within their hospital Keep an eye on our website and social media channels for biochemistry laboratory teams and highlight the news of an innovative online programme plus lots of ideas importance of newborn screening. Dr Sara Trom- for running your own online events and at-home activities peter demonstrates a day in the life of a consultant haematologist and paediatric haematologist Visit: www.rcpath.org/pathologyweek working with thalassaemia and sickle cell patients. Share: #PathologyWeek RETURN TO June Okochi and Courteney McLune-Calvin speak RETURN TO CONTENTS CONTENTS

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is based on a distributed service model where local the success of consensual management style and NHS Board departments work across a supportive investment in staff in public sector organisations. REGIONAL network of equals, each knowing what the other is Linking the COVID-19 experience to educa- doing, to share intelligence, expertise and workload. tion is vital. For us pathologists, expanding the This includes the diversity of scale across Scotland’s drive for public engagement should be extended to COVID-19 and the devolved nations geography from small Boards, like NHS Western include our colleagues in other medical disciplines Isles, to the largest, NHS Greater Glasgow and Clyde. whose understanding might be described as rudi- There has been cooperation between university mentary. There is a clear need to focus non-clinical hese three articles from the College Regional Councils in Scotland, Wales laboratories across Scotland and a so-called light- managers in the NHS and politicians on the inte- and Northern Ireland describe the different approaches and their particular house laboratory in Glasgow. Alignment of these gral nature of laboratories to modern healthcare. challenges around the introduction of testing during the pandemic. with NHS standards has been and remains a priority This is as true in Scotland as elsewhere. Investment T to ensure that a result in one laboratory would be in staff development and thinking about joined-up the same from another. This provides accurate and services – nationally coordinated, locally delivered Northern Ireland: our response to COVID-19 consistent data with which to ensure safe under- – are helpful spin-offs. Educational programmes standing and decisions as the pandemic evolves. for doctors, and clinical and biomedical scientists The Northern Ireland response to the COVID-19 has been mainly through the existing virology Looking ahead, capacity building is important urgently need to be reinvigorated. This requires pandemic has in some way been different from laboratories or via the development of a regional as we move from seeking the organism to meas- investment from Health Boards and flexible and the rest of the UK. This is in part due to geog- facility based at AFBI (Agri-Food and Biosciences uring people’s immunological response to it. An effective facilitation by the Deanery. The College raphy, with reduced travel between Great Britain Institute), in partnership with staff and equipment important consideration is having space for staff as has been quick and effective in developing guidance. and the island of Ireland. Reduced travel arose not from Queen’s University Belfast and Ulster Univer- well as the equipment required. Distancing effec- In Scotland, virology colleagues have over- only from people being placed into lockdown, but sity, with the first test processed in mid-May. This tively reduces the space in a building and so the seen a major effort, moving from a position of little also by the collapse of air travel precipitated by is despite the biotech firm Randox being based in pressure on facilities increases. Many laboratories resource to one where capacity is ahead of demand. Flybe entering administration; 90% of flights from Northern Ireland and supplying tests for the drive- were built before the expansion of clinical demand The establishment of management and delivery Belfast City airport were run by Flybe. through testing sites in Northern Ireland. for pathology services and were physically too groups and university collaborations are aligned Perhaps on a more positive note, there was a By the end of May, 523 deaths had occurred in small prior to the current crisis. While this is true with the Scottish National Laboratory Programme’s Professor Ken Mills unified approach to managing the pandemic by Northern Ireland with approximately 68,000 tests for many clinical areas across all care sectors, we tenet, ‘right test, right time, right place’, ensuring the Stormont Assembly, with all sides of the polit- completed. Recent calls have been made to increase need to ensure that laboratories and mortuaries results are recorded in correct, accessible patient ical spectrum appearing to work together while the number of daily tests for COVID-19 by around are not forgotten in developing safe environments records. trying to balance the advice and guidance from the 1,000 to enable cancer services to get back on track, for patients and staff. Space includes room for Communication within and around the system UK and Irish governments for the benefit of the particularly in the pathology departments that staff to relax and rest, socialise safely and foster a remains vital to success: ensuring people are valued, Northern Ireland population. will be dealing with the backlog of active and undi- supportive educational culture in which to work. and there is shared understanding and collabora- The preparation for the surge was based, similar agnosed cancers. While the role of pathologists in tive intent towards agreed objectives. There is a to the other countries in the UK, around three the current situation has not been fully recognised, Operational features need for investment to maintain capacity that will areas: creating capacity and expanding critical they have dealt with the challenges in a profes- Several lessons arise from COVID-19 in Scot- be adequate for now and flexible for future. This care; supporting staff and increasing availability; sional and efficient manner. land. Clinical leadership is among those. We requires ongoing commitment from government, its and reducing routine work. Interestingly, guidance have seen a lot of the ‘command and control’ offices, Health Boards, and pathologists. on these areas, issued by the Department of Health, This article was finalised on 11 June 2020. style of management in this crisis. There is value did not mention the role of pathology in the testing in facilitating ‘ground-up’ involvement in future- This article was finalised on 23 June 2020. plans or the need for an integrated approach. Professor Ken Mills proofing services while reinforcing this within Increased capacity for testing in Northern Ireland Chair, Northern Ireland Regional Council and from senior management. Literature supports Professor Peter Johnston Chair, Scotland Regional Council SARS-CoV-2: a Scottish perspective Laboratory medicine provides safe and timely data to favour advice from industrialists and entrepre- COVID-19: the Welsh response on which 21st century medicine is based. Testing neurs about COVID-19. There is a need for balance One of the problems in dealing with a widespread Initial approach to testing in Wales for SARS-CoV-2, its delivery and controversies have that involves credible, experienced NHS laboratory infection, particularly one we haven’t seen before, It is interesting to observe the different approaches demonstrated this point. Future safe management medicine and science staff at the heart of the testing is the early recognition of symptoms and likely the four countries of the UK took to the testing of of the outbreak is crucial to the health and safety strategy and delivery. Standards in laboratories spread. By the time SARS-CoV-2 was documented their populations. In this, Wales had two significant of the population at home, at work and in health- are not annoying nit-picking – they and the regis- in the UK, two clear observations could be made. advantages over England. First, our index cases were care. People are scared of the unknown and the tered staff who deliver laboratory care in accredited First, it must have been here before it was identi- defined later than in England, with the picture in the language of war that has been prevalent throughout settings are the assurance of safety the public needs. fied and there are data from Oxford supporting this. UK largely spreading from East to West and from the pandemic may have helped embed fear. Encour- Second, the UK stood to benefit from experience South to North (aside from a Real Madrid-induced aging people to re-engage with healthcare in Strategic approach in Scotland in other countries, particularly the experience in pocket in Liverpool). This means that we entered Professor Peter Johnston primary, secondary and social care will require Scotland has developed a clinical governance frame- South Korea, Italy and Spain. Instead, we delayed lockdown earlier in the course of the pandemic demonstration that environments are safe for them work with SARS-Cov-2 testing as the remit. Three Dr Jonathan Kell starting the age-old treatment for epidemic and the spread of infection may have been more to do so. A system for testing, tracking and tracing associated groups have responsibility for strategy, management – test, trace and protect. I will leave contained, although we had large outbreaks in that has the confidence of the population as well as delivery and quality. These groups are chaired by it to other people to comment on the initial UK Gwent and North Wales. Second, testing for health- healthcare providers is an important part of this. The senior NHS laboratory medical and scientific profes- response generally and, of course, it is easy to criti- care personnel and other key workers began earlier RETURN TO relevance of pathology specialties and virologists in sionals. They work collaboratively with Scottish RETURN TO cise in retrospect. and made a huge difference to the number of people CONTENTS this context is manifest. Governments are perceived government officials. The testing system in Scotland CONTENTS

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able to make an early return to work. A negative does not mean that half the healthcare workforce is challenges that face the profession, such as work- histopathology pay discrepancy concerns and test result = back to work. This was good for health- in isolation after being in contact with a patient, or a force capacity issues. has raised it in the Senedd (the Wales National care planning and provision, as well as for personal colleague who has. The College hosts regional councils, comprising Assembly) several times. well-being and confidence: it is quite a relief to be At the time of writing we are expecting an anti- specialty members, for the devolved nations. There was an article on Wales online in January declared negative for an unknown and potentially body test to be widely available within a few weeks These councils provide professional leadership in 2020 in which College Fellows discussed the pay fatal disorder. The Welsh government definitely and, by the time you read this, you may have been their country and contribute at a national level to discrepancy and the impact on the workforce. got this right and we were way ahead of England on tested. This is a crucial step forward as we can start the maintenance and development of pathology Dr Jonathan Kell, Chair of the Wales Regional testing for many weeks. to map the demography of who has been exposed. It services and the quality of care that patients Council, has met Chris Bryant MP, who has been will be particularly useful for healthcare workers as receive. The regional councils play a vital and very supportive of the College and our workforce Reliability of samples we attempt to return things to normal and recover important role in our engagement with parliamen- concerns. Alongside raising the issue in parliament, There remain concerns around testing. If symp- our surgical programmes and cancer treatment. tarians across the UK. Chris Bryant has also given media interviews about tomatic workers screen negative, what condition Engaging with and influencing the devolved the need for improvements to cancer services in do they really have? And is that OK to take to Other impacts of the pandemic Janine Aldridge governments in Scotland, Wales and Northern Wales and the shortage of pathologists to carry out work? There was little support for this. Concerns It is interesting to note that nearly all histopa- Ireland is key to our UK-wide political engage- testing. Jonathan also met Nick Thomas-Symonds exist about the reliability of samples – a single dry thology departments have reported an 80% decrease ment strategy. It is important that we tailor our MP (Labour, Torfaen) to discuss workforce and throat swab in Wales, rather than two wet swabs in their activity, while virology and microbiology communications when engaging with politicians retention pay equality concerns. in England. Does that affect sample quality? And departments have had to completely rethink how in the different nations since the policy areas and what about the lack of a tongue depressor? If you they provide their service, and clinical disciplines processes through which decisions are made vary. Scotland can’t see what you are swabbing, it is unlikely to be have been contributing to covering COVID wards. In our College priorities for the new govern- Professor Peter Johnston, Chair of the Scotland good quality. I didn’t even gag when I was swabbed. We have lost our core medical trainees somewhere ment document that was released before the Regional Council, met Sean Neill, Deputy Director I don’t think it went far enough. I was negative. It along the way and specialist registrars have had their general election, we called for the recruitment and for Health Workforce in Scotland, to discuss work- speaks volumes for the standardisation of sample training interrupted and their exams postponed, retention premium for histopathology trainees force concerns in 2019. A report on the laboratory procurement and laboratory testing. SOPs and adding to the immense stress this clinical situation to be extended to all, including specialist histopa- workforce in Scotland, Scotland’s Future Labora- accreditation standards exist to ensure tests are has caused. Wales has made significant contribu- thology trainees in areas in Wales, Scotland and tory Workforce, commissioned by the Diagnostic done properly and the results are reliable. The tion to COVID studies and Angharad Davies, Health Northern Ireland. Steering Group (DSG), has since highlighted the use of unaccredited commercial laboratories to and Care Research Wales’ Specialty Lead for Infec- Following the general election we have re-estab- need for a fresh approach to delivering diagnostics increase testing capacity is a political and unscien- tion, points to the huge efforts of colleagues across lished links with key MPs and ministers and have to bridge the increasing workforce gap. The report tific manoeuvre that pathologists should resist. Wales in recruiting to UK national trials. Wales hit sent briefings on workforce concerns to key stake- shows that across all laboratories, disciplines and the ground running and at the end of March, Welsh holders around the UK. Questions have been professions in Scotland there are too few people to Contact tracing Health Boards were the top recruiters in the UK raised in parliament on workforce. For example, deliver the service and too few in training to fill the As far as I know, little or no tracing of contacts was to the RECOVERY trial and have led on the initia- on 7 January 2020 during treasury questions Chris places of those who may leave or retire in the next done in the early days. Now that we seem to be over tion of convalescent plasma studies. To date, Wales Bryant MP (Labour, Rhondda) asked: five to ten years. the worst of the (first?) peak, we are invoking a large- has recruited over 2,000 patients to more than 30 ‘Unfortunately 9 out of 10 pathology labs in scale public screening test programme with tracing COVID studies. England, Wales and Scotland are short of patholo- Northern Ireland of contacts. The public remain the key partner in Of course, all this disruption demands that we gists, which means that people are waiting six and Following the reopening of the Northern Ireland this programme – if I have only mild symptoms, I rethink the way we run our labs, how we deliver seven weeks. Is it not time now that we had a major Assembly we sent a College briefing to Robin might need some incentive to find a drive-through our services and how we educate (and examine) incentive, financial incentive, to persuade more Swann, Minister for Health in Northern Ireland. centre or order a home test kit. If I have moderate or our trainees. I hope we will be able to look back at people to become histopathologists and patholo- This resulted in a meeting invitation for Professor severe symptoms, I might not be able to do either. these trying times as the birth pains of an improved gists in the NHS today?’ Ken Mills, Chair of the Northern Ireland Regional Furthermore, can I really remember everyone I had preventative, diagnostic, therapeutic and teaching Our histopathology workforce report Meeting Council, with Department of Health officials in a contact with over the last seven days? What counts National Health Service. Pathology Demand highlighted the variation in the Northern Ireland to discuss workforce concerns. as a contact? Healthcare workers will necessarily countries for departments outsourcing work. In The outbreak of COVID-19 in the UK has taken be in contact with definite or suspect cases almost This article was finalised on 11 June 2020. Northern Ireland, 67% of work was outsourced, priority recently with regard to engagement with daily. We then take it with us when we discuss a while Scotland outsourced 33%. The reason for policy makers. We have highlighted the amazing case with a colleague, or we go home and potentially Dr Jonathan Kell hospitals using locums in Northern Ireland was work that College microbiology, virology and take it with us. We need a definition of contact that Chair, Wales Regional Council 100% due to insufficient applicants for vacancies, infection control team members are undertaking. while in Scotland and Wales locum use for this They have been coordinating their work across reason was 67% and 60%, respectively. the UK to support patients, the public and College The findings of a College survey published in members during the spread of COVID-19. As the February 2020, The haematology laboratory workforce: virus spreads, laboratory testing has been ramped Highlighting UK workforce concerns challenges and solutions, revealed that haematologists up to meet demand and the College virology and are finding it increasingly difficult to undertake infection experts have risen to the challenge. vital diagnostic work in the laboratory. n this article, Janine Aldridge, Public Affairs Officer at the College, summarises the Janine Aldridge College’s political and stakeholder engagement in the devolved nations. Wales Public Affairs Officer Following distribution of the survey findings, I Dr Dai Lloyd, Chair of the Wales Health One of our core aims as a medical royal college in providing patient care, research, advancing Committee, has been in contact to further discuss RETURN TO is to work with governments, associated bodies, medicine and devising new treatments to fight RETURN TO the challenges facing the haematology workforce. opinion formers and decision makers to raise viruses, infections and diseases. At the same time Dr Dai Lloyd has also been very supportive of the CONTENTS awareness of the critical role pathology plays we also have to ensure that they are alerted to the CONTENTS

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The haematology laboratory minimised work- to hospitals, assisted in part by early reductions load by screening bone marrow biopsy requests in elective surgery and other non-emergency INTERNATIONAL from clinicians. When urgent biopsies were treatment. needed, these were moved away from clinical Educational and training activities including spaces to reduce contact with inpatients, and free conferences and seminars have been cancelled, Challenges for pathology laboratories up beds. Alternate tests to reduce contact were deferred or moved online. Medical students are performed, such as peripheral blood molecular restricted from wards and clinics, and students and tests rather than bone marrow assessments. Some residents are no longer permitted in the laboratory, during the COVID-19 pandemic: the lower acuity pathology tests were deferred to with weekly teaching rounds now held online. reduce workloads. Any consequences of delays in While these sessions are informative, virtual view from Australia diagnosis from deferred or reduced testing are not teaching cannot replace laboratory-based experi- yet known. ential learning and interacting with scientists and Professor Erica Wood pathologists. Examinations of the Royal College he pandemic has necessitated significant changes in how pathology laboratories Other operational issues of Pathologists of Australasia, and other specialist operate. Here, the experiences of microbiology and haematology laboratories Delivery of reagents and consumables was critical colleges, have been deferred. Long-term effects on from an institution in Melbourne, Australia, are summarised in three key themes. at this busy time – many are imported to Australia, junior scientists and registrars are not yet known. T with long supply lines. Fortunately, few interrup- Dr Michael Ashby Social distancing effects on laboratory Specimen collection, processing and reporting tions have occurred, but intensive management Conclusion operations Some specimen collection centres were closed and and contingency planning were essential. The coronavirus pandemic has required signifi- Our institution is a multicampus university consolidated to other sites, resulting in disrup- Urgent prioritisation of specific samples cant changes to workflow, sample collection and teaching hospital with over 2,150 beds. Strict tion for staff and patients. Non-urgent sample demanded clear communication of the processes processing within our laboratory. This has all been social distancing requirements have imposed limi- collections were reviewed and postponed where by pathology staff to the broader hospital and inten- during a period of increased workload but has been tations on staff and workflows in all workspaces. possible. At the same time, three new patient sive care units (ICUs) in particular, to ensure all made possible owing to the hard work, flexibility Where possible, clinical and laboratory staff have screening clinics and three staff screening clinics urgent tests were performed in-house. The opening and dedicated team efforts of all laboratory staff been separated, and working from home encour- were rapidly established to meet demand for coro- of new ICUs in new locations also required admin- involved. aged. All laboratory staff now work in discrete navirus testing. istrative support to ensure appropriate specimen teams without crossover, so that if members of one The microbiology laboratory rapidly imple- transport and processing. Dr Michael Ashby team became unwell, the laboratory would still be mented a new respiratory PCR assay to detect Changes in laboratory processes necessitated Haematology Registrar. Department of adequately staffed. Scientific staff either commence SARS-CoV-2. The dramatic increase in respira- new documentation, document control, communi- Haematology, Monash Health work earlier (6am) or finish later (11:30pm), tory swabs processed put significant pressure on cation and regular review as information became affecting sleep patterns and family time, including reagent and consumable supplies. This required available and guidelines changed. Major changes Dr Lucy Attwood Dr Lucy Attwood time available for care of quarantined children. changes in and validation of accepted swabs and in working arrangements generated significant Infectious Diseases and Microbiology Registrar, Splitting of shifts has required utmost attention to PCR extraction kits, as well as regular communica- workload for laboratory managers, for example Department of Microbiology and Infectious communication, with clear handover processes to tion with procurement to ensure ongoing supply. negotiating with staff and unions, ensuring change Diseases, Monash Health ensure tasks are not missed. Since PCR extraction kits used for the SARS-CoV-2 management acceptance, and organising rosters. In the microbiology laboratory, using every PCR were the same kits required for faecal path- Changes in work structure did impact staff morale, Dr Maryza Graham second bench ensures distances are maintained. ogen multiplex PCR and sexually transmitted especially early in the pandemic when anxiety Medical Microbiologist and Infectious Diseases Laboratory workspaces are separated, so that, for infection (STI) PCR, bacterial culture was used for levels and uncertainties were high. Physician, Department of Microbiology and example, molecular scientists do not interact with faecal processing and STI PCRs were sent to the To date, blood supplies have not been compro- Infectious Diseases, Monash Health bacteriology scientists during shifts. Additional reference laboratory. mised. Our hospital reviewed its emergency blood changes reinforce hand hygiene (lunch room The extraordinary number of swabs received management plans, but these have not needed Professor Erica Wood doors propped open, increased fixed alcohol hand (sometimes >1,500 additional specimens daily) activation. Australian Red Cross Lifeblood has Haematologist, Department of Haematology, rub availability) and breaks staggered to accom- was, at times, greater than our in-house analysis maintained adequate collections and supplies Monash Health modate maximum allowable staff in rooms at any capacity. Excess samples from less time-critical Dr Maryza Graham one time. Extra break rooms and dedicated outdoor requests were couriered to the state reference labo- spaces are available. ratory. Specimen triage increased scientific Microscope cameras and virtual meetings/ workloads and at times extra staff were called in screen sharing are used for reporting, such as to assist with specimen registration, packing and morphology and flow cytometry. Expanded use of transportation. technology including digital pathology has neces- Rapid reporting of new SARS-CoV-2 results sitated purchase and deployment of additional required coordinated input from scientists, infor- equipment for home use. mation technology and pathologists. There was Review of personal protective equipment constant pressure to expedite reporting of refer- requirements meant that some processes newly ence laboratory results; although these were required use of masks, gowns, goggles and transferred electronically to our laboratory infor- processing in biological safety cabinets. For mation system, our staff were required to sign out example, molecular staff are now required to wear these reports to ensure the correct results were N95 masks to process respiratory specimens, and uploaded. Testing off-site was much more time- RETURN TO therefore training in donning and doffing of these and labour-intensive than in-house, but essential RETURN TO CONTENTS masks was required. as a consequence of local reagent shortages. CONTENTS

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tape or queue stands to ensure a one-way flow of area, and a one-donor-only and donate-then-leave Reorganisation of mobile blood traffic and process. Donning of surgical face masks policy was implemented. After donation, blood was enforced for all healthcare workers and blood donors were reminded to notify the transfusion donors, who were provided with complimen- service if they became unwell or if they were noti- collections in the age of social tary masks if they did not have their own supply. fied as a close contact person of a COVID-19 patient. Strict hand hygiene was likewise enforced among Social distancing is now the new normal, even distancing: experience from Malaysia healthcare workers. Hand sanitisers were provided in blood collection. We will work hand in hand at entry and several points in the process flow for with our blood donors to provide a sustainable blood donors and staff. blood supply for our patients in the midst of the aintaining sufficient safe blood supply requires extensive community Screening counters were established to check COVID-19 pandemic. participation. This article describes the Malaysian perspective on maintaining donors’ body temperatures via non-contact essential transfusion services during the COVID-19 pandemic. infrared thermometer. Blood donors now had to Dr Christina Lee Lai Ling M complete an additional pre-donation question- Transfusion Medicine Specialist, Dr Christina Lee Lai Ling Malaysia was affected early, even prior to the in Malaysia, on 18 March 2020 further complicated naire requiring information on any potential risk Department of Transfusion Medicine outbreak being declared a pandemic. The first few donor recruitment activities. Blood donors were exposure. Restrictions were imposed, with no cases were reported in January 2020 with a surge apprehensive to come forward to donate blood accompanying person allowed into the donation in the following months. Over 800,000 blood in fear of exposure to COVID-19 and the penalty A local mobile blood units are collected annually for a population of 32 of travelling during the MCO period. An official donation set up with million, with about 60% of the blood donations announcement had to be made by the Minister of adequate distancing occurring at mobile collection sites. The ensuing Defence on 27 April 2020 to allay their fears and to and adherence outbreak resulted in blood collections dipping by reassure them that blood donors were allowed to to hygiene and 40% mainly due to cancellation of mobile blood travel during the MCO for blood donation. donning of PPE. collections. Reorganisation of mobile units In such uncharted waters, the transfusion services, as with other medical services, needed to reor- ganise and reinvent themselves to align with local societal norms. Social – or more correctly, physical – distancing has been the buzzword, with guidance for the maintenence of at least one meter distance between individuals in Malaysia to prevent droplet spreads. Lab Tests Online-UK: editors needed Several factors needed to be addressed during mobile blood collections to adhere to new require- ments. Space needed to be expanded. A space of Lab Tests Online-UK invites interested healthcare scientists, doctors and recently retired fellows to 60 m2 would have been considered adequate for join the voluntary team of editors for www.labtestsonline.org.uk a six-bedded mobile session but now needed to be expanded to 90 m2 to accommodate social Lab Tests Online-UK (LTO-UK) is written by practising laboratory professionals to help the public understand the distancing rules. Adequate ventilation and air many clinical laboratory tests that are used in diagnosis, monitoring and treatment of disease. It is supported by flow directions needed to be addressed. To ensure the Association for Clinical Biochemistry and Laboratory Medicine (ACB), the Institute of Biomedical Science (IBMS) optimal crowd control at donation sites, donation and The Royal College of Pathologists, and is entirely dependent on the efforts of unpaid volunteers. It is non- hours, target number of donors and process flows commercial and is consistently rated highly by patient associations and GPs as a trusted website. at mobile sites were carefully planned. Editing pages is interesting and plays an important role in helping patients understand the tests we perform. CPD points can be claimed as self-accredited points under the RCPath CPD scheme. Communication and new processes Communication is crucial during periods of Your role as an editor would involve the review of new and existing pages on the website about specific tests and uncertainty and anxiety. Information needs to conditions and the contribution to the articles for news feed. All specialties are welcome to apply and we have a be provided to blood drive organisers and blood particular shortage of editors with haematology, genetics and microbiology/virology expertise. donors on various precautionary measures imple- For more information, please contact: [email protected] mented by the transfusion services to allay their fears and encourage them to continue to donate blood. Prior appointments for donations were encouraged to prevent overcrowding. Further- more, travel authorisation letters were provided electronically to allow potential donors to travel An initial sense of trepidation among the during the MCO period. public led to cancellation of all planned mobile Other process changes included placing info- sessions by blood donor organisers and a reduction graphics at strategic points such as at the entrance in walk-in donors. The implementation of ‘lock- to advise donors on COVID-19 and blood donation. RETURN TO down’, called the Movement Control Order (MCO) The donation area was demarcated with barricade RETURN TO CONTENTS CONTENTS

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TRAINING FRCPath examinations during the COVID pandemic

ith the deferral of the Spring examinations because of the pandemic, the College reached out to trainees to ask their views on when and how Helen Melluish W examinations should restart. Friday 13 March 2020 will go down in the history Session intentions and candidate preparation of the College as the day that an entire examina- While the majority of respondents – approxi- tion session was deferred for the first time ever. mately 75% – expressed a clear interest in sitting Joanne Brinklow In the run up to this date, some overseas FRCPath the examinations as soon as possible (Figure 1), it Part 1 centres had reluctantly been cancelled, but should be noted that when candidates were asked it quickly became apparent that the entire session about their preparation for the examinations in Top to bottom could not be held as planned. Following discus- the current climate, just under half said they were sion at all levels of the College and agreement unable to undertake the preparations they would Figure 1: Respondents’ from the Trustee Board for a complete deferral, the have normally anticipated (Figure 2). This may plans for taking Examinations department began informing candi- have implications in terms of the Autumn pass FRCPath examinations dates, examiners and stakeholders. But what has rate and result in a higher proportion of candi- in the next 12 months. happened since, and how is the College facing up dates having to re-sit in Spring 2021 than would Figure 2: Respondents’ to the challenge of delivering examinations in the normally be expected. ability to work current climate? When analysed further, only 38% of UK-based and prepare for No sooner had the deferment of the exams respondents indicated that they will be able examinations. been announced than work began on exploring to prepare as they would normally, reflecting the options available for delivering a full examina- the significant changes seen in service delivery Professor Shelley Heard Figure 3: Autumn tion session later in the year. There are a number since the start of the pandemic. Although 26% of 2020 candidates’ of issues to consider in moving to online tests UK-based respondents have been deployed as a confidence at being of knowledge, including examination security, result of the pandemic, a slowing down of routine able to successfully sit accommodation of reasonable adjustments, virtual work across all other areas has meant that candi- an examination in the proctoring, oral examinations and internet connec- dates are not being exposed to the usual range of next 12 months. tivity, alongside safe social distancing where there cases in keeping with the curriculum. is a need for examinations to take place in person. The FRCPath examination is a rigorous test of Figure 4: Examination Furthermore, changes to the delivery of examina- knowledge and practice and it would be expected session preferences. tions for medical trainees require approval from the that, even in normal circumstances, asking candi- General Medical Council, so temporary approval dates if they felt confident about their ability to Figure 5: FRCPath as a applications must be drafted for submission. pass the exam would most likely provoke a range compulsory part To help us gauge the likely uptake of exami- of responses. Nonetheless, more than 50% of candi- of training for nations in Autumn 2020 and beyond, we carried dates feel not/slightly confident (Figure 3). This overseas candidates. Dr Sanjiv Manek out a survey of affected and potential trainees. may reflect not only the slowing down of routine The purpose of the survey was to contribute to the work or redeployment to a different area, but also planning process, alongside chairs of examiner the number of individuals adversely affected by panels in each specialty, about what could be done COVID-19 with respect to their personal circum- to deliver the examinations. Our survey received stances (e.g. COVID-related concerns, childcare, 1,285 responses. We have estimated that approxi- mental health, financial concerns). These factors mately 130 cellular pathology, chemical pathology can affect candidate preparation and confidence and medical microbiology and virology trainees and may have implications for pass rates over the will be delayed in training at a critical progression next few examination sessions. With the continued point at the upcoming Annual Reviews of Compe- need for more trainees to enter the workforce, it is tence Progression (ARCPs) and so it is imperative still a reassuring sign for the profession that over that we are able to adjust our examinations to meet 40% of candidates are confident or very confident this challenge. that they will be successful at their examinations in the next 12 months. RETURN TO Candidates should discuss with their educa- RETURN TO CONTENTS tional supervisors, training programme directors CONTENTS

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or equivalent the most appropriate timing for conditions such as dyslexia and other specific taking the examination, reflecting their personal learning disabilities (SpLDs), physical disabilities Digital pathology and safe workplace experiences during these challenging times. Candi- and pregnancy. While these accommodations can dates should be encouraged and supported in be implemented straightforwardly when examina- sitting their examinations at the earliest possible tions are delivered in the usual circumstances, the station awareness opportunity but should not feel pressured to sit impact on candidates of moving to a remote plat- any examination. form is uncertain at this stage. There will certainly t is important that workstations are optimised for digital pathology to prevent need to be consideration for delivering remote repetitive stress injuries and visual problems. This article analyses a survey Part 2 Histopathology and haematology written examinations for candidates with an SpLD of histopathology registrars in the West Midlands deanery. In the largest specialties – histopathology and who may require extra support with navigating the I haematology – consideration needs to be given software or oral examinations, and by video confer- Digital pathology has many benefits, including 36.4% were uncertain and only one person felt it to accommodating a potentially unprecedented encing for candidates with hearing difficulties who improved ergonomics compared with its more would not be helpful. number of candidates over the next six months. may rely on lip reading or other visual cues. The traditional counterpart – the light microscope.1 As The majority (54.6%) were uncertain, whether An ‘extended’ Autumn session is one option, as College has undertaken consultation work with Dr Leila Ahmed the era of digital pathology dawns on us and depart- regular occupational health checks would remote delivery of these two examinations is candidates who have previously requested reason- ments across the West Midlands are busy with the encourage them to embrace digital pathology, much less likely to occur given the dependence on able adjustments to the examination process to procurement of the technology required in their whereas 27.3% thought positively about it and practical microscopy. This would involve offering allow them to raise issues or concerns they may respective laboratories, an important aspect of 18.2% did not think it would help them embrace candidates the opportunity to sit their Part 2 exam- have over a move to remote examination delivery. digital pathology has been omitted. The workforce digital pathology. ination either in October 2020 or January 2021, but of the future, now trainees, have not been familiar- Although outside the remit of this survey, not both. Candidate preferences for sessions were Conclusions and the way forward ised with the workstation set up that maximises respondents were asked about how digital split more or less evenly between the two dates These are unprecedented and challenging times the improved ergonomics of virtual slides and pathology would affect their training and how (Figure 4). for all involved in the delivery of education and reduces the risks of computer and visual display any issues could be overcome. The responses A key issue is the availability and distribution of assessment. Across the majority of medical royal terminals syndrome, and eye and wrist fatigue. were mixed; 36.4% thought it would affect their examination materials, e.g. glass slides, which are colleges and faculties there has been a rapid push training, a similar number were uncertain and difficult to produce in sufficient numbers, with the towards online and remote examination delivery Method 27.3% did not think it would affect training at all. necessary quality and standardisation. In addition, that had perhaps been seen as a long-term project A survey was sent to West Midlands registrars who Several suggestions and comments on training the preparation and organisation of examinations for the future. COVID-19 is pushing these changes have been in training for at least one year (ST2 to and overcoming challenges were made as follows: Dr Bruce Tanchel with large numbers of candidates is challenging. rapidly up the agenda. Online examination solu- ST6) via a Google form. ST1 trainees were excluded • ‘More standardisation of using digital With COVID-19, the challenges are increasing, tions providers have also moved quickly to keep from the survey as they would not have had pathology across hospitals.’ since it is highly likely that an additional sitting pace with an ever-evolving landscape. Many organ- enough exposure to digital pathology. The survey • ‘Education and training.’ will be needed in order to run the examinations isations that had formerly only provided online was open for a period of 20 days (from 16 December • ‘Will not affect training negatively but will safely. question banking solutions are now working to 2019 to 4 January 2020) with reminders sent on day need to become a substantial part of training. offer remote delivery, either in test centres or on 10 and day 15 of the survey. Overseas candidates candidates’ personal devices. While these may be I feel that digital pathology will become more mainstream within the next few years and College examinations are also taken by a number challenging times for all involved in assessment Results will likely form the bulk of reporting practice of overseas-based candidates, for some of whom and examination delivery, it is also the time for the Of the 22 trainees invited to take part in the survey, within my later working life as a consultant the FRCPath forms a compulsory part of their College to modernise the examination process and 11 trainees responded. Of these, five were in ST3, histopathologist.’ training – approximately a third of applicants for deliver examinations in a way that is more reflec- three were in ST4, two were in ST5 and 1 was in ST6. • ‘I am uncertain if digital pathology will affect Spring 2020 (Figure 5). It is this group of candidates tive of trainees’ day-to-day life and practice. Exposure to digital pathology varied from less my training or not.’ who are likely to be most affected by restrictions than five hours to 5–10 hours. One person stated • ‘There are opportunities but very concerned in place as a result of the pandemic, given that Joanne Brinklow that they did not use digital pathology at all. Of about losing facetime with consultants when the future of international travel, visa issues and Director of Learning those who used digital pathology, 36.4% used it for they work from home, etc. Perhaps building imposed quarantine is uncertain. However, over- teaching purposes and a similar number used it for in an ability to video conference and live seas respondents to the survey felt that they were Professor Shelley Heard studying, while 18.2% used it for external quality demonstrate slides so trainees don’t miss out more prepared to sit the examination (70%) than Vice President of Learning assessment. Only one ST5 (specialty trainee) and on supervision time would be good. Am sure UK-based respondents (54%). Remote delivery of one ST3 did digital reporting and they spent five there are other issues, but this is a big one I’m examinations would be of particular benefit to this Dr Sanjiv Manek hours and one hour on it per week, respectively. worried about that needs to be planned for group of candidates at the Part 1 level, but the Part Clinical Director of Examinations Four of the respondents (36.4%) were aware and not just brushed aside in a forward march 2 examination format does not necessarily lend of the ergonomics of the workstation. The rest to digital regardless of consequences.’ itself to this approach. Candidates are advised to Helen Melluish were either unaware (36.4%) or uncertain about it consult the travel advice being issued by both the Examinations Manager (27.2%). UK government and the government of their own The majority (54.5%) thought they would need Discussion and action plan country before making any travel arrangements to support with the workstation set up when digital It appears that very few trainees in this albeit rela- sit the FRCPath examinations. pathology is introduced in their respective depart- tively small survey are aware of workstation set ment. The rest (45.5%) were uncertain. No-one said up in digital pathology. The wrong set up can lead Remote examination delivery and reasonable that they would not need support with worksta- to repetitive strain injuries such as computer and adjustments tion set up. visual display terminals syndrome, which encom- The College receives and implements a number When asked about whether workshops on the passes visual blurring, dry eyes, musculoskeletal RETURN TO of requests each session for reasonable adjust- RETURN TO ergonomics of digital pathology and health and symptoms such as neck pain, back pain, shoulder CONTENTS ments to the examination process to accommodate CONTENTS safety would be helpful, 54.5% felt that it would, pain and carpal tunnel syndrome, psychosocial

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Clockwise from top left Creating e-learning modules for Figure 1: Percentage of trainees familiar with ergonomics of Uncertain undergraduate medical students 27% the digital pathology Aware workstation. 37% racticing laboratory skills is vital for all pathology specialties; however, gaining Uncertain Figure 2: Percentage of 46% access to labs can be problematic. Here, Sabrina Fudge and Edward Moseley Need trainees anticipated to support P describe how they created an educational video to give students an insight into require support with 54% laboratory practice and test their knowledge. workstation set up. The environment in which medical students learn importantly, objectives needed to be practical to Figure 3: Percentage has changed significantly, with the internet now deliver at the medical school level. Dr Sabrina Fudge of trainees’ views Unaware a dominant tool in medical education. Online Planning began in the form of a story board, regarding workshops 36% learning, or e-learning platforms, are now increas- a visual representation of the shot of each scene on ergonomics of ingly utilised by medical schools, and have been in the video. The ‘story’ approach was taken digital pathology and found to possess distinct advantages over tradi- following the admission of a patient with sepsis health and safety. tional didactic models. E-Learning encourages of an unknown source. The video started with the students to exert greater control over their educa- journey of a blood culture and urine specimen Figure 4: Percentage tion by allowing flexibility over content and pace, to highlight the significance of the laboratory in of trainees’ as well as the facilitator being able to update mate- processing samples and ultimately advising clin- views regarding Will help Helpful rial in a timely manner to ensure delivery of the ical and laboratory colleagues on investigating occupational health 27% 30% latest evidence-based content.1 and treating all types of infection. Our patient was checks helping them A key feature of medical microbiology and identified to have urinary sepsis with an extended to embrace digital infectious disease training is spending time on spectrum beta lactamase-producing organism. We pathology. Uncertain the wards in intensive care units and outpatient used this aspect of the video to highlight the impor- 50% Uncertain 55% Dr Edward Moseley clinics, and this aspect is incorporated into the tance of ensuring that antibiotics were prescribed undergraduate curriculum. However, exposure to and used appropriately, by advising on patient Will not laboratory practice is more challenging. Tradition- management. Follow-up questions were posed help ally, teaching of medical students at the University based on the information provided in the video, Unhelpful 18% 20% of Bristol comprised a site-specific tutorial deliv- again verifying knowledge required at a medical ered in the form of a laboratory journey, where school level. medical students had an hour-long guided educa- The laboratory presents an ideal environment tional tour of the lab. During the tour there were for independent and active learning. A video tuto- opportunities to discuss the best samples to collect rial with questions can facilitate recapitulation of factors, venous thromboembolism, shoulder tendo- Workstation set up can be introduced as part to diagnose an infection, with subsequent advice 2 nitis, and elbow epicondylitis. These factors may of the local induction process, either as an online about how to treat based on the results. However, Right: Recording contribute to an overall decline in performance module or face to face. Surveys or audits to ensure the feedback received highlighted that the lab e-learning modules. and an increase in sickness-related absences. these procedures are being followed should be tour presented difficulties for a variety of reasons, According to the Health and Safety (Display undertaken by junior trainees and a lead person including the number of students in the lab at any Screen Equipment) Regulations 1992, employers in ergonomics should be available to discuss any one time and logistical issues for the department are obliged to pay for a regular sight test if you concerns. with the number of times the tutorial has to be request one and you are a display screen user. The Finally, Health Education England and educa- delivered. From an educational point of view, there regulations state that if the sight test shows that tional supervisors need to address the implications was also potential for variation according to the you need special corrective lenses specifically of the introduction of digital pathology for training, site used and the clinician leading the tour. for working with a display screen, the employer with appropriate learning needs incorporated into In the last couple years, microbiology and 3 is obliged to pay for them. Hence, occupational training programs. pathology laboratories have undergone signifi- health should have an active role in engaging with cant reconfiguration and the majority of them are trainees and encouraging them to attend at least Dr Leila Ahmed now located in a central hub, further highlighting yearly sight tests. ST5 Senior Histopathology Registrar, University the need to adapt the current teaching format. To Every department should have a standard oper- Hospital Birmingham ensure all students receive the same learning expe- ating procedure booklet outlining how to set up rience, we created an educational video within an workstations featuring correct seating position, Dr Bruce Tanchel e-learning module, incorporating all the learning screen positioning and lighting. Frequent breaks Histopathology Consultant, University Hospital objectives from the undergraduate medical curric- from the computer screen should be encouraged Birmingham ulum. The starting point was aligning the way to decrease the risk of computer and visual display the current pathology service is delivered with terminals syndrome. the current General Medical Council guidance on defining key learning outcomes that will be a RETURN TO RETURN TO meaningful addition to medical graduates. More CONTENTS CONTENTS

158 July 2020 Number 191 The Bulletin of the Royal College of Pathologists www.rcpath.org Number 191 July 2020 159 TRAINING TRAINING

information around basic science and also applica- the e-learning programme helps students with which is currently still being performed on glass. through triaging, with most slides being scanned tion to a clinical context. decision making and reacting accordingly when However, the situation might change in the future by default at low magnification, which takes less Pathology is changing rapidly and teaching encountering a real-life situation. Overall, we hope as the College is currently reviewing the feasibility time, while slides with inflammatory lesions or methods need to change with it. As a former that medical educators will continue to engage and practicalities of making the exam digital. those for dysplasia assessment get scanned at a medical student, and now a teaching clinician, I with e-learning to provide innovative approaches high magnification. However, with future techno- can confirm that these new educational methods to training medical students. Validation and scope of practice logical advancements, the time required for high are appreciated and have the potential to provide The guidelines specify that validation should be magnification scanning might become faster and better engagement compared with traditional References available on our website. restricted to a particular scope of practice. However, thus negate the need for triage. didacticism. It is expected that some sections of the trainees are required as part of their training to The final challenge I came across was the lack course will need some revisions or enhancements. Dr Sabrina Fudge rotate through different specialties and institu- of medical-grade calibrated monitors for trainee Participants and tutors will review the content and Dr Edward Moseley tions to fulfil the requirements of the curriculum, computers. Although there are currently no agreed feedback will help propose new ideas and adapt SpR Medical Microbiology and Infectious and the resulting repetitive and frequent revalida- specification standards for digital pathology learning methods. Assessing the impact by ques- Diseases, North Bristol NHS Trust tions can be off-putting for trainees. A solution to viewing monitors or computer systems, should tionnaire, we will endeavour to track whether this may be the development of a general-themed these become defined in the future, the required digital validation training set for trainees. equipment will need to be provided. However, some departments, and particularly those that have recently adopted digital pathology, Conclusion might lack training sets. Training sets are supposed Although my digital pathology validation expe- Digital pathology validation for to demonstrate the frequently encountered pitfalls rience might not be representative, there are of digital pathology and are an important step in numerous potential hurdles that trainees could the validation process. To compensate for this face when attempting digital pathology validation. trainees: the good, the bad and the ugly when undertaking my own validation attempt, I These will vary according to the training settings read about the limitations and issues identified in and locations. Nevertheless, these need to be antic- n this article, Dr Ben-Mussa reflects on his own experience of digital pathology the literature and ensured I had ample experience ipated and dealt with to comply with the RCPath validation, discussing the challenges he faced and offering potential solutions. of making diagnoses on digital slides through the guidelines and to avoid putting off trainees who use of public and private slide repositories. The will be at the forefront of the digital transition I availability of testing sets could certainly be an phase. This raises the question of whether there issue for some trainees, which could be overcome is a need for a local, regional or national trainee Background 2018 guidelines from the perspective of a histo- by regulatory organisations or scanner manufac- digital pathology representative or lead to voice The widespread utilisation of whole slide imaging pathology trainee in a district general hospital in turers providing departments with these while concerns on behalf of trainees and help implement in day-to-day histopathology practice is on the Northern Ireland. Dr Ben-Mussa they develop their own localised sets over time. solutions. horizon. This brings great opportunities for improving daily practice such as streamlining Digital pathology revalidation reflections Workload issues and equipment support Acknowledgements the workflow, allowing flexible distant working, The general diagnostic performance issues of The extra time required for sign-out can be a chal- I would like to express my gratitude and appreci- creating a better work environment, providing a digital pathology highlighted during my validation lenge since all slides need to be reviewed twice on ation to Dr Michael McKenna for facilitating my seamless platform for consultation and teaching, were comparable to those reported in the litera- glass and digital. Moreover, the process of scanning digital pathology access at the Histopathology and facilitating the use of image analysis software ture such as tiny structures (fine nuclear details slides and post-scanning image quality assurance department in Altnagelvin Hospital and for all the that can assist with mundane tasks such as meas- for dysplasia evaluation, inflammatory infiltrates, adds extra stages to the lab workflow and affects support and encouragement. uring, counting and scoring.1 lymph node assessment and Helicobacter organ- slide delivery times. This could be compensated However, the transition to digital is a monu- isms) and out of focus areas.6 However, there are for by reducing the number of cases/points given References available on our website. mental task2 and the process has encountered a additional challenges and obstacles that trainees to the pathologist during the validation period. wide range of attitudes from enthusiasm to scep- face when undergoing the validation process. Streamlining the workflow can also help reduce Dr Ben-Mussa ticism,3 with a clear need to address areas of These are discussed here, with some suggestions the delays, although this could have potential ST6 Histopathology, Institute of Pathology, concern, including provision of quality assurance. on how could these be remedied. implications on laboratory workload and staffing Belfast Health and Social Care Trust Initiatives have been put forward by professional requirements. Another way of reducing time is pathology regulatory organisations with publi- Professional expertise to undertake cation of guidelines for adopting the technology, validation: role of trainees training users and undertaking validation. The Currently, validation presumes that the validating first guidelines were produced by the College of user has professional expertise. The rationale for American Pathologists (CAP) in 20114 and these this is that the process is supposed to assess the were followed by UK guidelines from the Royal quality of the tool rather than diagnostic skills. College of Pathologists (RCPath) in 2018.5 Although this can be perceived by some trainees While the development of these guidelines as a barrier, the College guidelines endorse trainee is a positive step forward, engagement of early validation if taken as part of a supervised training enthusiastic users and prospective adopters from experience. In my opinion, this should ideally consultants to trainees is key to a successful tran- be done during the later years of training when sition and implementation. This would help in trainees are more confident and capable of making gauging real-life workplace barriers and help diagnoses before the consultant sign-out. This can bring more of those who are reluctant or sceptical be problematic for departments that have gone RETURN TO on board. Below are reflections from my digital fully digital as trainees will still need to use glass RETURN TO CONTENTS pathology validation attempt using the RCPath during training and for the final exam preparation, CONTENTS

160 July 2020 Number 191 The Bulletin of the Royal College of Pathologists www.rcpath.org Number 191 July 2020 161 CLINICAL EFFECTIVENESS

Patient safety has now taken on a heightened of circumstances, we must protect our patients and meaning and appreciation for us; on the one hand, promote their safety. That is why as a profession CLINICAL EFFECTIVENESS we are joining our other clinical colleagues in what- we are all uniting behind this effort. ever capacity we can to help patients and save lives. The COVID-19 pandemic has caused fear and But on the other, we are potentially facing the pros- uneasiness both in the general population, but What does patient safety in pathology pect of doing clinical tasks that we may not have also in the healthcare system. Suddenly, this has performed for several years. The difficult question not just become a matter of protecting the safety is where to draw the line. We must act within our of a few patients, but has become a matter of mean to me? competencies, and ‘first do no harm’. Whatever we protecting the safety of a population. Patient safety can do will make a difference. has become pertinent for each and every member atient safety awareness week ran 8–14 March and the College invited applicants Not only that, pathologists and laboratory staff of this planet. We all now have a responsibility to to submit essays describing what patient safety in pathology meant to them. have had to adapt very quickly to being able to help to ensure that. meet the demand for accurate and reliable testing. Read on for the thought-provoking winning essay by Dr Matthew Clarke. P However, we must also balance the fight against Dr Matthew Clarke Patient safety in pathology is very important to me. potential for harm had they not been identified the infection with maintaining the high standards Histopathology Clinical Fellow, Institute I consider it to be the foundation upon which all early. No pathologist sets out to cause harm to a of our usual diagnostic practice, e.g. cancer diag- of Cancer Research (ICR), Sutton, London my work is built. Anybody who works in pathology patient, but sometimes errors happen. The impor- nosis. Ultimately, even in these most challenging Dr Matthew Clarke will set out to work each day with this goal under- tant part is being open and honest about these pinning everything they do; it may not specifically errors; personal reflection is essential but also be in the forefront of their mind, but it drives the discussing them with our peers and colleagues to workflow, effectiveness and efficiency of our daily derive learning points so that others can learn and practice. Without an awareness and engagement prevent them happening again becomes a crucial Antibiotic prescribing following a with patient safety, we would not be able to boast part of ongoing training. the vital role that pathology plays in the diagnosis Pathology may not be as patient-facing as other positive Clostridioides difficile result and management of so many conditions across all specialties (depending on which subspecialty you the medical and surgical specialties. work in) but that does not diminish the responsi- An appreciation of the importance of patient bility for patient safety awareness and engagement. Background Aim and objectives safety has been embedded in me since my studies The pathologist is often the first stop on the diag- National treatment guidance for the management This audit will compare prescribing of at medical school. The idea of ‘first, do no harm’ is nostic pathway for a patient, and although they of Clostridioides difficile infection (CDI) recommends cephalosporins and clindamycin at UCLH in non- something every medical student in the country may not meet them face-to-face, they have a crucial the avoidance of clindamycin and second- and neutropaenic patients following a positive result will be familiar with. Throughout our education role in helping the patient on their onward journey third-generation cephalosporins, as well as mini- of either C. difficile antigen only or antigen plus and training, whether that be learning how do a to the correct treatment and hopefully a positive mising the use of fluoroquinolones, carbapenems toxin with the national standard. particular patient examination or how to identify outcome. The decision between benign and malig- and prolonged aminopenicillins.1,2,3 a particular disease by looking at the histological nant, the type of tumour or determining if there There have been numerous observational studies Standards and criteria features, we are all learning this to try and avoid is any evidence of disease at all weighs heavily demonstrating an association between C. diffi- The following criteria and standards were set: making a mistake that may ultimately lead to the on a pathologist’s shoulders. Experience helps cile diarrhoea and the 4C antibiotics (clindamycin, harm of patients. this pressure to lighten with time, as you begin to • criterion 1: 100% of patients with a posi- cephalosporins, co-amoxiclav and ciprofloxacin). One other point that I learnt very early in my trust more in your judgement and interpretation. tive C. difficile toxin result should remain A multilevel case-control study found third- and medical career is that one day, no matter how hard However, for trainees and those who have recently clindamycin- or second- or third-generation fourth-generation cephalosporins and carbapenems and how consciously you try to avoid it, something become consultants, it is the fear of the impact that cephalosporin-free during their hospital stay increased the risk of acquiring healthcare-associated will go wrong. I remember listening to a talk by an error may have on patient safety that makes the • criterion 2: 100% of patients with a positive CDI.4 Another cohort study found that restricting one of our senior lecturers within the first week of reporting process particularly daunting and drives C. difficile antigen should remain clinda- clindamycin reduced CDI rates by 88%.5 The Probi- medical school, informing us that at some point we us to maintain high standards of practice. This is mycin- or second- or third-generation otics for Antibiotic-Associated Diarrhoea (PAAD) will all get sued for a mistake. This statement had why engagement with independent reporting at cephalosporin-free during the same hospital study found co-amoxiclav was associated with a a profound impact on the audience; despite doing an early stage is such a crucial part of training for stay greater risk of antibiotic-associated diarrhoea (AAD) your best to help people, there is also a negative pathologists. • criterion 3: 100% of patients with positive compared with other antibiotics.6 side for all those involved. The realisation that one As I reflect on patient safety in pathology, we are C. difficile results should complete treatment Despite the results of a systematic review in day it will happen was very sobering. in the initial stages of the mounting pandemic of durations in accordance with national and 2003 demonstrating an association between diar- Errors and mistakes also happen in daily COVID-19. I have read extensively about the 1918 local guidelines rhoea and 4C antibiotics, the review was unable to pathology practice, which may not lead to a influenza pandemic and now we are witnessing a • criterion 4: 100% of patient outcomes relating establish whether this was causal owing to meth- lawsuit, but may affect patient safety nonethe- scenario that has many similarities, a very surreal to positive C. difficile toxin result and/or posi- odological flaws in many of the studies.7 less. I remember attending a talk by Henry Marsh feeling. A few days ago, I received an email from tive antigen should be recorded and reviewed. Local trust policy at University College London and a comment that he made had a vivid impact; Health Education England asking if I would be Hospital (UCLH) lists the antibiotics above as those ‘every doctor has a graveyard of cases and from prepared to pause my OOPR to help in the fight Method that exacerbate C. difficile diarrhoea, although time to time in their moments of quiet, they go and against the infection. It took me all of one second to Sample it does not recommend avoidance per se. In the sit on a bench in the graveyard and reflect upon say ‘yes’. In the last 24 hours, I have been informed The sample comprised 67 non-neutropaenic financial year 2016–2017, UCLH had 256 cases of C them’. I myself have cases that I have been a part of I will be working at the Nightingale Hospital in patients listed on the mandatory reporting list with difficile toxin and antigen, of which 22 were classi- throughout my career that continue to haunt me London. Many other pathology trainees across a first positive C. difficile result (either antigen or fied as recurrences. RETURN TO and refuse to be quietened, not necessarily because the country have also been redeployed to clinical RETURN TO toxin) during September 2016 to September 2017. CONTENTS I have done something wrong, but because of the practice. CONTENTS

162 July 2020 Number 191 The Bulletin of the Royal College of Pathologists www.rcpath.org Number 191 July 2020 163 CLINICAL EFFECTIVENESS CLINICAL EFFECTIVENESS

The sample size was calculated based upon a total 4C antibiotics often had complex histories, such as Table 1: Results of the audit Action plan population size of 256 patients: 71 patients would cancer or chronic diseases (e.g. Crohn’s and enteral 1. Review urology and surgical prophylaxis provide a representative sample based upon a nutrition), and antibiotics were used to treat aspira- Criterion Compliance (%) guidelines to reduce cephalosporins/clinda- 12-month population and would give a 90% confi- tion or hospital-acquired pneumonia or urosepsis. Criterion 1: patients with a positive 84.6% (22 of 26) mycins by December 2020. dence sample with 10% error margin. This sample Many of these patients were inter-hospital trans- C. difficile toxin result should remain 2. For ITU/surgery patients, generate a daily list was randomly drawn from a line list of the wider fers, long stay patients and went through intensive clindamycin or second or third of C. difficile patients on ITU and review 4C population (every fourth patient). Owing to time care. There was not one particular specialty asso- generation cephalosporin free during antibiotics on daily round by August 2020. limitations, data from 67 patients was included in ciated with 4C antibiotic prescriptions other than their hospital stay. (Standard = 100%) 3. Develop an elderly care antibiotic section on the final sample, which approximates the required ITU, but gastrointestinal or urology intervention Criterion 2: patients with a positive 76.9% (30 of 39) the trust antibiotic policy that avoids 4C anti- sample size. was a recurrent theme. C. difficile antigen should remain biotics by December 2020. It is concerning that symptoms of diarrhoea clindamycin- or second- or third- 4. Review patient leaflets to include 4C anti- Inclusion and exclusion criteria were exacerbated in 22.4% (15 of 67) of patients generation cephalosporin free during biotics and encourage patients to challenge All patients with a positive C. difficile toxin result or who received cephalosporin or clindamycin. Most the same hospital stay (Standard = these prescriptions when they have a known antigen result from September 2016 to September of these patients received short course therapy, 100%) history of C. difficile disease by December 2020. 2017 were included. Exclusion criteria included: suggesting that the agent and not just the duration Criterion 3: patients with positive Metronidazole: 65.0% (26 of 40) 5. Encourage registrars to discuss severe C. diffi- clinical specialty listed as haematology and antibi- of antibiotic are important. C. difficile results should complete cile cases at the daily departmental clinical Vancomycin: 80.8% (21 of 26) otic prescribing data from intensive care unit stays Of the overall sample, 19.4% (13 of 67) relapsed treatment duration in accordance with meeting if they are not being reviewed on a (unavailable on electronic prescribing system). (symptom recrudescence within three months). national and local guidelines (Standard consultant round by August 2020. Nine of the 13 patients (69.2%) had received a ceph- = 100%) 6. Identify clear follow-up triggers to include Data collection alosporin or clindamycin following a positive result Criterion 4: patient outcomes relating Overall all-cause mortality: 19.4% (13 in the initial registrar phone call, which can The following clinical data was collected: during their hospital stay. This suggests these antibi- to positive C. difficile toxin result and/or of 67) be embedded in the C. difficile smart text/ otics may have contributed to symptomatic relapse. electronic proforma, e.g. if a patient is due • demographic data positive antigen should be recorded and Only 3.0% (2 of 67) of the sample were readmitted Worsened diarrhoea: 22.4% (15 of 67) antibiotics/scheduled for surgery, please ring • dates of samples and results reviewed (Standard 100%) to UCLH owing to C. difficile within three months to discuss prophylaxis by August 2020. • classification of severity of C. difficile infection Relapsed: 19.4% (13 of 67) of of a positive result. Neither of these patients had (mild, moderate, severe), according to Public whom 69.2% (9 of 13) had received received cephalosporins or clindamycin. However, Re-audit date Health England (PHE) guidelines clindamycin or second- or third- it should be noted that this figure excludes re-admis- September 2020. • antibiotics prescribed before, during and after generation cephalosporin sions to any other hospital in the country and may first C. difficile result and policy compliance not represent the whole picture. Readmitted to UCLH: 3.0% (2 of 67) Addendum • use of clindamycin and second- and third- The advent of COVID-19 has disrupted the schedule generation antibiotics following a positive positive C. difficile result and metronidazole compli- Further observations of the action plan. However, considerable progress result within the same hospital stay ance. Critical care, surgical and geriatric wards are During their inpatient stay, 43.8% (28 of 64) of our had already been made in reducing C. difficile infec- • adverse patient outcomes, such as mortality areas to prioritise in terms of volumes of positive sample went to critical care. This is a high figure with tion. A C. difficile taskforce group led and monitored and readmission due to C. difficile within three results. Patients with known C. difficile need to be many plausible associations, for example frailty and the reduction plan, particularly focusing on the months, and relapse of C. difficile/re-prescrip- flagged up for microbiological discussion to ensure increased use of broad spectrum antibiotics, proton use of root cause analysis results and early diag- tion of C. difficile antibiotics within three prophylaxis and treatment options are reviewed. pump inhibitors, antipseudomonal antibiotics (e.g. nosis. A weekly review of patients by infection months. ceftazidime and ciprofloxacin) and parenteral nutri- control and microbiology facilitated early inter- Recommendations for improvement tion. However, this provides an opportunity to focus vention to avoid recurrences and failed treatment. Results There have been a number of changes to C. diffi- C. difficile stewardship on this area. In 2018/2019, total hospital-acquired toxin positive The results of this audit are shown in Table 1. cile management at UCLH since 2016–2017. These Of the sample, 36.9% (24 of 65) had surgery cases decreased to 56 against an objective of 96. include a consultant-led weekly C. difficile ward during their inpatient stay. Gastrointestinal and Commentary round, the introduction of UV terminal cleaning, urological surgery were common. ‘Dirty surgery’ References available on our website. 15.4% of patients with a positive C. difficile toxin the use of C. difficile polymerase chain reaction is associated with broader antibiotic prophylaxis result and 23.1% of patients with a positive as first-line testing and a Trust-wide IT overhaul and treatment. Alternative antibiotic prophylaxis Emma Wiley, Guan Hui Tricia Lim, Mariam C. difficile antigen result received a second- or third- of the EPIC electronic health record system with for patients with C. difficile could be considered, e.g. Ahmed, Ben Eliad, Alexander Chatburn, Sabaa generation cephalosporin or clindamycin during organism alerts. C. difficile numbers have signif- teicoplanin, metronidazole and gentamicin. Gauhar, Howell Jones, Surjo De, Frances Davies the same hospital stay. Most prescriptions were icantly decreased and it is likely that some of and Peter Wilson compliant with national guidance, but the excep- these changes will already have improved clinical Limitations tions are an area for improvement. The lack of management and outcomes for patients. However, The data is limited by the exclusion of critical care a flagging system on the Trust’s old electronic there have been no specific changes to critical care prescribing and emergency care, which are areas of patient record and the availability of cephalo- C. difficile reviews and a re-audit will be desirable. high antibiotic use. Death certificate data would sporins and clindamycin on the Trust’s antibiotic provide a better understanding of mortality attrib- policy may have contributed to these results. utable to C. difficile infection; however, there were Three patients (0.04%) received a cephalo- no serious infection review meetings naming C. sporin or clindamycin following relapse and 18 difficile as a cause of death during the audit period. patients (26.9%) received a 4C antibiotic after a positive C. difficile result. Of the 18 patients who Conclusion received a 4C antibiotic, six (33.3%) tested positive Compliance with national guidelines is good for toxins, eight (44.4%) tested positive for anti- overall but there is room for improvement, particu- RETURN TO gens and four (22.3%) were unknown. Thematic RETURN TO larly with the prescribing of antibiotics after a CONTENTS review indicates that the patients who received CONTENTS

164 July 2020 Number 191 The Bulletin of the Royal College of Pathologists www.rcpath.org Number 191 July 2020 165 people

PEOPLE Appreciation: Dr Denis Raymond Stanworth Appreciation: Professor Denis Stanworth (1928–2020), a retired immuno- chemist who spent his entire academic career at Frances Kate Gould the University of Birmingham, has died aged 91. He was a major international figure in immunology Professor Frances Kate Gould died on 27 March and a pioneer in the study of immunoglobulin 2020. She joined The Newcastle upon Tyne structure and function. Hospitals NHS Foundation Trust as a consultant Denis graduated with a degree in chemistry microbiologist in September 1988 and remained from the University of Birmingham, where he also there throughout her career. Between 2013 and earned a PhD for his work on the physicochem- 2017, she was the Lead Public Health Microbi- ical characterisation of reagin to horse dander, ologist for Public Health England. ‘Prof’ was an under the then Head of the Department of Exper- all-rounded microbiologist who was passionate imental Pathology (the late Professor John Squire). about her craft, particularly infection prevention This seminal work on reagins during the 1950s put and control. She was a fount of microbiological him in a key position to participate in the momen- knowledge and shared her brilliance widely around tous events that culminated in the discovery of IgE. the laboratory and hospital wards. She possessed In his lab in Birmingham, he carried out the func- an uncanny sixth sense, which meant she often tional characterisation of a rare myeloma protein, identified a source of infection or outbreak long IgND, which was discovered in 1967 by Johansson before the agar plates. Prof maintained a high clin- and Bennich. He found that IgND could block the ical profile and was well known throughout the Prausnitz-Kustner test for reagin and this activity Denis’s lab in Birmingham was a magnet for wards and multidisciplinary team meetings for her was mediated by the Fc fragment. In 1968, the young and seasoned immunologists from all over the expertise but also her unique dress style and flam- World Health Organization named IgND and its world and he would normally have a dozen national- boyant nature. equivalent γE, described by the Ishizakas, the fifth ities represented in his lab at any one time. Denis had Prof Gould was an immense educator human immunoglobulin class, IgE. a defining and lasting impact on the careers of many possessing ‘infinite’ patience, until it ran out! She In the decades that followed, Denis continued immunologists around the world, including us. We taught about microbiology wherever she went – his interest in the molecular pathology of IgE, were all PhD students of Denis’s and, like many of dispensing antibiotic and infection control advice describing a candidate vaccine peptide derived his students, we owe Denis an immense debt of grati- but also explaining the science and principles from the Cε4 domain of IgE that might be used in tude for his guidance and advice, for the rich research behind her recommendations. ‘Let’s keep it simple’ blocking certain allergic reactions. This approach discipline he instilled in us and for the continuing helped many a trainee. She provided unwavering was initially dismissed; however, when the crystal friendship we shared over several decades. support to those she trained: infection preven- Prof Gould was highly respected in the academic structure of the entire IgE-Fc region was solved, In the late 1990s, Denis was awarded a special tion and control nurses, scientists and medics. world. She published widely and lectured on a it was found to be acutely bent, and that the Cε2 professorship by the University of Nottingham in It was a real privilege to be trained by her. She wide range of microbiology topics with research domain contacted the Cε4 domain – in the very recognition of his exceptional and long-standing leaves behind a generation of microbiologists well interests including solid organ transplantation, in region of Denis’s peptide. We now know that contribution to the science of immunology and in equipped to apply scientific principles to solve vitro activity of antibiotics and laboratory-based the bent IgE-Fc conformation is critical for high- particular to our understanding of allergies. Denis clinical problems. research into biochemical substrates for bacterial affinity receptor binding, and thus antibodies spent his retirement years in his beloved Malvern, Prof Gould held numerous positions locally, isolation. Prof Gould was a founding member of raised to the peptide, binding to this region of Cε4, Worcestershire, and was an avid listener to the nationally and internationally. She was active Newcastle’s successful cardiothoracic transplant would undoubtedly interfere with the bending, music of its famous son, the English composer Sir in the International Society for Heart and Lung service. At a time when everything was new she perhaps ‘unbending’ the IgE-Fc. Edward Elgar. Denis will be sorely missed by his Transplantation. She served in many roles at the ensured microbiologists and laboratory testing Early in his career, Denis spent a year working family and friends. His wife Barbara passed away College over the years, including Chair of the were at the centre of the transplant service. in Ed Franklin’s lab in New York where he raised in 2013 and he is survived by his two daughters, Microbiology Specialty Advisory Committee, Prof Gould’s love of microbiology meant she antisera against paraproteins, which were, for Deborah and Sarah, and four grandchildren, David Elected Council Member and Chair of the England continued working during her final illness. She was the first time, capable of distinguishing the then and Elizabeth, and Daniel and Francesca. Regional Council. Prof was a member of the British an inspiration to many. Her death has left a huge known classes of immunoglobulins (IgG, IgM and Society for Antimicrobial Chemotherapy (BSAC) void not just in Newcastle and the North East, but IgA) immunochemically. During the 1970s and Farouk Shakib, Emeritus Professor of for over 30 years. She served on the BSAC Council throughout the UK microbiological community. 1980s, Denis published extensively on human Experimental Allergy, University of Nottingham numerous times over the years. At the time of We will miss her friendship, kindness, incisive wit IgG subclasses (particularly IgG4) and his inter- her death, she was Education Secretary and was and dry humour. She was one of the ‘greats’ and ests expanded into the biology and functions of Keith James, Emeritus Professor of Immunology, the current serving General Secretary and Senior totally unreplaceable. immunoglobulin-interacting cells, especially mast University of Edinburgh Editor on the Journal of Antimicrobial Chemotherapy. cells, macrophages and B cells. He also developed Christopher S Henney, Former Professor She was a formidable and brave leader who would Dr Alice Wort broad interests and expertise in the role of rheuma- of Immunology, University of Washington always stand her ground. She was an effective Consultant Microbiologist, Gateshead Health toid factors and complement in immune complex RETURN TO Chair, overseeing highly productive meetings that NHS Foundation Trust RETURN TO formation and how these elements contributed to David W H Riches, Professor, Pulmonary Sciences CONTENTS always ran to time. CONTENTS the development of rheumatoid arthritis. & Critical Care Medicine, University of Colorado

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interest in medical history from his undergrad- appreciation should be those of one of them. Appreciation: Dr Michael Gerald Rinsler uate days and indeed was founder of the Society for In 1998, after Michael suffered a stroke, John the History of Medicine at King`s College Hospital Anderson (President, 1978-1981) wrote to him: ‘I Medical School. He carried that interest into retire- am one of many people who benefitted from your Dr Michael Rinsler died in November 2019, aged 92. ment but with a wider scope of more general wisdom and generous help at the College. I believe He made a major contribution to the development historical reading. that you have contributed more than anyone else and organisation of British pathology over the Michael served with eight Presidents of the and am most grateful for the help you gave me.’ last two decades of the twentieth century. He was College to whom he gave high quality support, successively Council member, Registrar, Vice-Pres- coping admirably with their very different person- Professor Gerard Slavin ident and Director of Studies of the Royal College alities. It is fitting that the final words of this Professor Jangu E. Banatvala CBE of Pathologists, serving from 1976 until 1998 when illness forced his retirement from College activ- ities. He was involved in the delineation of new specialties in pathology, the progressive changes in the examination system and many other facets Appreciation: Professor of laboratory medicine which we now take for granted. Mohammed Sami Shousha Michael qualified in medicine in 1950, training at Cambridge and King`s College Hospital Medical Professor Mohammed Sami Shousha, a consultant School London. After house officer posts and histopathologist, clinical lead for the breast national service he entered pathology winning a histopathology service at Imperial College Leverhulme Research Scholarship to study aldos- Healthcare NHS Trust and honorary professor of terone metabolism in pregnancy, the basis of his histopathology at Imperial College London, died doctorate. He was appointed consultant chem- on Thursday 2 April 2020 during the COVID-19 ical pathologist at St Stephen`s Hospital, Fulham pandemic at the age of 79. in 1961 before moving in 1972 Northwick Park Prof Shousha graduated from Cairo University, Hospital (NPH) as the first consultant chemical laboratory and the recipients on the wards. His Egypt, in 1964. He trained in histopathology at the pathologist heading the NHS chemical pathology success led to him being the chemistry lead in the Royal Free Hospital and the School of Medicine, laboratory, where he remained until his retirement North West Thames Regional Health Authority London, before becoming a Fellow of the Royal from the NHS in 1992 . computing evaluation team in negotiations with College of Pathologists in 1976. In 1978, he joined At Northwick Park he worked in close asso- McDonnell Douglas before the introduction of Charing Cross Hospital where he led the breast ciation with the Clinical Research Centre (CRC) computing into district hospital laboratories in the histopathology service for many years and contrib- Division of Biochemistry headed by Dr Fred Region. uted to immense developments in the service. He Mitchell which proved a happy juxtaposition for But what of the man? Michael had a rounded, also served as quality lead and coordinator for the research and clinical care of patients. He did not emollient personality and greeted everyone national breast screening programme. confine himself to the laboratory and took part in with a welcoming smile. He was quiet and unas- He was a valued member of several professional ward rounds and in the interdepartmental meet- suming with an avuncular approach to those of his societies for many years, including the British ings that were a feature of NPH & CRC. Michael, colleagues who were newly appointed as College Medical Association, British Division of the Inter- as departmental head, valued his role in the officers. He did not seek the limelight or personal national Academy of Pathology, United States training of young pathologists who came to recog- advantage, but in office one was always aware Photo credit: Imperial College London and Canadian Academy of Pathology, Patholog- nise him as their mentor and friend rather than that he was pleasantly in control of the agenda. He ical Society of Great Britain and Ireland, European merely as a “Chief”. He was constantly aware for was meticulous in care of details and much of his specimen handling of different specimen types to Society of Pathology, and Association of Clinical their well-being and career development. It was success was due to his ability to make up the defi- diagnostic challenges. Pathologists. He was a great trainer and teacher entirely appropriate that the last office he held at cits for others who did not perceive the acute needs Prof Shousha generously shared his great who contributed to numerous teaching activi- the College was as Director of Studies where he of the moment. knowledge and intellect with his consultant ties and scientific meetings within the UK and extended this care to advising overseas trainees He was married for more than seventy years colleagues, trainees, students and laboratory staff, overseas. He ran the annual week-long ‘Hammer- who did not always find it easy to comprehend to Norma, who was Professor of French at King`s always with a friendly and welcoming attitude smith Diagnostic Histopathology of Breast Disease’ the rules and regulations of the College relating to College London. They have three children, four that made him popular with everyone. In addition course for the last 15 years, which is well recog- their training and examinations. grandchildren and eight great- grandchildren. to his professional input and dedication, he was a nised both nationally and internationally. Michael was ahead of his time with a major Music played a great part in their lives and they very kind and supportive gentleman who always He contributed significantly to research at Impe- interest in the use of computers in diagnostic labo- especially enjoyed chamber music at the Wigmore extended help to anyone who needed it. rial College London via a wide range of activities ratories. As early as 1969 he had written a paper Hall. They combined their musical interests, His family, friends, colleagues and trainees have and collaborations, producing nearly 300 scientific about the use of computers in compiling a blood perhaps unexpectedly, with a love of caravan- lost a great man who will be genuinely missed. It publications including original research papers, group register. At Northwick Park he collaborated ning. Each summer they took their caravan to was a pleasure and a privilege for the many who review articles and book chapters. His publications with the CRC Division of Computing and Statis- the Caravan Club site at Chatsworth from where were trained by Prof Shousha and who had the are mainly in the field of breast pathology, encom- tics to provide a system for chemical pathology they drove to Sheffield to the Music in the Round opportunity to work with him and learn from him passing diagnostic and prognostic parameters. He at Northwick Park. His was the demanding role Festival to hear the Lindsay Quartet. But even here as a personal and professional role model. was the editor of the book Breast Pathology: Prob- of defining the specifications and needs of his the scientist and enquirer in Michael was never lematic Issues, which covers practical diagnostic laboratory as a service provider. This required far away and amongst his publications is a short Professor Mona El-Bahrawy issues in breast pathology from dealing with gross RETURN TO considerable negotiating skills for he was the paper in The Caravan on the effects of nose weight RETURN TO Professor of Practice of Histopathology, CONTENTS interface between the Computing Division, his on towing characteristics! Michael had a keen CONTENTS Imperial College London

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Return to Cambridge The Sir Lionel Whitby archive collection at Archive of eminent pathologist In 1945, Sir Lionel was elected Regius Professor of Downing College Physic at Cambridge University. He was elected The collection, including original articles, Master of Downing College in 1947 and held both speeches, research papers and diaries, is open to Sir Lionel Whitby deposited positions until his death in 1956. In addition to his researchers by appointment. The full catalogue is college and university responsibilities, he was Pres- available to search via the Archives Hub. Please at Downing College ident of the British Medical Association in 1948 contact the Downing College Archivist for more and Chairman of its Education Committee. In 1953, information or to make an appointment. he was President of the First World Conference on esearchers will for the first time have the opportunity to access the personal Jenny Ulph Medical Education and conducted an extensive Downing College Archivist papers of Sir Lionel Whitby, including original papers, research articles and diary lecture tour of Australia and New Zealand as Sims entries, in a fascinating and extensive collection. Travelling Professor shortly before his death in late R 1956. Jenny Ulph The personal papers of pathologist Sir Lionel he began work on the biological assessment of Whitby (1895–1956) have recently been donated new synthetic compounds – the sulphonamides to Downing College Archive and made avail- – produced by May & Baker Ltd. In 1938, he identi- able to researchers. Over the course of a long and fied the activity of sulphapyridine (‘M & B 693’) in pioneering career in medicine, he played a signif- the treatment of pneumococcal pneumonia. After Deaths reported to Council icant role in the development of early antibiotics successful hospital trials, the drug was released and – the sulphonamides – and assisted in the treat- would later be used to treat Winston Churchill and ment and recovery of both the King (in 1928) and Dr Whitby himself. He was knighted in 1945 for The deaths of the following Fellows were announced at the April 2020 Council meeting. the Prime Minister, Winston Churchill, at the his research in this area. We extend our condolences to those who grieve for them. height of the Second World War. He commanded – and transformed – the Army Blood Transfusion The Army Blood Transfusion Service: ‘the James Hume Adams Glasgow, UK Frances Kate Gould Whitely Bay, UK Service during the war, returning to Cambridge greatest surgical advance’ of the Second William Brumfitt Elstree, UK Joan C Mackenzie Macnab Glasgow, UK University in 1945 as Regius Professor of Physic World War Vincenzo Cerundolo Oxford, UK and Master of Downing College from 1947. As the Second World War approached, Whitby took command of the Army Blood Transfusion Service, Dr Whitby in his lab stationed at Southmead Hospital, Bristol. Under at the Bland Sutton his command, the service provided and transported Institute of Pathology blood and plasma for troops across Europe, the in the late 1920s Middle East and Far East. He conducted a gruelling (© Whitby and tour of military hospitals in North Africa in 1943, Kennedy families). by which time the depot was preparing 20,000– 25,000 pints of processed blood every month. Major-General Ogilvie, a surgeon in the Royal Army Medical Corps in 1945, described the development of the transfusion service as the ‘greatest surgical advance of this war, more important even than peni- cillin’. In 1945, Brigadier Whitby was awarded the Gold Medal of the Royal Society of Medicine for his work on wound shock and blood transfusions. The Society’s President, Sir Gordon Gordon-Taylor – who had administered the transfusion that saved his life in 1918 – described him as ‘the greatest vampire the world has known’. Brigadier Whitby assisted Sir Charles Wilson (later Lord Moran), personal physician to Winston Churchill, when the Prime Minister developed pneumonia twice during the war. In February 1943, the Prime Minister was managed at home with the advice of Whitby and others, later praising ‘this Sulphonomides research admirable M & B’ for his recovery. The following Lionel Whitby matriculated at Downing to study year, Churchill’s illness was not made public. When medicine in 1918 after distinguished military he sailed for the Quebec Conference on the Queen service in the First World War. He completed Mary in September 1944, he was attended by Lord his training at the Middlesex Hospital, where Moran and Brigadier Whitby, whose diary from the he continued his research and work in clinical journey details anxiety over Churchill’s health. pathology at the Bland Sutton Institute, rising to RETURN TO prominence after Lord Dawson of Penn asked him RETURN TO CONTENTS to consult on the King’s illness in 1928. In 1936, CONTENTS

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Consultants: new appointment offers Region Employing body Base hospital Appointee North, Central Barts Barts Dr Victoria A Bryant and East London The following appointments have been offered and are subject to acceptance by the applicants. The lists Royal Free and Barts Across trusts Dr Lauren L Heptinstall are prepared by the College’s Workforce department, on the basis of returns completed by College asses- North East Gateshead Gateshead Dr Sree C Mussunoor sors on consultant advisory appointment committees submitted by 24 February 2020. Liverpool Liverpool Dr Gregory Cross North West Please note, we receive no return following 20% of AACs. Any forms received after 24 February 2020 will Liverpool Liverpool Dr Susan MacPherson be published in the next issue. If you do not take up your post, or have additional information, please inform Guy's and St Thomas' Across sites Dr Anu Malhotra the Workforce department. Whenever you move home or job, please inform the Membership department. South London Guy's and St Thomas' Across sites Dr Martina T Munonyara Chemical pathology appointments Wales Aneurin Bevan Royal Gwent Dr Sian E Morgan Region Employing body Base hospital Appointee Hampshire Basingstoke and North Dr Shalini Kalwani Wessex Hampshire North West Manchester Across sites Eric S Kilpatrick Portsmouth Queen Alexandra Dr Joanna S Cooke South West Royal Cornwall Royal Cornwall Rachel A Cooper West Midlands Birmingham Women’s Across sites Dr William Boyle Haematology appointments and Children’s Region Employing body Base hospital Appointee Immunology appointments

East Midlands University Hospitals Leicester Royal Infirmary Dr Sarah Wharin Region Employing body Base hospital Appointee of Leicester East Midlands University Hospitals of Leicester Royal Infirmary Dr Arthur Price Luton & Dunstable and Across trusts Dr Sneha Patel Leicester East of England UCLH South London King's King's Dr Rohit Ghurye The Princess Alexandra Princess Alexandra Dr Ali Shokoohi Brighton and Sussex Across sites Dr Victoria J Tindel Chemical pathology appointments Kent, Surrey and Sussex East Sussex Eastbourne Dr Abier Elzein Kent, Surrey and Sussex East Sussex Eastbourne Region Employing body Base hospital Appointee North West London The Royal Marsden The Royal Marsden Dr Sandra Easdale Mid and South Essex Across sites Dr A N Geraldine Guy's and St Thomas' Across sites Dr Richard Dillon Fernando Guy's and St Thomas' Across sites Dr E Mary Gleeson East of England North West Anglia Peterborough City and Dr Murugesh Jagadeesan Guy's and St Thomas' Across sites Dr Nita Prasannan Hinchingbrooke South London South West University Hospitals Across trusts Northern Ireland Northern Antrim Dr Peter K Yew Bristol and the Weston South West University Hospitals Across trusts North East County Durham and Darlington Memorial Dr Natasa Ruzman Bristol and the Weston Darlington The Leeds Teaching St James’s Dr Frances L Seymour King’s King’s Dr Mauricio A Arias Yorkshire and The Sheffield Teaching Royal Hallamshire Dr Peter Toth South London King’s King’s Dr Martin N Brown Humberside Hospitals King’s King’s Dr Carmel M Curtis South West The Royal Bournemouth Across sites Dr Pasco T J Hearn Histopathology and cytology appointments and Christchurch Region Employing body Base hospital Appointee Cwm Taf Morgannwg Across sites Dr Mohammad E Wales Abrishami East Midlands Northampton Northampton Dr Ponnavila Vidanelage Cwm Taf Morgannwg Across sites Dr Soma Gaur A M Saparamadu Luton and Dunstable Luton and Dunstable Dr Mary N D'Cruz Wessex Hampshire Hampshire Dr Rebecca L Houghton Mid and South Essex Basildon Dr Lilian Edmunds Yorkshire and the Humber Mid Yorkshire Pindersfield Dr Jayanta B Sarma Mid and South Essex Across sites Dr Anuradha East of England Kempalingaiah Consultant clinical scientist appointments – medical microbiology Mid and South Essex Basildon Dr Maria A Montero- Fernandez Region Employing body Base hospital Appointee Mid and South Essex Southend Dr Soumadri Sen North West London Public Health England Field Service (National Dr Andrew J Fox Kent, Surrey and Sussex Maidstone and Tunbridge Maidstone Dr Isabel J Woodman Infection Service) London Wells Northern Ireland Belfast Royal Victoria Dr James M Trainor

RETURN TO RETURN TO CONTENTS CONTENTS

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global temperatures are rising and the range of the of the Pontine Marshes would add much to the mosquito is increasing both in area and altitude. account of the part they played in the defence of REVIEWS Recently, the Asian tiger mosquito, Ae. albop- Rome, and campaigns of the American Civil War ictus, has been found in a number of Spanish cities would be easier to follow with sketch maps. There where there have been sporadic cases of dengue is no attempt to describe insect taxonomy, but the BOOK REVIEW The Rules of Contagion: Why fever. The range of diseases spread by mosquitos excellent photographs of Aedes and Anopheles spp. Things Spread − and Why They Stop has increased notably with the recognition of the deserve glossy prints. At under £20 this book is a Zika virus. bargain. By Adam Kucharski £13.59, 352 pp, hardbook This book is a comprehensive, well-referenced Wellcome Collection, 2020 ISBN: 987-1788-16019-3 review. It includes copious notes but few maps, Dr A Kennedy Professor Adam Kucharski released a book about Kucharski is a Professor of Infectious Disease which would improve its value, e.g. a diagram Retired Histopathologist how contagions spread right at the start of the Epidemiology at The London School of Hygiene SARS-CoV-2 pandemic. The timing may be uninten- and Tropical Medicine, a TED Senior Fellow, and tional, but he couldn’t have chosen a better moment has given a Royal Institute talk and regularly gives to educate both the general public and the greater interviews on national news channels. He is an BOOK REVIEW Infectious Disease, scientific community on this fascinating topic. effective and engaging science communicator (I Microbiology and Virology: a Q&A approach He begins with the story of Dr Ronald Ross, highly recommend you follow him on Twitter). It who in 1902 won the Nobel prize for discovering is therefore no surprise that this book is not only for Specialist Medical Trainees that mosquitoes spread malaria. Later, he uses his highly informative, with an in-depth examination By Luke SP Moore and James C Hatcher £26.69, 224 pp, paperback internship in investment banking to lead into a of how things spread, but is also a good bedtime Cambridge University Press, 2019 ISBN: 978-1316-60971-2 comparison between disease outbreaks and finan- read with plenty of interesting anecdotes. In this book, the authors have provided an excel- topics where guidance changes frequently, such cial bubbles. The SIR model (relating to susceptible, As someone who has always struggled with lent overview of the entire Combined Infection as post-exposure prophylaxis following varicella infectious and recovered individuals) is described, the complexities of mathematical modelling in Certificate curriculum. It covers topics from basic virus exposure. Understandably, the book makes and the recently much mentioned ‘R’ number and epidemiology, I found this book to be refreshingly cellular biology and mechanisms of antimicrobial no mention of the COVID-19 pandemic, so readers its role in both disease and social media spread is straightforward, with an enjoyable explanation of resistance through to the management of impor- will need to look to other sources for information discussed. Remember the ice bucket challenge the concepts involved. I think the appeal and rele- tant clinical syndromes, and touches on infection on this. Those preparing for the Part 2 FRCPath that seemed to be everywhere and then vanished? vance of this book crosses disciplines, and I would control, epidemiology and public health. Reflecting examination will still find the book useful to Kucharski describes and explains this further. recommend it to just about anyone who wants the style of the Part 1 Combined Infection Certif- refresh their knowledge, but it was clearly written Gun violence, the London riots, the anti- to better understand how things go viral in the icate examination, the authors provide a series of with the Part 1 examination in mind. Students of vaccine movement – these are all examined and modern connected world. ‘best of 5’ multiple choice questions, each accom- the Part 2 examination will need more in-depth the reader is shown how people can be influenced panied by a succinct explanation of the answer knowledge of topics such as laboratory manage- and movements gather momentum very quickly. Victoria Maddox with suggestions for further reading around the ment, infection control and biochemical tests than A discussion of how our data can be collected, Senior Clinical Scientist, Microbiology Services topic. The questions in the book replicate both the is covered in this text. and the information used to manipulate us to Laboratory style and content of the Part 1 Combined Infec- Overall this book would serve as an invalu- encourage the spread of certain ideas, makes for tion Certificate examination, and having already able resource for those preparing for the Part 1 uncomfortable reading. completed this examination, I noted how strik- Combined Infection examination. The questions ingly similar the questions in the book were to the are varied and relevant to the exam, and the expla- paper I sat, both in breadth and depth of content. nations are short and to the point, covering only BOOK REVIEW The Mosquito: A human The authors appropriately place greater emphasis the most important information. The result is an on clinical syndromes and important basic extremely useful, easily readable and enjoyable history of our deadliest predator microbiological concepts, such as resistance mech- resource, which readers can dip in and out of, both By Timothy C Winegard £16.62, 496 pp, hardback anisms and virulence factors of organisms, with to test their knowledge and to provide a framework Dutton Books, 2019 ISBN: 978-1524-74341-3 less emphasis on more esoteric organisms or the to direct further reading. technicalities of laboratory practice. This fascinating book covers the history of our World for it introduced both malaria and yellow While the information in the book is accurate James Veater battles with the mosquito from ancient Egyptian fever to the Americas. and relevant at the time of publication, readers ST7 Microbiology/Infectious Diseases, Leicester times up to the present day. This is not as daunting The author deals with malaria in a general way would be wise to check the latest clinical guide- Royal Infirmary as it might seem, for Winegard’s style is lucid and but gives a brief introduction to genetic conditions lines for any condition mentioned, particularly for easy to read. He uses a little black humour in that such as sickle cell disease and thalassaemia, which he often refers to the insect as ‘she’ but that is have developed as a result of malarial infection correct, for it is only the female that bites and so and provide some degree of resistance. The drug spreads disease. In instances involving major mili- treatment of malaria is given a general survey, as tary reverses he refers to the biting battalions as is how the availability of quinine played a major ‘General Anopheles’ and ‘General Aedes’. We learn role in the American civil war. Resistance to anti- of such events as the deaths of Tutankhamun and malarials remains a problem as well as the growing Oliver Cromwell, why Hannibal failed to enter resistance of the mosquito to insecticides such as Rome, why de Lesseps failed to cut the Panama DDT. Perhaps the most alarming statement is that, Canal and why Scotland faced bankruptcy at the out of the hundred billion people who have ever RETURN TO beginning of the 18th century. The slave trade was lived, nearly half have died as a result of mosquito RETURN TO CONTENTS disastrous for the indigenous peoples of the New bites. This is all the more significant at a time when CONTENTS

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leading to improved perceptions and resource BOOK REVIEW Death, Religion and allocation • pathologist integration in educational Law: A Guide For Clinicians programmes, including dedicated outreach By Peter Hutton, Ravi Mahajan and Allan Kellehear £31.99, 324 pp, paperback to attract and recruit undergraduate medical Routledge, 2019 ISBN 978-1138-59289-6 students, and greater emphasis on lifelong learning ‘on the job’, leading to a stronger, This book was recommended by Dr Maria Rollin The third section covers the legal aspects of more sustainable pathology workforce. MBE, Trustee of the Patients Association, in one death in the UK. It is unfortunately currently out of her regular talks at the College’s Medical Exam- of date, through no fault of the authors, following Panel member Dr Bethany Williams, Digital iner (ME) training days. The views of patients and the enactment of the emergency Coronavirus Pathology Fellow, Leeds Teaching Hospitals faith communities are central to establishing an Act 2020. However, the basic principles remain NHS Trust, UK, believes it is an important time effective ME service so I was keen to read this to unchanged and much of the legal framework for pathologists to speak out about the many discover how it could benefit those working in described is expected to resume when the Act is changes that the profession is facing. Dr Williams such services in England and Wales. repealed. Sections on the verification of death, commented: ‘We know how essential our work is It is divided into three main parts: belief systems, how to complete the medical certificate of cause to ensuring the best possible outcomes for cancer managing death in different communities and of death and when to refer deaths to the coroner patients – but hospital administrators, healthcare legal aspects of death in the UK. The first section remain apposite. There is a useful chapter on leaders, our multidisciplinary colleagues and the is an interesting and philosophical look at aspects deaths in Northern Ireland and Scotland and a final public are not always able to make best use of our of faith such as why people believe, different views chapter on the role of the ME. expertise. It is absolutely vital that we are proac- of what happens after death, and the links between This book gives a comprehensive overview tive in tackling the challenges our profession religion, ethics and society. There is liberal use of of the world’s major religions and their attitudes faces – and seizing the opportunities in front of us quotes from authors as diverse as Voltaire, Boyzone, towards end of life care and death. It is thoughtful – through a collaborative and forward-thinking Machiavelli and Bob Dylan. It sets the scene nicely and thought-provoking, and would make a helpful approach.’ for the second section, which explores the major reference for MEs, ME Officers and others working A short film of the launch event at the Royal religions and their approach to death, covering with bereaved families. It should definitely be in College of Pathologists is available at The Future of and other healthcare leaders who oversee and run 13 faiths and doctrines, from Baha’i to Zoroastri- all hospital libraries, and ideally in all ME offices. Pathology website. The site also includes blog posts, your hospitals. Meet with them, offer to help them, anism. For each religion, the book looks at origins vox pop videos from the event and more. share your ideas and insights with them. We can and beliefs, worship and lifestyle, care of the dying, Dr Suzy Lishman In the report, Dr Jerad M Gardner, Department help them improve patient care while maximising management of death, and views on autopsy and Interim Chair, Medical Examiners Committee of Pathology, University of Arkansas for Medical efficiency, and in doing this we are also proving organ transplantation. Sciences, USA, highlights that the increased profile our crucial value as part of the healthcare team. and visibility of pathology stands to benefit cancer Everyone wins.’ care overall. ‘I urge all pathologists to download You can follow the conversation on Twitter, Face- and read this report – and then act on it,’ Dr Gardner book or LinkedIn using #TheFutureOfPathology. comments. ‘The future is very much in our hands, New report calls for collaboration and we are the experts in laboratory testing and International Expert Panel, cancer diagnosis. Get to know the administrators The Future Of Pathology to improve cancer diagnostics

new expert report on the future of pathology urges pathologists and healthcare leaders to collaborate to transform cancer diagnostics. Charming snakes: a seminar A on reptiles The Future of Pathology is part of an initiative focus areas, written by Dr Matthew Clarke and launched by Leica Biosystems at the College’s Dr Bethany Williams from the UK, and Dr Jerad International Pathology Day 2019 and is available Gardner and Dr Tiffany Graham from the USA. n this article, Dr Jeffries explains how understanding the behaviour of animals can on Leica Biosystems’ website. Recommendations in The Future of Pathology result in life-saving treatments and potentially even novel therapies. This report details how the field of pathology report include: can evolve to meet the challenges facing the I • realising the potential for digital pathology profession – particularly given the uncertain A seminar on ‘Reptiles and Snakebite’ was held at husbandry. Some of the final year veterinary and artificial intelligence, and embracing times currently faced by healthcare communities the Kenya Snakebite Research and Intervention students will have been inspired to join the ‘Snake new technologies to deliver efficiencies, globally. It outlines key areas driving change in Centre (KSRIC) near Nairobi on 11 March 2020, Charmers’ who volunteer and learn at KSRIC with better quality of care and greater support for pathology worldwide, identifies challenges, and Dr Valerie Jeffries organised by Mrs Margaret Cooper and Professor mentor Dr Jessicah Murere, who is also responsible pathologists shines a light on the opportunities to transform the John Cooper, together with Dr. Atunga Nyachieo for the health and welfare of the reptiles in the • unlocking the power of molecular pathology profession and improve cancer diagnostics and the (Chief of Research, Institute of Primate Research) Nairobi Snake Park, National Museums of Kenya. to make a forward leap to personalised medi- delivery of patient care. for the benefit of Kenyan vets, wildlife park This work requires much knowledge and experi- cine and improved cancer treatment and care The report was developed by an international managers, museum curators, students, and anyone ence, as reptiles indicate stress and ill health less • engagement with hospital administrators panel of pathologists in consultation with health- interested in snakes. obviously than mammals. to enable pathologists to demonstrate their RETURN TO care executives, cancer stakeholders and pathology RETURN TO The seminar was well attended, showing that Are you doubting whether your first response value to hospitals and cancer departments, CONTENTS leaders. It features chapters on four priority CONTENTS snakes are an up-and-coming sector of animal to finding a snake on the path would be ‘Does it

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feel unwell?’ You are not alone. Local communi- sensitive insides. This is all done in the interests of Dr Ahmed was Each country and region has its own way of ties naturally have a primary interest in their own a good yield of clean venom, which is used in the invited to Darul Sehat providing laboratory medicine services. It was welfare and no sympathy for snakes. However, treatment of snake bites. To cope with venomous Hospital and Medical insightful to see the approach taken by a small- to KSRIC biochemical research has a medical snakes as enemies you must treat them as friends, School in Karachi, medium-sized district general hospital in Pakistan. purpose, and the scientists have a close relation- and respect all their legal rights as captive animals, Pakistan, as part of Here, a clinical pathologist, rather than a chem- ship with the nearest hospital so that research and Mrs Margaret Cooper (UK/Europe and East Africa) the Foreign Speaker ical pathologist, oversees the various branches clinical knowledge can interact. It saves human reminded us. After ‘milking’ for venom, retired Programme. of laboratory-based pathology services such as lives. Motorbike ambulances can send an expert to snakes are released to an appropriate habitat guided biochemistry, haematology, microbiology and the victim of a bite, bringing injectable antiserum by Kenyan wildlife professionals for conservation. immunology. This approach is useful where as soon as possible. KSRIC is planning their own There were further presentations by Dr Jessicah resources need to be maximised to provide care antiserum production unit for antiserum tailor- Murere and Mrs Margaret Njeri (NMK, Kenya), to the local population. There are eight tertiary made to the bites of Kenyan snakes. For venom Dr Jaanvi Patel (veterinary practitioner, UK) and centres in Karachi (the largest city in Pakistan), production, a supply of healthy, happy, deadly Professor John E Cooper (UK/Europe and East which facilitate services and postgraduate training donor snakes is essential, so it is vital that ‘Snake Africa). Even before the welcome refreshments, in chemical pathology. There is a set curric- Charmers’ learn to tell how a snake is feeling. the seminar participants were feeling more fondly ulum with some integrated training in metabolic The highlight of the seminar was a tour of the towards our scaly brethren. Thank you to Professor medicine provided, followed by a final check of Herpetarium at KSCRIC by Mr Geofrey Kephah. and Mrs Cooper for another terrific day of instruc- competencies through an exit examination, as in There are snake-restraining implements all along tion and entertainment. Thanks also to Dr George the UK. the corridor walls, protective clothing, alarm Omondi, Head of KSRIC. Not only is snake venom It was useful to compare Pakistan’s health buttons, and health and safety equipment of all being used in the production of life-saving anti- service provision and delivery in relation to chem- kinds. The snake room is temperature- and light- serum at KSCRIC, but also in other aspects of ical pathology. Existing links and channels for controlled, with shelves of labelled plastic box medicine including endometriosis research. Here, training between the UK and resource-challenged cages. Each cage contains a water dish and an medical progress is advancing all because some countries in the form of sabbatical placements and upturned cut-out bowl for a bedroom, and one Kenyan vets actually do know how a snake is The term clinical biochemistry or chemical MTI (medical training initiatives) could do with small venomous snake. Geofrey explained the feeling. pathology traditionally lends itself to being viewed being utilised further within chemical pathology. importance of keeping the snakes content and solely in relation to the laboratory. There is indeed Further engagement with medical students showing their natural behaviour. Dr Valerie Jeffries much more to it than that as the clinical appli- remains high on the agenda with events and activi- The tour explained the role of staff in assessing cation of this specialty is vast. This is a field that ties planned for later on in the year. the condition of the snakes and providing adequate Adapted with permission from both overlaps and bridges the gap between many I would like to express my thanks to Dr Abdul food – mice, frozen then thawed, exactly enough The Frightened Face of Nature mainstream clinical disciplines, providing highly Malik, Consultant Neurologist, and Professor to preserve freshness while not chilling their specialised biochemical insight into fields such Rashid Naseem, Principal of Darul Sehat Hospital as endocrinology, cardiology, nephrology, gastro- and Medical School, for their kind invitation and enterology and rheumatology, to name but a few. for providing this opportunity to learn from one Physicians see the results of blood tests in terms of another and our different systems. numbers, whereas we aid interpretation and the Highlighting chemical pathology and rationale behind biochemistry tests and provide Dr Farhan Ahmed insight into their limitations, overseeing the Consultant in Chemical Pathology and metabolic medicine overseas process at every step of the way. Metabolic Medicine, Milton Keynes University Hospital

r Farhan Ahmed is working to inform and inspire the next generation of chemical pathologists and metabolic physicians. With the aim of engaging D medical students and trainees, and debunking myths surrounding the specialty, LETTER: Reporting of race in autopsy his latest venture took him to Pakistan. As a trainee registrar and now as a consultant, I Foreign Speaker Programme. There were around reports – time to review? am well used to the puzzled looks I receive when 200 medical students, trainees and consultants in Dr Farhan Ahmed replying to the question ‘what specialty are you attendance to hear my talk on interesting cases in In England and Wales, each year about 100,000 accurate about the person’s external appear- in?’. It doesn’t help matters when this specialty chemical pathology and metabolic medicine. people who have died are examined by patholo- ance as well is both highly specialised yet multifaceted. It is I defined my role and daily routine in an often gists. For the adult cases, at least, the subsequent 3. we know, or think we know, that certain esoteric yet has a broad application. Giving people misunderstood field and I was greatly encour- descriptive reports are likely to open with the state- pathologies correlate closely with race or the opportunity to learn and understand more aged by their questions and curiosity. For those ment: ‘Caucasian male’; ‘Middle aged Asian female’; ethnicity, so we are applying the principle of about chemical pathology and metabolic medicine who have yet to choose their specialty, providing ‘Young black female’; or ‘Elderly African male’, etc. consistency. is vital for the growth of this specialty and I take a space to listen to the career pathway of consult- Why do we do this? I think there are three great pride in delivering talks on my profession. ants in non-mainstream areas and allowing them But consider the following circumstances and reasons: Much of this work is focused on medical students to ask questions helps to make a more informed the problems arise. Bodies decompose and tend to in the UK and overseas who have yet to choose career choice. There was interest regarding the 1. our teachers did, so we follow suit, and no one darken in colour over time. I have been taken to their training specialty. entry criteria but few had considered practical has told us not to task by relatives by labelling someone as ‘black’ RETURN TO In January 2020, I was invited to deliver a lecture issues such as work-life balance or the prospect of RETURN TO 2. since we measure the heart weight to the who had lain undiscovered for weeks and who CONTENTS in the city of my graduation, Karachi, as part of a lengthy exit examinations. CONTENTS nearest 5 g, it is reasonable pari passu to be

178 July 2020 Number 191 The Bulletin of the Royal College of Pathologists www.rcpath.org Number 191 July 2020 179 REVIEWS

happened to have tightly curled black hair: ‘No, he prematurely from accelerated atherosclerosis, it was white when alive, please amend the report’. seems a smart thing to document his ethnicity as Then a male suicide with a long Islamic name. ‘South Asian’, knowing that there is a correlation NOTICEBOARD He was white/Caucasian, but since I thought – between (some) people from that part of the world from the name – that he came from the region of with atherogenic metabolic disorders. The prin- Baluchistan or Afghanistan (perhaps travel tempts ciple of consistency, which we like to see flowing College conferences one to be clever), I wrote on the external form through our autopsy reports. And most recently, ‘Asian’. My wife, who types up my draft autopsy the apparent excess of deaths among BAME (black, reports, misread the word, and the computer’s Asian and minority ethnic) medical and paramed- spell checker ended up printing ‘African’, which I ical staff during the COVID-19 pandemic might did not spot at the time. Again, the relatives were force us to confront the problem sooner. SEPTEMBER NOVEMBER up in arms: ‘He was not African, please amend’. So Recently, I raised this issue with Adam Ruther- 2020 2020 I redid it and wrote ‘Asian’. That did not help much ford, author of How to argue with a racist,1 at his since, via the coroner officer, no doubt becoming presentation at the Emirates Literary Festival in as fed up with this rigmarole as I was, I was told Dubai. ‘Please advise us pathologists what we that he actually was white English, but had been should do?’ He agreed it was a problem, but had no radicalised. At this point I began to question why concrete suggestions. As he says in the book, there I automatically document the ethnicity, or race, of is no simple relationship between genes and skin SEPTEMBER NOVEMBER the persons I autopsy. colour. Further, ‘not only were we diverse in our 2020 2020 In perinatal work, one does not, for the simple skin colour long before the dispersal from Africa reason that the skin colour of fetuses is usually and [70,000 years ago, leading to the current global similarly pale, whichever ethnic group they belong population] but we were diverse in our skin colour to. I learned this years ago when performing a peri- before we were our own species [Homo sapiens]’. natal mortality study in Nairobi, Kenya, and most One way out of the mess is to abandon NOVEMBER NOVEMBER of the fetuses I examined were white. The black attempting to classify cadavers racially and via skin 2020 2020 pigmentation develops just before and after birth. colour, and stick to gender only – that could also What does ‘Asian’ mean in terms of ethnic become a minefield in due course, but is for another description, which is mainly skin colour, partly discussion. We could ask our employers: ‘coroners eyelid epicanthic fold configuration and the – tell us what you want, as you are the only guar- general shape of the face? It has to include the pale anteed readers of our autopsy reports?’ I would be Afghans and Pakistani peoples, the darker central surprised if the 90-odd senior coroners would agree Indian inhabitants and the much darker south on a single position – they disagree among them- Indians and Sri Lankans. But what about Tibetans, selves on most other significant things, such as CPD-accredited events Chinese and Japanese, who are mostly paler, ‘what is an unnatural cause of death?’, after all. And yellowish, but very varied? And where do Filipinos we might consider asking the public what they fit in? They don’t, of course. Trying to be clever think – they do usually get the autopsy reports. with ‘East Asian’ is not going to help. We should start there, and open up the discussion Who among us is brave enough to attempt to among ourselves, the morbid anatomists who do SEPTEMBER NOVEMBER distinguish ‘African’ from ‘African American’ from the work. Any further comments and suggestions 2020 2020 ‘Afro-Caribbean’? I suspect we have all tried, and are most welcome! it is pointless. But mere ‘Black’ seems somehow incomplete or perhaps disrespectful. References available on the website. What about the correlation of perceived ethnicity with diseases? I used to think that Professor Sebastian Lucas SEPTEMBER NOVEMBER those with sickle cell diseases were all African, or Emeritus Professor of Pathology 2020 2020 derived from Africa via the historical slave trade, since the middle sub-Saharan belt of countries is the epicentre of the sickle gene (traditionally associated with partial resistance to falciparum malaria). Then I encountered a patient who died of sickle who was from India. And then, a young OCTOBER NOVEMBER girl who was paler than my granddaughter and had 2020 2020 flaxen fair hair, from North Africa, who had died of a sickle crisis. Before putting knife to skin, I felt bound to contact her hospital doctor just to double check that the information sheet read correctly – she really did have the HbSS genotype – and it was the right patient. RETURN TO When we encounter a dark-skinned middle- RETURN TO To see all 2020 and 2021 conferences visit our website. CONTENTS aged male from south India who has died CONTENTS

180 July 2020 Number 191 The Bulletin of the Royal College of Pathologists www.rcpath.org Number 191 July 2020 181 NOTICEBOARD Pathological Society of Legacies Great Britain and Ireland The Pathological Society of Great Britain and Ireland offers a wide range of grant schemes. The objectives of the College are to develop and this country through schools, colleges, hospitals EDUCATION GRANTS/COMPETITION maintain high standards of pathology education, and many other sites where the general public can training and research; promote excellence and have access to important healthcare information. Bursaries for undergraduate elective or vacation studies 27 February & 28 April (available to Associate Undergraduate Members of the Society) advance knowledge in pathology practice; increase If we are to safeguard the future of our profession the College’s influence through a clear, coherent, in the face of increasing competition from other Education Grant 1 April & 1 October professional voice; and resource the future of the medical and science career opportunities, it is vital Intercalated Degree 31 March College. Financially, the College aims to match that we commit ourselves to the promotion and (available to Associate Undergraduate Members of the Society) activities to projected income. The College is funded awareness of pathology, and continue to train our Student Society Bursary Scheme Open from subscriptions, examinations and related fees, young professionals to the very highest standards. (available to Associate Undergraduate Members of the Society) investment income, grants from outside bodies and This public engagement programme will Undergraduate Essay Competition 31 August Daniel Ross charitable donations. require financial support from the College for years (available to Associate Undergraduate Members of the Society) Bequests or legacies are always gratefully to come and we hope very much that we can build New for 2020 received. Leaving a gift to charity in your will is a on the tremendous support you have already given Jean Shanks/Pathological Society Summer Studentships 1 March, 1 July & 1 October very special way of helping to secure the future for and ask if you would consider leaving a legacy. organisations such as the Royal College of Patholo- Additions to your existing will can be made using RESEARCH GRANTS gists. Legacies to the College have the added benefit a ‘Form of codicil’, available on our website. Alter- Best Trainee Research Impact Award 1 October of being exempt from inheritance tax. natively, please write to us and we will be happy to Best Trainee Research Paper Award 1 October An open legacy may be made toward the post you a copy. general purposes of the College. This is preferred Please note that witnesses should be present Consultant’s Pump-Priming Small Grants Scheme 1 April & 1 October because it allows the College to apply the funds when you sign the form, but it should not be CRUK/Pathological Society Predoctoral Research Bursary 26 March & 26 September donated where the need is greatest at the time witnessed by a College member or the spouse of Cuthbert Dukes Grant 1 April the legacy eventually becomes available. This can a College member. We recommend consulting Early career Pathology Research Grant - Hodgkin & Leishmann 1 April & 1 October be quite different from the perceived need when a a solicitor or qualified will-writer before making Equipment Scheme 1 April & 1 October will is made. However, you may legally oblige the a will; they should give you all the legal and tax International Collaborative Award 1 October College to spend the money in a particular area of advice that you require. PhD Studentship 1 October College work or for a specific purpose by making a If you are considering including a legacy to the restricted legacy. College in your will, we would very much appre- Post-Doctoral Collaborative Small Grant 1 April & 1 October The College undertakes many educational initi- ciate being informed of your generous act. To Trainees Collaborative Small Grant 1 April & 1 October atives. We are actively undertaking an outreach inform us of your bequest or for specific advice on Trainees-Clinical Scientist Partnership Grant programme that spreads the awareness of pathology legacies to the College, please contact me. Funding Scheme in Morpho-Molecular Pathology 1 October throughout the UK and abroad. No other UK Trainees’ Small Grants Scheme 1 April & 1 October college has committed so much time and resources Daniel Ross Visiting Fellowships 1 April & 1 October to the future of our profession. This will promote Chief Executive ([email protected]) the importance of pathology to the grass roots of TRAVEL GRANTS Pathological Society Meeting Bursaries 31 May & 31 December Pathological Society Meeting Bursaries for undergraduate 31 May & 31 December Travel & Conference Bursaries Open Advertise in the Bulletin JEAN SHANKS/PATHOLOGICAL SOCIETY (JSPS) RESEARCH GRANTS Pre-Doctoral Research Bursary 1 April & 1 October Want to reach nearly 9,000 practising pathologists, including all of the UK’s clinical Clinical PhD Fellowship 1 April & 1 October directors of pathology and consultant pathologists – the leading decision-makers in pathology purchasing? Clinical Lecturer Support Grant 1 April & 1 October Intermediate Research Fellowship 1 April & 1 October Advertise in the Bulletin and get your product or service noticed New for 2020 Our readers also include senior pathology trainees, many of whom personally specify their Clinical Lecturer Grant 1 April & 1 October choice of equipment upon consultant appointment, as well as more than 1,300 senior Clinical Academic Research Partnership (CARP) 1 April & 1 October pathologists across 85 overseas countries. The Bulletin is published four times a year and is available on our website. OTHER GRANTS Open Scheme 1 March, 1 June, 1 September & 1 December Want to know more? Pathological Society Meetings Bursaries 31 May & 31 December For rates, copy deadlines and technical specifications,visit our website. Public Engagement 1 March, 1 June, 1 September & 1 December For more information, email the Publishing team or call us on 020 7451 6730. Full details are available on our website: www.pathsoc.org or from: RETURN TO Julie Johnstone, Deputy Administrator, Pathological Society of Great Britain and Ireland. E: [email protected] Due to the current COVID-19 crisis, grant deadlines may be changed and/or rescheduled. Please refer to the CONTENTS Pathological Society website for up-to-date information.

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