Dominique Joyal, MD

• Interventional Cardiology Fellow
• Cardiology Division
• Loyola University Medical Center
• Maywood, Illinois

Which other crystals appear similar to those seen in this urine and may cause confusion in identification Explain any discrepancies observed between the micro scopic and chemical findings androgen hormone pregnancy buy fincar 5 mg amex. Color: Appearance: Specific gravity: pH: Protein 3: Glucose: Ketone: Bilirubin: Blood: Urobilinogen: Nitrite: Leukocyte est: Brown Cloudy 1 androgen hormone blood test buy discount fincar 5 mg on-line. Suggest sources of error in identification of urinary sedi ment that these structures may present prostate fluid buy discount fincar 5mg. Examination of Urinary Sediments: An Atlas of Use of Sternheimer Malbin Staining Technique prostate oncology of san antonio generic fincar 5mg otc. Recognize when bright field prostate cancer 5k pittsburgh purchase fincar with mastercard, phase contrast prostate vaccine fincar 5 mg discount, polarized light, and interference contrast microscopy have been used. Compare and contrast urinary sediment viewed using bright field, phase contrast, polarized light, and interference contrast microscopy. Compare and contrast urinary sediment viewed using bright field, Stemheimer Malbin staining, and Sudan Ill staining. This edi tion contains not only most of the images from previous editions but also images from other sources. Having a tool such as a detailed atlas is essential to proper identification of uncommon urine sediment. The images in this chapter are organized into cells, crystals, casts, and other urinary sediment as well as arti facts. When the cast in the previous fig u re is viewed u nder low power, the color of the cast is more promi nent (200x). Correlate diluents that may be used during hemocytometer counts with the fluid for which they most likely would be used. Analysis involves multiple departments of the laboratory and specialized knowledge of each type of body fluid. Hematology is important in examining the cells and crystals found, chemical analyses are required to assess significant physiologic changes in the patient, microbiology can help detect infectious agents in a nearby body cavity or membrane, and immunological tests and other miscellaneous tests can also provide the physician with critical information. Further consultation with pathology may be required for the identification of tumor cells and other abnormal cells. Accumulation of Excess Body Fluids the amount of serous fluids found in the space between an organ and the membrane sac that encompasses the organ varies according to body site. Normally, only a small amount of fluid is present: 30-mL pleural fluid, 50-mL pericardial fluid, and 1 00-mL ascites. Body fluids are necessary for lubrication of the body cavity/organ interface during move ment. A delicate equilibrium is maintained by the capillaries and the lymphatic vessels. Any obstruction or altered pres sure in these vessels can affect the amount of fluid and its constituents. Several forces, within and outside of the capillaries, work together to maintain fluid equilibrium. Normal removal of fluids entering into the interstitial space is handled by the lymphatic system. However, an imbalance in pressures causes excess egress of fluid into tissue spaces and can lead to accu mulation of fluid in the body cavity. Body Fluid Composition While body fluids vary in composition, they share some ele ments in common. The critical roles of water and electrolytes are important determinants of any fluid composition and movement in the body. Water enters the system through consumption of either water or food and also through cellular metabolic processes. Fluids of the body can be intracellular or extracellular, with about 55% of the water being intracellular and about 45% being extracellular. Extracellular fluid can be further divided into interstitial fluid, transcellular fluids in various body cavities, and plasma. Fluids typically move around in body because of various forces and body conditions. The electro lyte and enzyme composition of intracellular fluid differs from extracellular fluids and knowledge of these differences can aid in understanding disease processes. For example, potas sium levels are higher inside the cell than outside and sodium concentrations also vary between the intracellular fluid and the extracellular fluid. Depending upon the local conditions of various adjacent membranes and tissues, other fluid con stituent concentrations can be altered as well. Types of Body Fluids Body fluids are diverse, with variation in physical appear ance, properties, cell types, and cell counts. In general, studies of body fluids are most helpful to assess inflammation, infec tion, malignancy, and hemorrhage. At arterial end of capillary: predominant movement of fluid is from bloodstream i nto i nterstitial spaces. Body Fluid Collection the procedure for collecting body fluid specimens involves a minor surgical procedure that is usually named for the site of collection. Fluid from the abdomen is collected by paracentesis and fluid collecting around the heart is collected by paracardiocentesis. Table 1 1 - 1 lists the body fluids commonly examined and the procedure used to collect each. Cerebrospi nal fluid and synovial fluid are normally colorless and clear, whereas serous fluids are usually slightly yellow and clear. This is espe cially true in serous fluid where the normal amount of fluid is quite small, only the amount between the two adjacent serous membrane layers. In disease, this fluid level can increase from a few milliliters to a few liters of fluid. Each platform contains an etched grid that is scored with markings for ease of counting. These grids are etched into thick glass plates and have a moat that isolates them. A spe cial optically corrected coverslip is placed over the grid area with edges resting on the moat walls. This depth must be con sidered when calculating cell counts performed on the hemo cytometer. Once the specimen settles to the grid lines, both sides are counted and averaged if within 20%. If 20% or better precision is not obtained, the specimen is mixed again, reloaded, and recounted. However, if the concentration of cells is high, adjustments can be made to the procedure. Fewer square millimeters may be counted, dilutions may be made, or a combination of both. Laboratory professionals must use judgment in estab lishing criteria for when to employ adjusted cell counting techniques for body fluid cell counts. If many nucleated cells are present, counting these cells in the four corner square millimeters is often sufficient. For example, if an undiluted body fluid is counted and 35 white blood cells are counted in 9 mm2, the calculation is: [35 x 1 x 1 0] /9 39 per cubic millimeter. In order to accurately perform these counts, some body fluids require addition of diluents or other substances to the sample to facilitate counting by reducing viscosity or pre venting coagulation of the sample. Acetic acid cannot be used for synovial fluid because it precipitates the hyaluronic acid present in synovial fluid. A solution of hyaluronidase may need to be added to perform the synovial fluid count accurately. Cellular Morphologies an d Differen tials Morphologies of both abnormal cells and cells that are nor mal for that body fluid need to be learned to assess body fluids. A cytologist or pathologist can assist in identifying these cells, especially in malignancies. Preparations made using a cytocentrifuge are preferred for body fluid cell exam ination. Cytocentrifugation requires relatively little sample, is fast, requires little skill, and provides good cell recovery with much less cell distortion. Cytocentrifuged body fluid prepa rations are suitable for a variety of staining techniques. The preferred method of performing differential cell counts on body fluids uses: a. Stain added to the hemocytometer count Match each substance with its appropriate use in body fluid cell counts. The cytocentrifuge preparation contained cells that were not recognizable, many of which appeared fragmented. List the indications and contraindications for performing a cerebrospinal fluid analysis. Discuss the mechanism for maintenance of normal cerebrospinal fluid chemical levels. Differentiate between uncompromised and compromised cerebrospinal fluid results (hemorrhage vs. Explain the pathophysiology resulting in abnormal cellular constituents in cerebrospinal fluid. Suggest appropriate microbiology procedures for the detection of micro organisms in cerebrospinal fluid. Explain the use of immunologic procedures in diagnosing central nervous system disorders. Correlate cerebrospinal fluid analysis results to possible etiologies for central nervous system disorders. This procedure is usu ally performed on patients with unexplained seizures or on those who have fever of unknown origin. Lumbar puncture should not be performed if there is infection or inflammation over the puncture site. This cushions and helps prevent injury to the brain that could happen as a result of gravita tional or inertial forces. It also bathes the brain and spinal cord and serves as a nutrient and metabolic waste exchange fluid. The process that occurs is a combination of active secre tion and plasma ultrafiltration. Approximately 30% is formed by the ependymal lining cells of the ventricles and the cerebral/subarachnoid space. Cerebrospin al An atomy the brain is contained within the skull, whereas the spi nal cord runs down the center of the vertebrae. The outer most membrane is the dura mater, the membrane in the middle is the arachnoid (also referred to as arachnoidea), and the innermost membrane is the pia mater. These villi are herniations of arachnoid membrane into the lumen of the dural sinuses. The structures lined by epithelial cells called ependymal cells include the cerebral ventricle and the neural canal of the spinal cord. Epi thelial cells that originate from the mesoderm line the pia and the arachnoid. The nucleus is usu ally located eccentrically in the cytoplasm and may exhibit nucleoli. Some substances, such as creatinine, glucose, and urea require several hours to reach equilibrium. Contraindication to performing this puncture is the presence of infection at the puncture site. Lumbar puncture through an area of infection may cause the spread of infection into the meninges. The most common site used for lumbar puncture is the intervertebral space between lumbar vertebrae L3 and L4. Using this site avoids damage to the spinal cord in adults because the spinal cord does not extend that far down. The lumbar puncture site is thoroughly cleansed and a local anesthetic is applied. If a fourth tube is collected, or when the cell counts are completed, the tube may be refriger ated and observed for pellicle formation. Abnormal turbidity is observed if blood cells, microorganisms, or flecks of protein are present. If there is a significant difference in the amount of blood present between the first and last tubes collected (later tubes gradually clearing), then the puncture was traumatic. If all tubes collected show the same degree of blood, then a sub arachnoid hemorrhage is most likely. Cell counts are performed manually rather than using automation because of the low level of cells normally present. Red blood cells add little to the diag nostic value but are often reported as they may help identify a traumatic tap. In addition, nucleated red blood cells and other bone marrow cells may be seen in traumatic tap during which a vertebral process was nicked. Neutrophils Neutrophilic pleocytosis is present in cases of bacterial men ingitis and in the early stages of other forms of meningitis. Lymphocytic pleocytosis predominates the later stages of meningitis that are viral, tubercular, fungal, or syphilitic in nature. Increased numbers of lymphocytes Chapter 12 Cerebrospinal Fluid 1 89 can also be seen in other inflammatory processes and degener ative disorders such as Guillain-Barre syndrome.

Hansel stain consists of eosin-Y and methylene blue prostate lymph nodes buy discount fincar 5mg, which allows for the visu alization of reddish-orange eosinophils against a blue back ground prostate juice recipe 5 mg fincar with mastercard. Globules of neutral fat or triglycerides floating free in the urine or contained within cells or casts may be difficult to distinguish from other objects but stain orange or red with lipid stains such as Sudan Ill or Oil Red 0 prostate cancer 38 years old order 5mg fincar. Cholesterol and cholesterol esters do not stain but can be confirmed with polarizing microscopy prostate gland problems generic fincar 5 mg. Sternheimer-Malbin Stain Care and Preventive Maintenance Modern clinical microscopes are preclSlon instruments and should be handled and used with care and respect prostate yeast symptoms cheap fincar 5mg visa. A micro scope should be carried firmly with both hands (one under neath the base) prostate histology effective 5 mg fincar. Dust, dirt, or other particulate matter should be removed from lenses with a soft, "camel hair" brush, or blown away with an ear or nose syringe. Some residues can be removed with lens paper after breathing on the lens surface to deposit a thin film of moisture. After using an oil immersion objective, the immersion oil should be wiped off with lens paper followed by lens cleaner and additional lens paper. Gauze, facial tissue, or laboratory wipes should not be used to clean lens surfaces because scratching can occur. Proper covering and stor age of the microscope minimizes the accumulation of dust. The National Committee for Clinical Laboratory Standards Sternheimer-Malbin stain, the most commonly used stain in the clinical laboratory, is a mixture of crystal violet and safranin. One or two drops of the stain are mixed with the concentrated urine sediment before examination. Sternheimer-Malbin stain is supplied under various trade names by clinical and biologic supply houses. For example, it aids in distinguishing between cells of similar size, such as leukocytes and small renal collecting duct cells. A microscope slide with a dried preparation of urine sediment is heat fixed, then placed on a staining rack. The slide is flooded with crystal violet, followed by iodine (used as a mordant to fix the stain). The specimen is decolorized using alcohol or acetone and counterstained with safranin or carbol fushin. Wright Stain Wright stain is primarily used to differentiate among white blood cells in blood and body fluids. Which of the following lenses produces the primary image in brightfield microscopy Interference Which technique(s) would you use in order to determine if a urinary crystal demonstrates birefringence Polarization A specimen will appear three-dimensional when using which technique(s) Aperture diaphragm Condenser Field diaphragm Light source Mechanical stage Ocular Objective Place the following methods of improving contrast into their appropriate category. Accuracy of these test results depend on the collection and handling of specimens. Several techniques and preservatives are used in the collection of urine, which should be used appropriately to allow for the most accurate results. Specimen Collection Methods the performance of an accurate urinalysis begins with the proper collection technique. However, situations exist-such as in pediatric patients or patients producing a low volume that dictate modification of methods used for testing. Rou tine physical, chemical, and microscopic tests are described in subsequent chapters. Disposable containers provided by most laboratories are the container of choice, because they avoid the possibility of contamination from improperly washed patient provided containers. The problem with this method is that the specimen cannot be used for bacterial examination. Moreover, specimens from female patients may be contami nated with vaginal discharge. This procedure can be modified if the spec imen is not needed for bacterial examination. The midstream collection, without prior cleansing or the use of a sterile con tainer, provides a satisfactory sample for routine urine test ing. If a specimen for culture is being collected into a bedpan first, the bedpan must also be sterile. In the three-glass collection, all portions, beginning, middle, and final portion of the void, are collected in three separate containers. Urinary tract infections will show increased white blood cell counts and bacteria in the second and third containers, while prostate infections will demonstrate white blood cell counts and bacteria higher in the third container than in the second. Clean-catch, or dean-voided midstream, specimen is usually the method of choice for obtaining noncontami nated specimens. It is easy to perform and it provides a sam ple that can be used for bacteriologic examination as well as for routine urinalysis. Prior to collection, the external geni talia are thoroughly cleansed with a mild antiseptic solution. During the collection the initial portion of the urine stream is allowed to escape while the midstream portion is collected into a sterile container. It can also be used in a female patient to avoid vaginal contamination, especially during menstruation. However, since this procedure carries with it the possibility of intro ducing organisms into the bladder which may, in turn, cause infection, it should not be routinely used for the collection of culture specimens. This procedure involves the insertion of a nee dle directly into the distended bladder. Chapter 6 Collection and Preservation of Urine 75 Unacceptable Urine Collection Methods Unacceptable urine collection techniques include collecting the sample into a container that may still have detergent res idue or bleach, or one that has not been adequately cleaned. Urine collected in a bedpan that also contains feces is not an acceptable specimen, nor is urine that has been squeezed out of a diaper. These collection bags are soft and pliable and cause little discomfort to the patient. The bag opening, at the point of attachment varies according to its use for male or female infants. The first-morning urine is usually the most concentrated and is the preferred specimen of choice. Postprandial specimens are often used screen for carbohydrate metabolism disorders. Some substances, such as urobilinogen, demon strate diurnal variation (concentration varies according to time of day). The container that is used for the 24-hour specimen should be kept in the refrigerator during the entire collection period. Various chemical preservatives may need to be added to the collection container depending on the substance to be tested. For some tests, such as creatinine and protein, refrigeration alone is sufficient. To get an accurate test result, it is important that all urine excreted during the timed period be collected. Because of the difficulty that is sometimes encountered when obtaining 24-hour collections, physicians sometimes order 12-hour or 2-hour timed specimens. Specimens that are stored at room temperature will soon begin to decom pose, mainly due to the presence of bacteria in the sample. U rea-splitting bacteria produce ammonia, which then com bines with hydrogen ions to produce ammonium, thereby causing an increase in the pH of urine. This increase in pH will result in decomposition of any casts that may be present, because casts tend to dissolve in alkaline urine. If glucose is present, bacteria may use it as a source of energy potentially resulting in a false-negative test for glycosuria. Even if bacte rial contamination is not present, some urinary components such as blood cells and casts still tend to deteriorate on in the specimen over time. However, if the pH of the sample is low and the specific gravity (concentration) is high, deterioration will take longer to occur. Preservatives There are times when a urine specimen must be saved for a longer period of time than is recommended. This is a common occurrence when specimens are sent to commercial laborato ries for analysis as well as current methods for routine urine screening. There are several chemical preservatives that can be added to specimens; however most of them interfere in some way with the testing procedure. Understanding the effects of preservatives on laboratory tests will help to ensure that tests are performed on properly preserved specimens. Preservatives that can be used to preserve urine specimens include boric acid, chloroform, chlorhexidine, formalin, thymol, toluene, and formaldehyde generating preservative tablets. Boric acid is the preservative used in tubes used to preserve urine for culture and sensitivity. At this concen tration the formaldehyde will not interfere with the test for reducing substances, but higher concentrations will result in false positives. Because toluene floats on the surface of the urine, it may be difficult trying to separate the preservative from the specimen for testing. Collection into a U-bag What is the best method for testing urine that is delivered in a sterile cup Use a sterile aspiration device or cap port to transfer urine into a urine preservative tube. Judge whether a method for measurement of specific gravity needs correction for temperature and chemical effects. In addition, urine appearance correlates with chemical and microscopic findings in these disorders. This color may vary from a pale yellow to dark amber, depend ing on the concentration of the pigments urochrome and, to a lesser extent, urobilin and uroerythrin. The most common cause of red urine is the presence of hematuria (the presence of red blood cells). Red urine may also be due to hemog lobinuria (the presence of free hemoglo bin), myoglobinuria (myoglobin in urine), or large amounts of uroerythrin that can occur in acute febrile disease. In some types of porphyri nuria the urine may have a red or a port wine color; and only develop a red color if left standing. The dye phenolsulfonphthalein, which is used kidney function tests, can produce a red color in alkaline urine. In addition, some individuals have an inherited metabolic sensitivity which results in the excretion of red urine after eating beets due to the presence of complex pigments called anthocyan ins. These include medications and diet as well as various chemicals that can be present in disease. This table should not be considered as an all-inclusive list, for there are numerous drugs that are capable of chang ing the color of urine. It should be noted that the pH of the urine influences the color that many chemicals produce. In addition, there may be several coloring factors present in the same urine, which may result in a different color than that expected. Pale to Colorless Urine Very pale or colorless urine is very dilute and can result from high fluid consumption, diuretic medication, natural diuret- Urine that contains red cells or heme pigments can vary in shades from pink through black. For example, an acid urine which contains hemoglobin will darken over time because of the formation of methemoglobin (oxidized hemoglobin). This reaction can occur either in vivo, as in the bladder, or in vitro, while waiting to be tested. Another cause of dark brown to black urine is alkaptonuria, a rare disorder that is characterized by the excretion of homogentisic acid in the urine. The presence of homogen tisic acid in alkaptonuria is due to the congenital lack of the enzyme homogentisic acid oxidase, which mediates an important step in the catabolism of tyrosine and phenyl alanine. In patients with malignant melanoma, a colorless pigment called melanogen occurs in the urine. On exposure to light, this chromogen is converted to melanin, which is black, thus darkening the urine. Yellow-Green Urine Patients with obstructive jaundice will excrete bile pig ments such as bilirubin, and the urine will be yellow-brown to yellow-green, or similar to olive green in color. The green pigment is due to biliverdin, the oxidized product of bilirubin, and over time the green color will intensify. There are several medications and dyes that can impart a char acteristic color to the urine. Although these colors are not clinically significant, they may interfere with color-based test ing methods (explained in the chapter on chemical testing). Methylene blue is also used as a urinary anti septic and can make the urine blue or blue-green. Even food dyes such as those used in can dies can be excreted in the urine, thus affecting its color. Normal urine is usually clear but it may become cloudy due to the precipitation of amorphous crystals. Amorphous phosphates are a white pre cipitate which will dissolve when acid is added. Amorphous urates frequently have a pink color from urinary pigments, and they will dissolve if the specimen is heated. The presence of these cells can be confirmed by microscopic examination of the sediment. Bacteria can also cause cloudiness, especially if the specimen has been sit ting at room temperature. Other substances that alter urine color usually do not alter the color of foam that may be formed upon agitat ing the specimen.

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Syndromes

• Low body temperature (hypothermia)
• Problems at home, school, and with peer relationships
• Weakness
• Cystometry (a measurement of the pressure within the bladder)
• Puberty
• Signs of fluid in the pericardium (pericardial effusion)