[Urinalysis] Sperm

                                          Image by Cooldesign, from FreeDigitalPhotos.net

When we take a look at urine under the microscope, there are things we tend to look for. Most of them seem pretty clear cut on why they are reportable - they are signs of infection or conditions that the doctors can then treat. Bacteria, and WBC are both obvious signs of urinary tract infections; yeast signal a yeast infection. White cells casts can predict pyelonephritis, and red cell casts glomerulonephritis.

 But what about sperm?

Shouldn't sperm be something we see in every male midstream sample?

Nope.

Spermatozoa are only normal if the sample isn't midstream, AND the patient has had sexual activity within five hours of collection. As collection protocol for urinalysis is midstream, we should not expect to see sperm in sample.

Sperm is seen in midstream urine when the bladder sphincter fails to produce the usual tightening before ejaculation. The sperm then travel into the bladder instead of out of the body, and are excreted during urination. This condition is called retrograde ejaculation, and can be due to nerve damage, diabetes, medication side effect, post bladder/prostate surgery, or weak muscle condition. This is one of the more common causes of male infertility, and can be treated.

Another reason sperm may be seen in male patients' urine is prostatitis. When the prostate is swollen with fluid, it can block off the paths that sperm would normally travel, causing a redirect. This can be due to prostate cancer, recent surgery, bacterial infection of the prostate or urinary system, or arousal without ejaculation. Sometimes this is also seen when methods to avoid mess are used in sexual expression; the interference (or application of Hughes Method) to prevent ejaculation can cause backflow into the bladder. Unless other symptoms are present, treatment is generally unnecessary.

Reporting sperm in male urine can be a real clue to infertility patients

.What about females and children though? You should never see sperm in a child's urine. If you do, you must report it; that child could be sexually abused. I would advise confirming with a second sample if you can, to ensure there are no mistakes. Know that you cannot be sued for bringing this to your hospitals' attention so they can follow up; this is part of your duty to report as a technologist. In one case, the parents attempted to sue, but failed. Seeing sperm in an adult female's sample is a non-clinical finding.

[Hot Topic] CBS Blood Donation Policy, Update

Last year, the big news was Canadian Blood Service's attitude change towards accepting blood donations from gay men. Previously completely banned, gay men can now donate blood if they have had no same sex sexual activity for the past five years.

This is a huge step for Canadian Blood Services.

Last year, they had still not quite ironed out how this change would echo through the rest of their policies.

For instance, what about women who had had sex, even once, with a man who had had a male sexual experience? Up until last May, they were also still excluded from giving blood. Even last May, when I called and spoke with a CBS associated nurse, they were still excluding those women from giving blood, as they "just didn't know" how things would play out.

I called back this year and clarified. Now the question for women has been changed from

"Are you a woman, who has had, even once, had sex with a man, who has had sex with a man?" 

to,

"Are you a woman, who has had sex with a man, who has had sex with a man, in the last five years?"

I.e. if the same sex sexual experience took place greater than five years ago, then you can donate.

This is particularly applicable for bisexual men and women, or partner's of those who "experimented" in college. Previously, if they were aware of their partner's past, they would have been permanently deferred. Now, if it has been more than five years since the MSM encounter, women are eligible to donate again.

As always, if you have questions about your eligibility to donate blood in BC, call the donor line at 1888- 2DONATE, and ask for the nurseline. They will be able to help address concerns about whether you are a good fit for a donor.

CBS continues to collect data to see if it can relax it's deferral policies in the manner any further.

It will likely be at least ten years of data collection though before we see any more change. One step at a time though is all we can do.

Hopefully, the screening process will continue to move more towards an actual sexual-risk based policy based on number/frequency of sexual partners rather than the sexual orientation of the donor.

[Acronym of the Day]: DAP

Acronyms are certainly part any workplace's jargon; the lab is no different in that respect.

One of the more important ones to know about is DAP.

What is DAP, and what does it do? The Diagnostic Accreditation Program, according to the DAP website:

"sets accreditation standards for best practices that are evidence based, outcome focused and aligned to the principles of continuous quality improvement. The accreditation standards are comprehensive and address medical, technical, and management aspects of service delivery."


Since 1971, each facility in British Columbia that performs laboratory testing must be DAP reviewed, public or private.

What this boils down to is every four years, an outside team of your profession/stakeholders comes in and goes over your work with a fine toothed comb to ensure you are meeting standards in patient care, quality, and safety. It sets an external standard of trust in the system, and encourages vigilance in maintaining current methods, up to date safety procedures, and overall evidence based best practice.

DAP also produces a line of external quality control samples, or blind controls, to ensure your results are accurate. They are released quarterly, and laboratories that do not meet standards are held accountable.

The DAP is headed by some of the top minds in each discipline in the province; there are representatives from the management, educational and the vocational views on each board. They in turn supervise DAP teams, each formed depending on the facility and disciplines necessary in review.

If you have a chance to participate in a DAP review of another facility, take it; it's a great way to learn from the ground up.

New in Serum Osmolality: Zander's Formula

Serum Osmolality and OGAP... two of the formulae chemistry techs can do in their sleep. We all know the standard textbook Worthley et al equations;

Serum Osmolality (all in mmol/L):

2 Sodium + Urea + Glucose + 1.2 Blood Alcohol

Osmolar Gap  

Measured Osmolality - Calculated Osmolality

To make it easier for doctors or nurses without a lab handy, many websites/apps are even set up to do the math, with the reference ranges and criticals on the side. We've used the same formula for more than twenty-five years.

Last year, 2013, Zander's Formula was released as a "better, more useful calculation" for osmolality.

Zander's Osmolality (all in mmol/L): 

(Sodium + Urea + Glucose + Potassium + Bicarbonate + Lactate +6.5)x0.985

How is it better? Not only does it show a much better correlation between calculated and measured, it also has the closest 95% limits of agreement, when compared to 36 other possible formulae, (including the Worthley.) 

This new formula also only uses analytes commonly found on a blood gas analyzer panel. This will enable, in the future, a calculated osmolar gap to be added on automatically to trauma panels, giving the clinician one more piece of the puzzle in differentiating metabolic acidosis.

This is important because with such improved accuracy of OGAP, we would reduce the necessity for follow up methanol or ethylene glycol testing on many of our trauma patients who present with elevated gaps due to renal failure/shock/lactic acidosis, thus speeding diagnosis. (Remember though, the measured osmolality MUST be done by freezing point method if looking for any types of alcohol, as vapour pressure methods don't detect volatile solutes such as ethanol/methanol)

That said, Zander's is built to be used broadly; it doesn't include ethanol contribution as a matter of course; you would have to add the 1.2(ALC) yourself, to rule out/confirm any gap being due to ethanol rather than methanol, mannitol, or any of the other usual suspects. Depending on your population and preferred use, it could do with some tweaking.

[Hot Topic] Changes to Blood Donation Policy

Jargon: none

The right to donate blood into our national Canadian reserve has been limited to straight donors for over twenty five years (since 1985). The act of "men having sex with men, even once" has been listed as a clear high risk activity on questionnaires, and up until this year, has been a cause for a lifetime deferral, or ban, from donating. This was during the start of the AIDS/HIV epidemic, and we simply didn't have the testing knowledge to differentiate who had AIDS/HIV and who didn't. What we did know is that AIDS/HIV was being seen mainly in one population (MSM), and we needed to do everything in our power to prevent it's spread. At the time, generally everyone agreed that it was a good idea to ban donation.

Canadian Blood Services website states:

"All men who have had sex with another man, even once, since 1977 are indefinitely deferred. This is based on current scientific knowledge and statistical information that shows that men who have had sex with other men are at greater risk for HIV/AIDS infection than other people."

While the highest incidence of AIDS/HIV diagnosis/transmission is still from men having sex with men, there is also a high rate of heterosexual women being diagnosed each year. Our rules are no longer taking the appropriate risk factors into consideration... It's not the orientation that increases risk, it's the sexual behavior.

Right now, the donation questionnaires default to permanent ban on blood donation for any male on male experimentation at all; a permanent deferral for women who have sex with a man who has ever had any sexual contact with a man(bisexual men); and yet only a six month deferral on heterosexual people who have had sex with someone new. It's deemed to be "too invasive" and possibly "would deter donors" to ask any more specific questions about the sex lives of heterosexual donors. So Suzie, who has had three failed dating relationships this year in which she didn't use a condom, gets a six month deferral; but a gay man who has been monogamous with his partner for tens years would still be automatically banned for life. If Suzie starts a relationship with Jim, who experimented in college before deciding that he was heterosexual, Suzie now is deferred for life as well.

Over the last ten years or so, momentum to lift this ban has increased exponentially. The argument states that it is not the genders of the people have sex that is risky, it is the sexual behavior. Our technology has improved to the point of being able to screen for HIV in under three minutes, if testing for HIV antibodies (Health Canada approved BioLyticalInsti HIV test), or within ten days of infection, with the RNA amplication method. These testing methods have a 99.96% accuracy rate, and current process ensures blood is double checked for HIV/AIDS with a traditional test as well. We no longer have to worry about not detecting the AIDS virus.

On May 22, 2013, Canadian Blood Services release a memo updating it's policy to reflect this advance in technology and a more action based deferral policy. Now, Men who have had sex with men, if they are abstinent for five years, are now eligible again to donate blood. This change in policy, while a step in the right direction, is still problematic. The centre's media contact states that they will be collecting data on the blood donated from this new group of donors, and if encouraging, they will be opening up more opportunities for gay men in monogamous relationships to donate as well.

Wrinkles that are still being ironed out include the donation status of women who have had sex with bisexual men,  and the timeline of the introduction of these new policies.

CBS is currently aiming for a summer 2013 change to it's questionnaires, and further changes to come.

So You Want To be a Medical Technologist - Practicum Tips

So you have entered the medical technologist program, and are about to embark on your first practicum, away from your classmates and familiar environs. You've arranged a new place to live for the quarter (as most practicums at BCIT and NAIT are speckled throughout B.C and Alberta), and are armed with your Blue Book of Learning Requirements. For some of you, this will be your first foray into a workplace.

Welcome.

Some things to remember though about your soon to be teachers.

Teaching technologists are a thing of the past.

All technologists showing you the ropes will be expected to do so on top of holding their regularly scheduled benchwork. The majority of us will not be paid for teaching you during your practicum. Those that will, will be paid at most an extra three dollars a day (oh, wonderful 0.30/hr differential). If they are to do a through and useful job teaching you, you can bet they have put in time at home to prepare lesson plans, review sheets, and to dust off the hows and whys to explain things they know bone deep. They will have shown up five or ten minutes early to plan out the day's work, pull some interesting cases for you, and figure out how to fit giving you the most experience as well as the odd rare test (oh, fecal meat fibres) into the schedule. In return for this, they expect three things.

1) Respect for the fact that they are taking the time to do so.
2) That you listen, learn, and review pertinent theory before time if asked.
3) That you follow instructions.

They are, for the most part, not millenials. The style of discourse you may be used to among your peers (and to your parents) is not found in this particular work environment. Talk-back, whining, or arguement when your instructor or section head asks you to do something is both unappreciated and will frankly prejudice against your hiring (and your school's students being accepted back) for in the future.

After putting in said thought, it highly irks to give instructions for a student to help out for a few minutes with a skill they have already mastered, and be met with talk-back and stated entitlement of Learning All Teh Time. Simple logic states that if you want more of your teacher's time to help walk you through doing new things, the workload must be met too. Loading samples onto machines, or aliquoting tubes under supervision can help make that twenty minutes to talk about fluid pH theory, or to learn how to troubleshoot an osmometer. What is helpful is having two or three topics you want to cover in your head, so if we have a spare ten minutes, you can bring that up and we can plan that into the day.

Your Blue Book:

Yes, we are aware you have one. Every program sends their students with some version of competency requirements. We absolutely do not want you to bring the book to every bench day. As it must be returned to your practicum supervisor at the end of the three years, we want to keep it non-biohazardous. ^^ Ideally, you would bring it on your second to last day on each area, so we can then zero in on anything not covered during the usual process.

Appropriate Dress:

In general, scrubs are safe. Some labs allow street clothing, if gowns are worn overtop, and others prefer business casual. All of these work.

Do not wear shirts with obscenities on them, revealing clothing such as tube tops or shortie-shorts, or flip flops. You may think that an obvious statement, but we've had to memo two separate schools for students thinking "casual" meant variations of club-wear.... And flip flops will not protect you if you drop a glass tube on your foot. Think professional.

Break Times:

Finally? Each department generally has a break schedule of where they go each day. Take at least the first few days and follow along to get to know people, and how the department functions. Show off your social skills, and that you can fit in. After those few days, feel free to eat where you want, but if you don't follow your trainer to where ever the pack eats, people will think you are stuck up, socially maladusted, or simply not remember you from the multitude of other students coming through. All are negatives when it comes hiring time.

[Case Study] Bright Green Urine

Patient A is admitted for cardiac surgery on January 10. All his pre-op chemistry tests are normal, and he is cleared for surgery. His surgery is sucessful, and post-op blood and urine samples are submitted to check his status. His urine sample immediately drew notice upon arrival to the lab. Upon analysis, the urine showed:

Colour: Bright Green
Clarity: Clear
pH : 5.5
Specific Gravity: 1.015
Leukocytes: Negative
Hemoglobin: Trace
Protein: Negative
Ketones: Negative
Urobilinogen: Negative
Nitrite: Negative

Microscopic analysis confirmed the occasional red blood cell and 6-10 epithelial cells. No bacteria were seen.

The pre-operative urine sample was pulled, and the colour was a normal clear yellow with normal results.

But what was causing the urine to be so oddly coloured? Was it clinically significant? Upon investigation, the ward confirmed sample quality and a list of possible causal drugs were produced. Among those drugs was a short-acting, intravenous sedative-hypnotic agent by the name of Proprofol (Diprivan). Used to induce and maintain anesthesia or sedation, one of the more infrequent side effects (in < 1%) from Proprofol is a production of bright green urine. It is not clinically significant, and the colour change is known to cease once the proprofol is discontinued.

Other more common causes of the colour change are:

1. Methylene Blue: (Blue + Yellow = Green): used in treatment of malaria (third world countries due to cost), methemoglobinemia, cyanide poisoning, and cancer. Also a component of an older urinary analgesic.
2. Pseudomonas infection: This produces a deeper, forest green colour with a grapey smell.
3. Dietary changes: Examples are excess quantities of Clorets or Blue Listerine
4. Magnesium Silicate (Doan's pills): A NSAID used for back pain. OTC medication.
5. Medical imaging: Some dyes such as biliverdin are used to assist in in vivo scanning.

Medscape has done an article on similiar cases here.