Haematinic Guidelines

HEFT Pathology Guideline Investigation and Referral Pathways for Anaemia in Primary Care

Produced by:

Dr Sukhbir Kaur (Senior Clinical Biochemist)

Approved by:

Dr Kartsios Charalampos (Consultant Haematologist)

 

Dr Marcus Mottershead (Consultant Gastroenterology)

This guidence covers the following areas

1. Anaemia Testing in Adults

2. Iron Deficiency Anaemia Testing in Adults

3. Iron Deficiency Anaemia Treatment and Monitoring Advice

4. Vitamin B12 Deficiency Testing, Treatment and Monitoring

5. Folate Deficiency Testing, Treatment and Monitoring Advice

6. Renal Anaemia Testing in Adults

biochemistry, haematology, haemainics

Read more: Haematinic Guidelines

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Lipid Clinic

Lipid results

What is it?

Adult lipid and cardiovascular risk clinic. We see patients with high blood fats/lipids, review their results to try and establish the cause of the high lipids and work out if treatment is required and, if so, what options are available to you. Some lipid conditions run in families and it may be that your relatives e.g. your children need testing. One major role of the clinic is to make sure that we do not miss asymptomatic relatives in order to try and prevent future heart attacks and strokes.

Who do we see?

Dyslipidaemias (high or deranged blood lipids). People with complications of lipid problems e.g. pancreatitis and premature vascular disease People with side effects to lipid lowering medication People with poor control on current medications who require more treatment Specialist testing particularly looking into families with potential genetic lipid conditions or family history of premature vascular disease such as heart attacks and strokes. Limited screening of relatives directly, advice in regards to when family screening is required and what tests to perform. Also see general Metabolic patients particularly at Good hope hospital and sometimes at Heartlands

Location?

Outpatient department in Heartlands.

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    Outpatient department Good Hope

    Contact information (if you want to speak to clinic organisers)?

    Booking service for appointment alterations via contact information on the appointment letter

    Contact Lipid clinic secretary for all other queries as follows:

    Heartlands hospital Secretary: 0121 42 43228 This email address is being protected from spambots. You need JavaScript enabled to view it.

    Good Hope hospital Secretary: 0121 42 47246 This email address is being protected from spambots. You need JavaScript enabled to view it.

    What are the prereferral tests?

    To help guide us with your management your GP will arrange for you to have some blood tests

    What do you need to bring?

    It is helpful to have a list of your medications if you can’t remember what they are.

    What do I need to do?

    Besides bringing your tablet list sometimes we ask people for fasting blood tests. Sometimes lipid tests can be done non-fasting. Please let us know if you cannot make an appointment as sometimes, even at late notice, an emergency patient can be asked to attend to fill your slot.

    What do we do?

    Diagnosis is based on your medical history, clinical examination and blood tests. Sometimes further investigations e.g. treadmill test may be indicated. Once a diagnosis is established then most treatment involves diet and lifestyle changes and some require medications, such as statins and fibrates, to reach treatment targets.

    Who will I see?

    The team at Heartlands consists of

    Dr Alan Jones (Consultant Chemical Pathologist)

    Dr Ummu Mayana (Honorary Consultant Chemical Pathologist)

    Dr Ateeq Syeed (consultant endocrinologist)

    Mrs Katherine Peers (Advanced Nurse Practitioner).

    Dr Sud Ramachandran (Consultant Chemical Pathologist) sees patients who have been referred to Good Hope at Good Hope Hospital. Heartlands and Good Hope are teaching hospitals therefore occasionally medical students and doctors in training may be present.

    Other services available?

    Some patients can be referred to the dietetics department for dietary advice. In rare cases we may ask cardiology or the diabetic team to become involved in your care. There is no paediatric or genetics service attached to the clinic. For children picked up in the clinic as having a genetic lipid disorder we refer them to the Birmingham Children’s Hospital to discuss further treatment.

    Useful links

    Diet advice

    Exercise Advice/counselling

    Heart UK

    BHF

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    Tumour Marker Use in Primary Care

    In the last 5 years requests for tumour marker tests from Primary Care have more than doubled. This high use in Primary Care is worrying because the majority of tumour markers (eg. CEA, CA19-9) are neither specific nor sensitive enough for use in the diagnosis of malignancy. See this link for a summary of the main tumour markers, their uses and limitations.

    The main use for tumour markers is in monitoring disease progression, treatment or recurrence of a histologically diagnosed cancer. A recent audit of Primary Care requests for tumour markers found that only 9% of CEA and 4% of CA19-9 were requested for these reasons; the rest being for non-specific symptoms.

    In contrast to the above, CA125 and PSA do have use in diagnosis of their related cancers, however it should also be noted that these are still only a diagnostic aid and should be used with caution as both can be raised in a number of other benign conditions (see table). Please click the relevant links below of links to guidelines relating to their use in Primary Care.

    CA125 link https://pathways.nice.org.uk/pathways/ovarian-cancer

    PSA link https://www.gov.uk/guidance/prostate-cancer-risk-management-programme-overview

    For symptoms and referral guidelines of other malignancies see the NICE Suspected Cancer Recognition and Referral guidelines. http://pathways.nice.org.uk/pathways/suspected-cancer-recognition-and-referral

    You can also use the search bar or test database on this website to find more specific information on the use of each tumour marker.

    Tumour marker

    Main application

    Other tumour elevations

    Other limitations

    CEA

    Monitoring colorectal adenocarcinomas

    Breast, lung, gastric, mesotheliomas, oesophageal and pancreatic

    Raised in smokers

    Raised in other benign renal, liver, lung or GI disease

    Poor sensitivity in early disease and may be absent/low in poorly differentiated tumours

    CA19-9

    Monitoring pancreatic carcinoma

     

    Raised in obstructive jaundice, cholestasis, cirrhosis, pancreatic hepatitis and non-malignant GI disease.

    Not present in those negative for the Lewis blood group determinant.

    CA125

    Monitoring ovarian carcinoma

     

    Raised in patients with ascites, pleural effusions or free fluid in the pelvis

    Raised in patients with congestive heart failure

    Raised in benign renal and liver disease and other adenocarcinomas

    Mildly raised in menstruation and the first two trimesters of pregnancy

    Can be raised in endometriosis

    CA15-3

    Monitoring breast cancer

    Lung, colon, ovary

    Raised in benign liver, breast, ovarian disease

    AFP

    Diagnosis and monitoring of hepatocellular carcinoma and germ cell tumours

    Gastric and other GI (oesophageal, pancreatic)

    Raised in pregnancy and neonates

    Raised in benign liver disease

    PSA

    Diagnosis and monitoring of prostate carcinoma

     

    Also elevated in benign prostatic conditions

    Increases with age (as prostate size increases)

    Elevated in UTI, catheterisation, prostatitis or other prostate manipulation

    hCG

    Diagnosis and monitoring of germ cell tumours and gestational trophoblastic neoplasia

    Lung

    Raised in pregnancy

    Transiently elevated with cannabis use

    LDH

    Diagnosis and monitoring of germ cell tumours

     

    Elevated in cardiac disease and benign liver disease

    Elevated in some anaemias relating to non-malignant disease

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    Clinical Decision Limits

    Phoning limits for biochemistry tests are as follows:

    Decision limits for phoning

      Below Above Units
    Sodium 120 150 mmol/L
    Potassium 3 6.5 mmol/L
    Urea   30 mmol/L
    Creatinine   500 umol/L
    Glucose 2.5 20 mmol/L
    Calcium adjusted 1.8 3.5 mmol/L
    Magnesium 0.4   mmol/L
    Phosphate 0.3   mmol/L
    AST   700 U/L
    ALT   400 U/L
    Total CK   500 U/L
    Amylase   600 U/L
    TBA   20 umol/L
    Iron   70 umol/L
    Total bilirubin   225 umol/L
    Carbamazepine   25 ug /mL
    Digoxin   2.5 ng/mL
    Theophylline   45 mg/L
    Phenytoin   20 mg/L
    Phenobarbitone   70 mg/L
    Lithium  <0.2 >1.5 mmol/L
    Valproate   100 mg/L
    Cyclosporin A   200 ug/L
    CRP  

    300

    phoned with other abnormal results

    mg/L
    Salicylate   20 mg/L
    Paracetamol   10 mg/L
    Ammonia All phoned    
    Lactate All phoned    
    beta-HCG All phoned    
    progesterone All phoned    
    CSF glucose All phoned    
    CSF protein All phoned    
    NNU results All phoned    

    Read more: Clinical Decision Limits

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    Copyright heftpathology 2013, 2014, 2015, 2016, 2017, 2018

    HTA licence number is 12366

    Protection of Personal Information – Laboratory Medicine comply with the Trust Data Protection Policy and have procedures in place to allow the Directorate and it’s employees to comply with the Data Protection Act 1998 and associated best practice and guidance.

    The Trust Laboratories at Heartlands Hospital, Good Hope Hospital and Solihull Hospital were awarded UKAS (United Kingdom Accreditation Service) accreditation to the internationally recognised ISO 15189 standard in May 2015. For a list of accredited tests and other information please visit the test database http://www.heftpathology.com/frontpage/test-database.html.
    Tests not appearing on this scope are either under consideration or in the process of accreditation and so currently remain outside of our scope of accreditation. However, these tests have been validated to the same high standard as accredited tests and are performed by the same trained and competent staff.

    For further information contact Louise Fallon, Quality Manager, 0121 424 1235

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