Dec. 2, 2021

#57: Pee is the key: how to unlock your cases with perfect-practice urinalysis. With Dr Kristen Todhunter

#57: Pee is the key: how to unlock your cases with perfect-practice urinalysis. With Dr Kristen Todhunter
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Season 1

For such a seemingly simple sample there’s a lot you can learn from a urinalysis. Many of us also have a fair amount of uncertainty around much of the 'how' of urine sample handling, analysis and interpretation. It’s also the one bit of lab work where being good at in-house testing can make a big difference to the reliability of your results. 

We KNOW you’ll have had some disagreements at some point in your career about at least a few of the questions we answer in this episode, like fridge vs benchtop, how old is too old for a urine sample, how long after starting antibiotics can you still culture, is it even worth culturing a free-flow sample, WHEN should I culture, can you trust your dipstick, can you trust AI, why some urinary bugs just won't die, and what the heck is the deal with casts?! I also suspect that, like us, you’ll learn a few things that you didn’t even KNOW you should know. 

Our guest is Dr Kristen Todhunter, a pathologist for the SVS Pathology Network who confesses to having a bit of a soft spot for all things microbiology. She answers all of the questions we've ever had around how to get the most from your urinalysis. 

 

Thanks to the SVS Pathology Network, who our Aussie listeners will know as Vetnostics in NSW, QML Vetnostics in Queensland, TML Vetnostics in Tasmania, ASAP in Victoria and Vetpath in WA, for providing us with the brainpower for our pathology series and for supporting the podcast. If you love new toys and tech (or if you like lasers!) you should definitely check out this video about Maldi TOF spectrometry - the amazing new technology that will explain why SVS clients will now get super-fast turnaround times for their microbiology testing. 

 

Go to thevetvault.com for show notes and to check out our guests’ favourite books, podcasts and everything else we talk about in the show.

If you want to lift your clinical game, go to vvn.supercast.com for a free 2-week trial of our short and sharp high-value clinical podcasts.

We love to hear from you. If you have a question for us or you’d like to give us some feedback please leave us a voice message by going to our episode page on the anchor app and hitting the record button, via email at thevetvaultpodcast@gmail.com, or just catch up with us on Instagram. 

And if you like what you heard then please share the love by clicking on the share button wherever you’re listening and sending a link to someone who you know will enjoy listening.

 

 

 

 

 

 

 

Ization, Crystal Matrix vaporize flight time of molecules, bombarded by lasers.I mean, frickin lasers.You might think I'm talking about some 1980 sci-fi movie, but nope, this is actually how I sponsor for the pathology series will be doing your microbiology samples.
It's called multi tough.Which sounds a bit like something you set on fire and throw it a building during a revolution, not the Pinnacle of diagnostic microbiology, right?There's a video that I'll link to in the show notes, which is just Too awesome in itself, but what's even better is the first comment.We want user says, wished machine actually made those pew, pew.
Sounds in all seriousness.If this is the standard of high quality, high tech Diagnostics that SBS, which if you've been listening, you'll know by now, to be the SVS, pathology Network, composed of red gnostics in New South Wales qml.In Queensland tml witness takes in Tasmania ASAP in Victoria and vet path.
And wa if this is what they're doing, I reckon your results are still inside.Hands, you knew they were good but this is some next-level stuff.It beats the crap out of smearing some gunk out on an agar dish and chucking it in the incubator or the stinky bait.It like we used to call it at the previous job of mine, and then sitting around for two days, while you have to wait for it to grow or not to grow.
And then repeating the process again to isolate the bike from all of the other gun crying on there.And then seeing, if you can kill it with those little and party, confused discs, not with this stuff though.How multi tough, which is short for Matrix, assisted Stood laser desorption/ionization time-of-flight, Mass spectrometer.
How it works.Is that your microorganism sample gets fixed on a matrix and then the little bastards, get nuked by a laser, which totally vaporizes it into its basic molecules so long and then the molecule gets sucked up in a vacuum tube onto a sensor.
But of course, the fat kid molecules, will get there long after like, several microseconds later, then the whoopity little lightweight ones and the Machine is smart enough to calculate who they've just been Right by identifying, the temporal pattern of the molecules hitting the senses.If you're getting confused.
Don't worry.I am too.But did you hear that?I said, lasers.I swear the next time I'm sick.I'm sending my own sampled for multi tough, just to have the joy of knowing that some of the things making me sick, going to get vaporized now because this process only needs a tiny samples to identify unknown molecules.
And means that the guys at SBS can eliminate the purification stage where you have to Res me, the samples to isolate the different parks.What?All of this means is faster results.Better decisions for your patience and help your clients.I guess for this episode is SVS pathologist.
Dr. Kristen todhunter who admits that she has a little bit of a soft spot for all things microbiology and our topic is urine for such a seemingly.Simple.Sample is actually a lot of uncertainty around much of the sample handling and interpretation it's also the one bit of lab work, we're having a solid understanding of how to do some of the testing in-house.
Can make a big difference to the reliability of your results which is why this is such an important episode.Now I know you've had some arguments Least a heated debate at some point of your career about at least a few of the questions we answer in this episode like fridge versus non fridge.
How old is too old for urine sample?How long after starting antibiotics can you still culture?Is it worth capturing a free-flow sample?Can you trust you dipsticks?Can I trust a i that's maybe a broader philosophical question but we mean specifically in the context of urinalysis, I also suspect that you learn a few things that you didn't even know, you should know.
So take that part of pay out of your pocket, sit back and enjoy.Enjoy dr.Kristen tidehunter Kristen welcome to the vet.Well, thank you.Thanks, for having me.Let's talk about P.We have a, we have a rule in our whole school.
That I think I walk around with the whip whipping the Vets at and that's with every biochem needs a urinalysis.So we started the very, very Basics, get your urine and start with a dipstick dipstick.First of all, I never know how much to trust them.
We were taught at that.We all use the human dipsticks and we were told that most of it, you should take with a grain of salt because it's made for humans and some of the results don't translate well to animals.As that changed, you, jumped ahead a little bit how you get it and the circumstances that you're getting it from.
I mean, evaluating a urine that you get out of a kitty litter.Train versus a urine that you've done by sister and synthesis can make a difference Ellis.How soon was it processed, did the owner collected at home?
Did you collect it in the clinic and you're doing it straight away?Those kind of things can actually affect the dipstick.So if the owner drops it in and it's been refrigerated, it needs to warm up otherwise you can get false results on the dipstick.
So I don't think much has changed for dipsticks except as you probably are aware, there's now automated dipstick read so we don't have to decide what color that pH.Is.But the accuracy of those is that any better than human eye?
There's some controversy about that if you're trying to make things quicker than just automate things.Then, you know, doing the dip stick with those automated readers, can be helpful.But whereas with every test that you do need to know what the pros and cons are what, what they actually mean in the circumstances that you collect them.
So with the dipstick, most people tend to look at it.Eph, quite commonly glucose blood, the things that you shouldn't pay attention to would be things like the leukocytes, because that's test just one part of the leukocytes still ketones.
You can look at those and and protein.But again, collection method can play a role in what you get.So you know, are you doing ketones and then absolutely normal dog.What do you do if it's positive?How do you interpret that?
It's a normal dog.There's no glucose and you've got positive ketones so knowing what can affect each test is, as important as doing the test, I guess to some extent.And if you go back with the glucose, you know, reading that it needs to be is the glucose going to be positive because that cat is absolutely freaked out in the exam room, or a nice.
Benign Basset Hound that you've gotten urine from, that's go to 3 plus glucose.And also, as you say with the biochem interpreting it, In context with the biochem.I can't tell you how many times I look at urine and really the urine specific gravity.
It's quite important certainly interpreting eyes at emia just looking at a biochem.If the only thing you can get is a urine specific gravity, it might make a difference in understanding, some of those blood work results, a totally 100% agree there and sometimes urine has the answer.
Like, there's a fever on an origin and then you get, you know, what's the missing link of?What's the In tests which one of you need done year and his dog in way or because I don't like doing sisters or something like that.And and then there you go, you get some pie you year or something like that.Like, sometimes the year and could be the key I think.
Yeah, exactly.But pop in a female dog that you've got avoided sample promise completely different from by area in a dog, done a Sisto mm-hmm.Whatever you take this we're going to go back to bit of sampling things or well I think there's some situations where that Chihuahuas going to bite your hand off and it.
He's on the table.Yeah.Can you use that urine?I use the fewest G.Yeah.Or you can use the urine, but as you say, with a grain of salt in it, your interpretation is different.And if you can do an ultrasound guided sister, absolutely fantastic.
Obviously, most of the guidelines for testing recommend a system for most things, but there are situations as we all encounter, where it's just not possible, you still just didn't like me.It's ampuls.And then you mentioned there for females and they have you see back to you there then you know, doesn't rule in a UTI.
Basically, like doesn't mean that there's an infection higher up.That was my interpretation of that.But what all the things with voided sample?Should you be wary of well?Obviously with voided samples things that pass through the distal urinary tract can create contamination, protein blood did any of those things where you might have contamination from the urethra, the mucous membranes of the penis or the vagina.
There's a lot of lovely Flora that live in those areas that we consider pathogens, that may not necessarily be pathogenic.And, you know, there are cases where you have people who monitor, bladder infections with voided samples that have pyuria and they have a multi, drug-resistant pseudomonas.
However, When I've done a sister, they've got no pyuria and no bacteria.So it's really quite important to understand what's the normal flora of the prepuce and the vagina just because you get it in pure growth.
Doesn't necessarily mean it's something.It means that is a very dominant bacteria, you know, hmm.Especially like a I'm sure everyone can visualize a prepuce the dog with the discharge that comes out of that and then you get it.
A urine sample that it's there.I'll that definitely.But you could you could alleviate some things, by cleaning it before you get that, we same with the vagina.I mean, humans, don't on a routine basis.Don't get sterile sister synthesis from patients.
So there are things you could do to minimize it, by cleaning those areas and, you know, pulling back the freakiest on, you get a sample avoided sample or party.The vulva to some extent or cleaning that area prior to urination that might give you less chance of contamination.
Mmm.Because yeah, open ass.Should I culture it?Should I culture voided urine?Sure, you can culture it, but it always needs to be interpreted in context with your clinical signs and how you collect it.Can I jump back?
A few steps at the beginning right at the beginning.You mentioned how long?How old is the sample?Has it been refrigerated?All that sort of stuff.Yeah.Did you say you need to warm it up before you?Look at it, if it have, if it has been refrigerators or do so, obviously, the, in the ideal world, you collect that sample by a sister synthesis and you hand it to your nurse, or you do it or your intern, if you have one and they Go back and they run that urinalysis straight away.
They do the dipstick, they spin it down and make all the slides.They look for crystals, they look at the psychology you know all done, within 10 minutes, that's not the reality of general practice.So you get the urine and you can leave it on the countertop, but keeping in mind that if you've got bacteria in there and you want to do a quantitative culture that those bacteria will multiply because they love it.
So, I'm doubling in numbers for every half hour, it sits on the bench.If however, and this is an important point, if you want to know any bacteria there.So qualitative you just want to know what's there and what the sensitivity is, then you can leave it on the bench, but this of that is that any fastidious organisms that don't like cold will not be stressed, but the problem is that bacteria Area that might be a dominant makeover.
Grow anything else?It's a man.So most people will put that label it, properly course and put it in the fridge so that when they get to a quiet moment, they can get their lab tech or whoever to process that.So obviously doing that dipstick and they really do recommend that you do those things quite quickly.
But within ideally within two to six hours each day processed.So if it's put in the fridge however you need to warm it up to room temperature.Because Refrigeration can give you false positives on your dipstick.And it can also create crystals that weren't there when you put collected.
It so calcium oxalate and struvite crystals can precipitate in cold urine.So you warm it up.Get a picture before you do any testing or just leave it out till it warms up or in a water bath.Yeah.Going to microwave at first but I think the best way to do it is to warm it up to Room temperature in a normal fashion, it depending on what you collected in, you could put it in a pocket of your shirt, or you could have someone slip it in just under their shirt and your back pocket.
As long as you don't forget it and that warm it up quicker without shocking it.There's ways to do it but probably not a water bath, not in sync and probably not in the microwave.Yeah, okay, cool.Okay, so I didn't know about that but they're the warming it, that's because a lot of it.
Especially the ones that come from home that clients bring in Old Bridge rated and ideally you want them to drop that urine off as soon as I possibly can.So you really don't want them to collect it that night, leave it in the fridge for 12 hours and get it to you in the morning.Because by end the chaos of the morning.
Somebody's not going to process that to punch time.That's an 18-hour old sample.Yeah, I suppose then also if you get a morning voided simple then you get the patient's most concentrated urine as well.I do.Really.Yeah.So there might be helpful in terms of interpreting or evaluating in the kidney function.
I supposed yeah.Then the storage we've touched on this with bread on the in the previous episode but he said you should ask a microbiologist.So again, if I'm going to send it off for culture, I want to know if there's bacteria in there and then I put it in the fridge and which I never understand why should it be in the fridge?
I feel like, but it is that the word you said before because it's quantitative because it's going Slow down, excessive for some people if they're trying to decide whether that bacteria is relevant.They'll want to know how many Colony forming units were there.They want to qualitative and want to know so they can decide whether they're significant or not.
Okay?I would say, on the balance for most clinical practitioners they want to know, is there anything there?Because they suspect that this dog is or a cat, is symptomatic.The The owner wants to treat it with something and they've got obvious, they've done in your analysis or you send it in for your analysis and there's obviously pyuria.
And, you know, the things that you would say this animal has a UTI and then, the most disappointing thing sometimes is to come back with a no growth.Hmm.But that happens.But when you come back with a growth, people want to know like growth moderate growth heavy growth and pure culture or not.
So if you're looking at something that you've been trading and, you know, there's something there and you just want to know any bugs and you can leave it on the bench, gotcha, but your interpretation needs to be, you know, it on the bench for 12 hours.
So keep that in the back of your mom's.It just made my whole car like the whole decision.Making process a bit harder.I just love it.Do you want one?No one do.I want to know what's in there?Real for real or do I Wanna Know There's He things in there.So yeah it also depends on your clinical case, is this the first time I've ever had a UTI current UTI is it associated with something else?
Is this a diabetic or hyper?A dog?That's got a UTI.So if you knew that, okay, so let's say that you knew that those bacteria there and you're treating for a while and you wanted to know when things were getting better or not then you'd use a refrigerated sample because it personally, I wouldn't.
Okay.The news is that you'd given me just a completely different scenario.Sure got a patient that you're treating and you want to know is it working correctly?Yeah, yeah.Yeah.So if you want to know if it's working, maybe you those bacteria to Triple because that means there's a single organism in there.
Okay, cool.Okay.Yeah.A better chance of finding out if it's there and a sensitivity to it.Okay, gotcha.So we wouldn't agree if you're on a fishing Expedition.Yeah.You're just doing a urinalysis is part of a complete workup.Yeah your analysis is fairly okay.
And it comes back with an inner caucus.That's a whole different situation where you've got an animal who's possibly not symptomatic and you've got back to your area.Yeah, the clinical bacteria so there's a whole set of guidelines that have been published in 2019 by an infectious disease group on UTIs.
It Is brilliant.It's a good read and it's good to just refer to.It has a list of all of the antibiotics and how to interpret your sensitivities and in my sea levels and stuff like that.I think it really good levels in the urine things that get better levels in the prostate.
It's quite a good reference article to have when it comes to, you know, simple UTIs versus recurrent purses, prostatitis versus pyelonephritis versus, you know, those situations that we often encounter, Counter.Yeah, get a link to that somehow will.
Yeah, I've got it on this notes and I'll send it to you.It's the international Society for Companion.Animal infectious disease, guidelines, awesome.I put that in China is for sure.Yeah, and it lists all of the antibiotics that we give sensitivity levels to that people, you know, as you probably are, well known clinical practice for coming across multi, drug-resistant bacteria, all of the time.
And so It gives you a nice little rundown of all of these types of things as they apply to the urinary tract.Cool.That sounds awesome.Now, I feel like we're talking about culture.We sort of straight into to be my area.I think we may have to backtrack back to the the in-house analysis.
But let's ask questions about culture, then how long after starting an antibiotic does culture become affected by it?So let's say it's an animal has a full some It has a jab of clever locks in hospital and then you, and then later an hour or two later, you go, oh shit, I should actually be doing urine culture.
Not that quick, not that great 24 hours.Maybe.Okay, cool at times because you gave the job, what the drug is, and what the situation is.So if you are able to take the sample after the animals started on antibiotics or you want to know sedated it for something else and giving it antibiotics.
So now you can take all your samples that that's On, if you got an animal, that's, you know, you're worried about systemic disease or pyelonephritis.Then you'll be taking blood cultures and sister and doing all sorts of stuff like that, and giving antibiotics at the same time, or prior to that, who knows?
So you've got about 12 to 24 hours, leeway on that.But the other thing is is that if the bacteria that you culture ultimately is is or isn't sensitive to that antibiotic, that will also tell you something as well.
So so if you give an antibiotic it's sensitive to it but it's still growing.That means maybe you should continue that particular antibiotic for the appropriate amount of time before you determine its not working or whatever because you only gave you gave the antibiotic 12 hours but you take in the urine so you may know it killed.
Everything does that Ivy and sub caught?It doesn't matter like it depends on the antibiotic.It depends on the levels that they get in the year.And how quickly they reach those.So it might reach.Therapeutic levels in the urine within, you know, two to five hours.
Does that necessarily mean it's actually going to get to the bacteria?That's in the Earth.Are you going to kill off?All of them?This is a really good conversation because this is like a conundrum that we have.That's kind of like we need all the samples of what we give IVs.But then the dogs looking like it's dying of sepsis, you know, and then kind of like every hour that you delay, giving anybody asks, The more likely the patient's going to die.
So yeah, I don't know.And if something grows then, you'll know maybe that's something else in there that you aren't treating without antibiotics.It's quite a good scenario that, you know, some people recommend culturing while you're under treatment to see how it's going and what happens when you get a couple of different results?
What what should you assume from those results while they're on the antibacterial treatment?I think I'll always thought like so before And then stop, then maybe adjust when you get your results.And then it's like every concert was a two weeks and then then two weeks after you get a negative or something like that, like that's dumb head.
Yeah, I guess that would be in a really, just a simple uncomplicated UTI and you've got resolution.Do you need to follow up and keep going?Maybe not.Maybe you don't need to do that to week, six week, you know, if you've got a recurrent Action.
That's that's a whole different ball game as far as what you're doing because generally after two weeks sometimes, as early as 5 days, you get a recurrence of the symptoms and frustratingly.You're growing the same bug with the same sensitivity pattern that you should have gotten first time.
And usually when you get that sort of situation, may be something else going on or you're not getting through to that biofilm, which is really what people need to start, considering that b word, in a lot of bacterial infections.No matter the area often bacteria, make these biofilms that are quite protective and you can get mixed organisms in these biofilms, incredibly frustrating like the ear.
So you're in the most difficult biofilm to try and penetrate through is the E.coli, which is the number one bacteria isolated from urine.Cultures and these E coli can make not only extracellular biofilms on the surface of the bladder but also intracellular biofilms within the cells.
So They've got multiple layers of protection that you're going to have to try to figure out.If this is the case and often, if you have multiple UTIs within a short time of each other and it's an E coli, that's probably what you need to start thinking about.
There's a lot of research out there and all of the current research these days especially for humans is what can we do to dissipate or get through that biofilm without actually hurting the mucous membrane and mucus layer.Our of the GI system of the bladder, what can make the antibiotics that we use more effective in getting through those biofilms and actually becoming more effective in eliminating infections and that's a problem in the bladder.
So just to be clear, the biofilms.Not just around the bacteria.They sit on the bladder wall and actually cover themselves with a focus.Yeah.The mucus disabled.So the antibiotic can't even get near them because it can't get through the wire form.That's right.So what's the answer?
I was about to say.They go in their hands on the bacteria.There's no one answer for one every situation and it just depends on the bacteria and the more distant the bacteria probably the less biofilm.So the more susceptible your bacteria is especially E.coli the, more likely it is to be about a film producer really, so your results say yeah I'm easy to kill, you'll know before.
And that's what the dog was on.And then yeah, it goes off its back again.So the bacteria says, yeah, don't worry, you can kill me.Try those drugs at me.I'm fine.And then it says on your underlying causes like Cushing's or diabetes or whatever or some kind of immunosuppressive city and then, yeah.
And then you've got these little bastards with biofilms.Now, still want to know what you do then.There's a lot of things out there that can help.So you have certain antibiotics that are very good at penetrating biofilms.So, it'll act times aren't penicillins aren't, but they're actually a really good drug for certain types of bacteria like inner caca, but they just don't penetrate biofilms as well as say, fluoroquinolones who go right to the problem.
But we don't want everybody pulling out loans, right?Out of their pocket.Do we?They may not need it.So to be reserved for the situations that are chronic and problematic and symptomatic.So if you've got that situation with a biofilm, there are some things like a pseudomonas where you can use to medication to antibiotics together one to sort of dissipate the biofilm and one to actually get through it and kill the bacteria and there's a lot of research on that in humans.
But these multi drug-resistant bacteria but it You can imagine how hard it is to get a pseudomonas.I think I would rather tackle that though, then one of these Eco lies that are so sensitive and living intracellularly and just keep my currently happening.
So, this information is part of that guide or in the guide at the bottom, it is.Yeah, it is.But these are guides and not, you know, rules mmm.So they can't say okay specifically in this case, this bacteria with this circumstance, this is how you Read it.
That's why you develop a relationship with an internal medicine Specialist or a microbiologist or someone who can you say to them?I've got this case this situation.What do you think?This is where your phone your pathology.The question always have with those like consensus statements which come out with kind of dissing your body for this particular thing and like the its research like microbiologist.
From around the world or something like that.Is their Regional differences on you take when I was consensus statements and then go, yeah, that applies to us or is are big differences between us and Australia with those.Yeah, there are differences.Are certainly differences between the US and Australia and certainly, this is even how you get reactions to drugs from us and Australia.
But what's really good about this consensus statement that I was speaking about?Is it actually recommends that you as an Jewel, practitioner in your hospital, come up with your own antibiogram to figure out what's happening in your area.So to they have an example is what I mean is that just take all the urine is that you do by sisters and tasteless and send off for culture, whatever you got back, E.coli in our caucus, whatever, just collate that information into how sensitive they were.
And then what you can see is that At.Wow. 60% of the Eco lies that I get back or actually sensed it to penicillin or amoxicillin.That's your first line.Say none of them are sensitive to Amoxicillin but all of them have been sensitive to clambulance.
So what drug are you going to pick first on that first time?Hmm.And if you do in-house urinalysis and you do see rods or cocci.Even if you go, that basic, which one are you going to pull out?If it's rods then your chances are 60% that it's going to be a Nicolas.
Hmm, Paco, High then it could be an inner caucus or staff so knowing what you've gotten in your historical in your area.That doesn't mean you don't do culture, that just means that when you have to put the animal on something first before you get that culture back, or if it's the first time, you know what, you can pull out, that have the best chance of working and that is strictly Lee for your hospital in your area.
Hmm how do you regionally?We've looked at things in Victoria versus things in Sydney and in one group in one area, the E.coli were fairly sensitive to Amoxicillin.So that'll be the first thing you pull out, but they were not sensitive to amoxicillin and another it was cloudy locks Catrin interesting think that the biomes would be that Regional.
So no, but the I guess it's about what they've been treated with before.What their humans have been treated with before.There's a lot of things that come into play in your area.If you have a low socio-economic group where there's not a lot of preventative medicine and you know that happens or if you have a rural area it can make a difference of Europe.
Nick that's been there for a long time.Probably, the local biome is created by you.It's partially created for you over the last couple of decades.Yeah, definitely still influence.And what about the ones you mentioned earlier where you do your in-house urinalysis and you see pyuria and then you send it off and then you get back up my nothing, nothing grew.
What does that mean, why does that happen?Is that something I did wrong in the clinic?Well, there's a couple of different reasons.So if you've done your analysis and you, then you do your sediment.So you do what?Prep?And ideally, you've done your one stained with methylene blue and the other.
No stain at all.Drop your condenser down and see what you see.Sometimes people misinterpret, what they stay as bacteria.So the other recommendation is to make a dry prep of that sediment as well.Now, the reason this can be incredibly helpful, is once you make that, you have Frozen everything in time.
So if you need to send that to That have someone else review it, if you can.But the thing is, is that what you might not exactly recognized as cocci, and it looks like Brownian movement or whatever.You might think you see under the microscope with the wet prep.
If you stain it with a diff quick, then you might definitely see that.That's cock.I can't miss that.That's yeast.That's rods.So when you use your sediment, my recommendation is to use four drops, you can use for size, you can do is one for the wet.With with a little cover slips, and do one stain one on stain.
And then to dry ones where you can put them on the side, and you can just sort of slide them together to make two for you to separate ones.But they need to be smeared out, gently air dry them and then stain one to look yourself and keep one on staying.
In case you want to do a Gram stain or send it to the lab for a second opinion.So it's a really quick thing.You've got the sediment made you might as well just do it.Beep.What you might mistake is cock.I might not necessarily be that.And the other problem is that you can get anaerobic, cop car that don't grow well in Aerobic, which it's being shipped to the lab in a container with air and stuff like that and stuff actually.
So that can happen to and that.Or that's what happens with all my samples probably they could die.So as you say, they're very sensitive and so they're not wrong.Those are just going back Brownian movement that's a little I'll be looking down.The microscope is a little busy thinking yeah but keep in mind though unless you're trying to do it unless you train another nurse or technician who does it all the time?
Hmm some people aren't going to really know what they're looking at and so they're just going to think any round things under the scope or Kaka and must be bacteria.Yeah.Any tips that you because that can be challenging.I feel like I'm I've been looking at urine for 20 years and we spend a lot of time with our unique look.
It.Yeah, but I still sometimes struggled.Sometimes you still look at them and go.Are you a bacteria or are you just how often do you change your stain?So what you might see as oh God it's full of whatever but you haven't changed that stain in you know, a month or more.
Yeah.So how do you know that's real?So it's a matter of evaluating your own lab practices as well mythili.Blue.What does it do, does add contrast highlights?Well, it does stain some things so that you can see.
And I think what you would say it gives it contrasts, but if you don't have it you don't need it.As long as you drop the condenser on your microscope.Yes.So that's gives you the most contrast really so you can pick out things and if you can use methylene blue, that's fine.
What they're hoping is.It might stain?Some of the bacteria.Lipid obviously won't take up staying because will be hydrophobic So it might help differentiate some of those things, that might be a little bit, you know, you can upgrade it and identify maybe what some small leukocytes look like versus a red cell and things like that might give you some degree of detail that differentiates between things under the microscope, but if you don't have to have it, mmm, but it can help it's great to look at them side-by-side.
That's why putting one drop undercover without stain and one with stay.They could be helpful and you're looking at the time is 40 or times 100 or always need to scan first for X because you want to look for Cass.
Doing a urinalysis and house during your own.Psychology is the best chance of looking forecast.Mmm.You know in transit, they'll break up.They'll fall apart casts aren't common but you you'd be the best one to look at it.And also just picking up crystals.
It's hard to know whether that's real when they're in transit refrigerated everything else because like I said crystals can precipitate they form they dissolve.So looking at looking for crystals right?Out of the animal is the best and just to clarify, why not just go straight to diffic?
Why do we have to look at the and stained or the plus or minus the the methylene blue, what's the advantage of can?But then again also did quite can distort things as well.And if we're going to be better for cellular elements, especially if you're concerned about neoplasia dysplasia or something like that, it's going to be better for the things that we would normally look at not necessarily crystals or it might alter some of the aspects of the urine that, you know, probably might misinterpret.
So okay, you can do that.But again, more information is best the quickest way to evaluate it is going to be without Mustaine and wet Mount.If you ask for, Cytology when you send it away, all of those cells will fall apart in transit.
They just can't help it especially if they're bacteria there, and he's probably really frustrating for people to send away your analysis for cytology.And we just say, look, the cells are two degenerate, I'm sorry, I can't tell you anything.So if you make that sediments near there and that's ideal, otherwise, I recommend people actually send in an aliquot of the urine in EDTA and a purple top.
To because the bacteria don't grow in the presence of EDTA, it does preserve cells when you send in peritoneal fluid or abdominal fluid.We always ask that you send it in a purple talk to you so we can do a cell count and do appropriate cytology but we don't culture from that because ETA will prevent bacterial growth rather than eight.
Wow, that's the first time I've ever heard of that.Now, here's another first to to know exactly if you take a system, Stout and you're not concerned about quantitative numbers.What a blood culture bottle?Okay, that's a great media for enhancement.
It works for both anaerobic and aerobic and if anything is going to grow is going to grow in a blood culture book, so that's like if there's a UTI there.If anything, is there in there, you want to know if there's anything in there because you won't be able to say oh that's really low numbers because you've enhanced it so they'll be fine.
And I will ask for enhancement because, you know, it's a situation where there is going to be bacteria.There, we just got to make sure we just got to make sure there's not.So let's recap if I'm hunting bacteria, then as you say, consider culture bottle, then this is don't necessarily put it in the fridge and send it off to you guys if I'm concerned about cells.
So if they say technology, if I see something, I go, what the hell is that?Then consider sending a sample in ETA and make a fresh smear and send your smear along with the sample.Yep.That's it or ideally if you don't have enough urine because, you know, we don't get huge parts of it.
Just send us men.Yeah, okay.Mmm, I'm a big fan of blow dryer things because of emergency and like a can't wait for it.How much?Like a I kill things with the urine.What is it?Dude, it can certainly alter things.I mean, what does it do to your hair when you're blowing it dry?
Makes it gorgeous.Keep in mind that, you know, you're blow drying it.So you putting that heat really close to cells.It's not a gradual thing.You're like fry and so it can distort things, it can be really quite annoying.If you're that, if you're that impatient get a slide warmer and just put it on there and that will gradually warm it up.
I've seen people put them on top of coffee machines.Yeah.Anything that has a little bit of warmth to it will speed it up without hurting it.If you have an Apple Watch The, you monitoring your movement or any of them, go with your watch hand because that adds a heap of Steel to watch them your way steps.
Here's my tip, for the day, is there anything more there?Because this is, I've learned a lot from.I almost feel like we could just wrap it up.What you did want to know about the AI machines?Did yes, that's an exhibition other that's it.Is that is it evidence?I'm old school again.I love looking at my own stuff and then this machine or ivory My old job is like, I don't trust this thing to give me results.
Are they what are they like?Do we know?Well, they've been debates on them.There's been discussions in groups versus these AI machines and the pros, and the cons, and things like that.And if you're very time-poor again, it's just like doing your own samples.You've got to know what the circumstances are and what their drawbacks and everything else.
So with these machines, if you think about what you do in the clinic, basically, now you Just dipstick slides stain.Maybe that's it.This machine is going to be consumables.On the other hand, you can train anybody to do it.
You know, you can train somebody to set it up but in the end, both of them require a degree of knowledge about things because they will show you photos of the sediment depending on what you do.And you need to judge whether that's right or not those papers out there that talk about It is good for.
Is it good forecast?Well, you know do you really see that many was that what you're interested or you really just interested in the crystals and the setup?So yeah, there's some degree of if it's negative then that that so you can be comfortable that.It's - but if it's positive, you might get false positives and things like that for crystals.
Most of them only look for the two main crystals which are calcium oxalate and struvite crystals my forecast, Then either their hyaline casts or non hyaline casts.How well, they're not giving you the amount of detail.That's what you want.
You can hand out a nice report to the owner with pretty pictures on it and that might go towards your marketing.It just depends on what you want out of your machines, but it's about time, I be the kind of guy that if I saw something on the sediment images, I got get the slide and I go and look at it myself, it's like, yeah.
Hematology machine is these kind of things.I want to see myself to dude.Like I don't know if I'd ever so you should.So yeah, we're they both work to some degree and they make a difference for people who Are only interested in ruling out, the common things, which is what they're made for, but there is a degree of sometimes.
They miss the common things, and that's actually the key to the diagnosed.So you need to always look at the at the photos of the sediment and K.Now if you want to look at the 70 photos that would be me, would it be like a good?
Like if you see a clear if the machine gets it, clear, then to Clea as opposed to, this gets a positive, then I would still go to the sediment but it could be like a ruler, like Misty, put it through the machine.Machine gets all clear.It doesn't say anything.Then you kind of know, sort of it.
Like it's a very sensitive test.Yeah, it's very specific.It's not okay.Yeah.And I always have to look up the meaning of those but yes, if it's negative you can be comfortable in it, that it's Even if it's positive, then that could save a lot of time actually.
Should we dig into costs for a little bit?Because I'm a, like a big cast kind of dude in a sense that like, once you know what they look like in a way then you kind of see them.But some people don't.Yeah, so I for me there like a tubular structures, like you shouldn't have a tubular things like shaped things in there.
And if you shake every sample too much, you get it all gets broken up.But once I saw it last once, then I knew, then that's what it cost look like.It's like a bull.I can see them now so it will kind of microscope.You got 2 times 4 times 10 and then you've got the times 40 times. 100 or 4100.
Yeah.And so you can ideally you want to scan the whole sample under for and you want to put things.If it's avoided sample, you've got to be cautious because you can get for and debris that can mimic casts.But what's really good is to have some A really nice posters moocher out there on the wall at the microscope.
So that when you're scanning it for x and you look up and you go, oh yeah.Okay.And generally if you have to ask, is this the cast?It's probably not.They stick out you because once you see them as you said, you know.
Oh, that's a cat.Oh, that's a glucoside casa.Yeah, that's cool.You know, that's why having the methylene blue as well.Can help bring that contrast to it. but it's really helpful especially if you're not looking at huge numbers to have those on the wall, next to the microscope or available ideally so you don't have to page through pages but so that you can remember what each individual type of cast looks like so that when you do come across it or your technician or your nurse or whoever then they don't have to spend time looking it up they can just look at that and go oh no no that's too irregular that's too small and then they're worried and they can come and see Anil to you and say, hey can you just come?
Look at this, some just a little bit worried, it's a cast and and that's a great collaboration because and you can both agree or disagree on it.So it's the same thing with a lot of epithelial cells or anything like that, where you're looking at them and having those reference pictures, people, remember, pictures, and remember pictures in color and things like that.
A lot better, my tight with cars or my understanding of them is like okay it's fine if you got white cells, right?And there'd be like basically tubular structures full of bacteria and white cells, right?Like something like upon the fried or something.But if you got like some kind of kidney damage and the epithelial cells of the tubules or something, we're starting to Slough off like my thought was he was a spectrum like the more cellular they are, the more acute the injury is and the more clearer gets the more chronic.
It has is, is there some kind of relationship like Like that or not really, not really that I could find.And certainly people who look at a lot of, I would say some of them are Urology, Specialist would probably be have a point of view on that think that most people are just lucky to find the cast's to decide whether or not your kidney damage has acute or chronic and in context with biochemistry and acute phase proteins.
And things like that, you're probably going to have an index of suspicion that whether it's a cuter, On it anyway.Severe as a team here, and you look on the markets going to this costs everywhere.And you're like, just as nasty one, at least economy, it means is kidney involvement if we're going costs.
Absolutely.So you should see most casts at times war, and then you can zoom in to kind of see what they're made of, but casts generally, tubular structures shape of a, of a tubular, in a sense.Yeah.Well, sometimes they can have, they definitely a tubular structure, but they can have tapered end.
At times.So I guess some people might look at them and in that context as parasites or, you know, broken off bits of something.Like I said, it's really good idea to have photos or some sort of reference material when you're looking at them, especially if you don't see them very often.
Yeah, I've looked at a lot of them here in Psychology, I've never seen a cast except in a wet in a clinical practice.So that's one of the good points about doing it in-house.Is that you're going to See more casks and I do yeah, okay, let's start wrapping up one, very simple, very straight, very practical question.
I asked about how long between starting antibiotics.There's a start affecting your culture, same with the HG.We haven't even really touched on HG.Very often you have these cases and they come in and they don't fluids because the bladder is empty and you can't get to sample until later.Yeah.
How much can I trust?What my SG says, once the animals on fluids is it as soon as I put it in a drip?Don't trust it.SJ anymore because the urine that's produced when you say, no, it's not as soon as you put it on fluids, but if you can think about in your treatment history, how long does it take for an animal on fluence to pee?
Mmm.So kind of depends on the volume, the boluses, how thick it is.Yeah, I thought urine from dogs, who have been on fluids for 67 hours because if they haven't as a team Mia, and then they have concentrated urine still or like something like 10:30 then, And if you don't fluids and I've given a couple balls has then I know that urine was concentrated to begin with.
Yeah.And exactly.Yeah.It's a matter of being in context, I mean and you can most of the time when they give you reference intervals for your own specific gravity they are assuming that it's without any fluid therapy or diuretics.So that's really going to be a clinical call and I would say that as soon as you could get urine, you stood and these days you can what almost scan it with your phone with an Ultrasound, you know, as soon as you can is great, but always that interpretation will have to be in context to the clinical situation.
Yeah.Magnificent just a new religion, thank you.That was really interesting.Thank you so much.Every time we do this I think I know what I'm going to led by that.Every time I lived so much like this results in that you deterioration of those were the good and then like that and then the differences between refrigerating and not refrigerating, I think that was pretty.
Be good to.So your colleagues are going to see you walking around with tubes of urine and your pockets.So, I generally actually this regions of Europe against my ego, that's why I won't have enough pair to the worst.Is when you get home, just grabs any on the back, you get your keys.
I think, why isn't it?

Dr Kristen Todhunter