urine past – present- future dr. david petts. in the beginning l 6000 years ago –babylonians –...
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URINEPast – Present-
Future
Dr. David Petts
In The BeginningIn The Beginning
6000 years ago– Babylonians – recorded – colour & clarity
500AD– Brahmins – melita or ‘honey urine’
9thC Razes – a Persian – Haematuria
MedievalMedieval
Matula 24 types of
urine– Colour– Clarity– Smell– Taste
Early Urine BenchEarly Urine Bench
1818thth Century - Century - ChemistryChemistry
Dobson – Urine from diabetics fermented– Residue sweet
Richard Bright– Bright’s Disease – Glomerulonephritis– Albumin
went cloudy when heated in a spoon
1919thth Century - Century - MicroscopyMicroscopy Vigla & Rayer 1837
– Established microscopy of urine Becquerel 1841– Irregular Erythrocytes in Bright’s Disease
Simon– Casts in Bright’s Disease
Bird 1844– First Book Devoted to Urine Deposits
Rieder 1898– Comprehensive book Urine Sediments
Lionel BealeLionel Beale
Some urine Some urine depositsdeposits 1858 1858
1919thth Century Century Bacteriology Bacteriology
Pasteur & KochPasteur & Koch
Early Bacteriology of Early Bacteriology of UrineUrine
Edgar Crookshank– Manual Of Bacteriology 1885– Urine as a Culture Medium
Collect after cleaning with – Corrosive Sublimate!
Early Bacteriology Of Early Bacteriology Of UrineUrine
Dr S L Schenk– Elements of Bacteriology 1892– Bacteriuria has been described – appears to be of a morbid nature
Thomas Bowhill - 1902– Micrococcus urea, Micrococcus urea liquifaciens, Bacillus
urea, Urobacillus pasteuri, Basillus glischogenus
Most mention Tuberculosis & Typhoid, and collection with a catheter from ladies
Early Mid 20Early Mid 20thth C C
Topley & Wilson 1st ed 1929 MacKie & McCartney 3rd Ed 1931– Cystitis - Bacterium coli
Whitby 4th ed 1944– Bact. coli
When I was Lad (1962)When I was Lad (1962) Universal -
– Note appearance – colour & clarity– Culture -1/6th McConkey & 1/6th Blood Agar
Centrifuge – 10 min. Microscopy on deposit
– Cells per high power field Introduction to Medical Laboratory Technology
– 1st ed 1955– 2nd ed 1957
Supernatant – Chemistry– Boil to detect albumin
The RevolutionThe Revolution
Quantitative culture Quantitative microscopy New culture media Chemical Dip Strips Mechanisation
Quantitative CultureQuantitative Culture
Kass 1956 & 1957 Mantra
105 = significant 104 = borderline <104 = not significant
Quantitative Quantitative MicroscopyMicroscopy
Little 1962 showed WBC counts on deposits unreliable
Un-centrifuged urine– Counts per ml or litre
Used Haemocytometer Costly, fragile, slow
New Culture MediaNew Culture Media
MacConkey–Without salt
CLED–With Andrades
Beta-Glucoronidase Agar (BGA)–With spot indole
Chromogenic media
Quantitative Culture Quantitative Culture MethodsMethods
ScientificScientific Dilutions Pipettes Whole Plate Pour Plates Not suitable for
routine use
Quantitative Culture Quantitative Culture MethodsMethodsRoutineRoutine
‘Standard loop’ Blotting Paper Strip Multipoint Dip – slide The drop The Swab Bit of a plate
Counting BacteriaCounting Bacteria
Standard loopStandard loop– 1μl, 2μl - down to 101μl, 2μl - down to 1044/ml/ml– 5μl, 10μl - down to 105μl, 10μl - down to 1033/ml/ml
Paper stripPaper strip– down to 10down to 1044/ml/ml MultipointMultipoint– down to 10down to 1044/ml/ml
Modified Counting Modified Counting ChambersChambers
Hilson 1964 Petts 1972 Kova Slide Microtitre tray
HilsonHilson
Petts 1972Petts 1972
Inverted MicroscopeInverted Microscope
Lumac
Orbec RAMUS 256
CellfactsCellfacts 2
Clinitek 200
Sysmex UF 100
UF 1000iUF 1000i
sediMAXsediMAX
939UDx™ Urine Pathology System
iQ 200 SprintiQ 200 Sprint
Mastascan Elite
‘Standard MethodsStandard Methods’
Where are We Now?Where are We Now?
You Therefore You Therefore Now Have a Now Have a
National StandardNational StandardMethodMethod
Which Everyone Uses ?Which Everyone Uses ?
The Routine The Routine UrineUrine
The Routine The Routine UrineUrine
A lot of unnecessary pissing about ?
A lot of unnecessary pissing about ?
Size of the ProblemSize of the Problem
400 specimens/day 350 labs in British Isles = 140,000 a day About 1million litres a year Olympic swimming pool 2.5 million litres
Quality MattersQuality Matters
Squamous Epithelial cells Squamous Epithelial cells – 54% of hospital samples 54% of hospital samples
– 64% of hospital samples from females64% of hospital samples from females– 44% of GP samples44% of GP samples
– 54% GP samples from females54% GP samples from females Mixed growth Mixed growth
– 18%18% <10% of samples abnormal<10% of samples abnormal
Use of UrineUse of Urine
UTI is the 2nd most common infectionUTI is the 2nd most common infection Used to investigate more than UTIUsed to investigate more than UTI
NephritisNephritis HaematuriaHaematuria ProstatitisProstatitis
And other infectionsAnd other infections
Why Is It Sent ?Why Is It Sent ?
Does the patient have UTIDoes the patient have UTI MC&SMC&S
““Fishing trip”Fishing trip” ‘‘Routine’Routine’
JICJIC To check results obtainedTo check results obtained
Who Does the Work?Who Does the Work?
The most junior staffThe most junior staff The least experienced The least experienced
The least knowledgeableThe least knowledgeable The locumThe locum
Low status sampleLow status sample
What do we look for and What do we look for and why?why? WBCsWBCs RBCsRBCs CastsCasts
CrystalsCrystals Epithelial cellsEpithelial cells Other thingsOther things
Do we answer the Do we answer the Questions being askedQuestions being asked ?
Sometimes Most of the time Standard approach– One size fits all
How Do We Reached How Do We Reached Nirvana?Nirvana?
Or Should We Reach For Or Should We Reach For Nirvana?Nirvana?
Tomorrow’s World
If I Ruled the WorldIf I Ruled the World Education– Requester
Education– Patient
Education– Laboratory
Make the investigation very expensive
Wish ListWish List
Better patient-side test Standardised container Improved preservative All ? UTI specimens to be
supra-pubic aspirates
Next WishNext Wish
Automation–Not mechanisation
From specimen to result Hands off 24hrs a day
How?How? Improved flow cytometry for bacteria– Greater use of specific fluorochromes
Dilution and liquid culture– Count after a few generations
Positives – direct broth sensitivities & IDs– Viability fluorochromes and fluorescent
antibodies– Size comparison flow cytometry– Enzyme ID
Vitek etc
The MachineThe Machine
Cumulo-cuculus-terra
Cumulo– Cloud
Cuculus– Cuckoo
Terra– Land
The End