urine past – present- future dr. david petts. in the beginning l 6000 years ago –babylonians –...

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