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Absolute Beginner’s Guide to Algorithms: A Practical Introduction to Data Structures and

Algorithms in JavaScript (for True Epub) 1st Edition Kirupa Chinnathambi – Ebook PDF Instant
Download/DeliveryISBN(s):9780138222505, 0138222509 Product details: ISBN 10: 0138222509 ISBN
13: 9780138222505 Author: Kirupa Chinnathambi A hands-on, easy-to-comprehend guide that is
perfect for anyone who needs to understand algorithms. With the explosive growth in the amount
of data and the diversity of computing applications, efficient algorithms are needed now more
than ever. Programming languages come and go, but the core of programming–algorithms and data
structures–remains the same. Absolute Beginner’s Guide to Algorithms is the fastest way to
learn algorithms and data structures. Using helpful diagrams and fully annotated code samples
in Javascript, you will start with the basics and gradually go deeper and broader into all the
techniques you need to organize your data. Start fast with data structures basics: arrays,
stacks, queues, trees, heaps, and more Walk through popular search, sort, and graph algorithms
Understand Big-O notation and why some algorithms are fast and why others are slow Balance
theory with practice by playing with the fully functional JavaScript implementations of all
covered data structures and algorithms Table of contents: 1. Introduction to Data Structures 2.
Big-O Notation and Complexity Analysis 3. Arrays 4. Linked Lists 5. Stacks 6. Queues 7. Trees
8. Binary Trees 9. Binary Search Trees 10. Heaps 11. Hashtable (aka Hashmap or Dictionary) 12.
Trie (aka Prefix Tree) 13. Graphs 14. Introduction to Recursion 15. Fibonacci and Going Beyond
Recursion 16. Towers of Hanoi 17. Search Algorithms and Linear Search 18. Faster Searching with
Binary Search 19. Binary Tree Traversal 20. Depth-First Search (DFS) and Breadth-First Search
(BFS) 21. Quicksort 22. Bubblesort 23. Insertion Sort 24. Selection Sort 25. Mergesort 26.
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248
Graft's Textbook of Urinalysis and Body Fluids
Uterus
Amnion
Amniotic fluid
K··:::_:,..--,----/jr- Kidney
I
Renal agenesis
Urinary tract obstruction
Chronic loss of amniotic fluid
·
OLIGOHYDRAMNIOS
Hypoplastic
·-;i<=T----11-kidney
·H-.,...- Urinary tract
obstruction
Leakage of -
amniotic fluid
·
Amnion nodosum
Pulmonary hypoplasia
(respiratory insufficiency)
Abnormal position
of hands and feet
Hydronephrosis
•žrt"-Flexion
contractures
Figure 1 7-2.
Potter complex resu lts from leakage of amn iotic fl uid,
oligohydramnios. Congen ita l hydronephrosis resu lts from urinary tract
obstruction.
Amniocentesis is generally performed between 15 and 18
weeks of gestation for genetic studies although it may be used
later in the pregnancy in cases of fetal distress. The amount
collected is usually 10 to 20 mL (maximum 30 mL), with col-
lection into several different syringes to prevent the contami-
nation of all specimens with the blood from initial puncture.
Immediately after collection, the fluid is dispensed into
sterile plastic specimen containers. Glass containers are less
desirable as cells have more of a tendency to adhere to the
glass surface. Proper handling and transport of specimens
depend on the tests that are ordered.
· Specimens for cell culture and chromosomal studies
must be stored at body or room temperature to keep fetal
cells alive.
· Specimens for bilirubin analysis must be protected from
light. An amber plastic container may be used or the
tube may be wrapped in foil.
· Specimens for phospholipid analysis should be trans-
ported on ice and centrifuged at 500 g and the supernatant
saved for testing.
Figure 1 7-4.
N u merous squamous epithelial cel ls, and other cells
observed i n cytocentrifuge preparation of amn iotic fl uid (Wright stain
200x) . (Courtesy of McBride, Textbook of Urinalysis and Body Fluids.
LWW; 1 998.)
bilirubin, whereas a green color indicates meconium, the
newborn's first fecal bowel movements. Blood can appear
as pink or red and the source of the blood, whether fetal or
maternal, can be distinguished by the Kleihauer-Betke test
for fetal hemoglobin. A very dark red-brown amniotic fluid is
associated with fetal death.
Microscopic Examination
Microscopic cytological examination of amniotic fluid may yield
information on the diagnosis of ruptured membranes or chorio-
amnionitis. During the early stages of pregnancy, amniotic fluid
contains little or no particulate matter. By the 16th week of ges-
tation a number of cell types are present as they begin to shed
from the surfaces of the amnion, skin, and tracheobronchial tree.
As pregnancy continues other fetal cells appear such as hair,
vernix caseosa (covering of fetal epidermis).
Smears of amniotic fluid may be made by cytocentrifuga-
tion and stained with Papanicolaou, hematoxylin and eosin,
or Wright stains. Figure 17-4 shows a few of the cells from
amniotic fluid that can be visualized this way. Microscopic
evaluation of amniotic fluid may be of limited value, but
may provide additional information on the diagnosis of fetal
maturity and disorders.
TESTS FOR GENETIC AND
CONGENITAL DISORDERS
Cytogenetics
Cytogenetic studies (analysis of chromosomes and DNA) are
a common reason for performing amniocentesis. Amniotic
fluid contains fetal cells that can provide material for genetic
testing and provide valuable information related to the sex of
the fetus and any potential genetic abnormalities. Congenital
neural tube disorders can be detected as well as Down syndrome
Chapter 1 7
Amniotic Fluid
249
and anencephaly prior to birth. Cytogenetic methods used
for testing of amniotic fluid include chromosome karyotyping,
fluorescence in situ hybridization (FISH), and polymerized
chain reaction (PCR).
Alpha Fetoprotein
Fetal neural tube defects such as anencephaly and spina bifida
cause elevated alpha fetoprotein (AFP) in amniotic fluid
and in the maternal circulation. AFP is present in the fetal
serum and is secreted in the fetal urine and thus appears in
the amniotic fluid. In normal fetal development, AFP peaks
at about 16 weeks of gestation and then declines gradually
to term. With neural tube disorders, the neural tube is open
250
Graft's Textbook of Urinalysis and Body Fluids
0.4
0.3
w
0
z
0.2
<(
ro
a:
0
(/')
0.1
ro
""
<(
A
350 365
II
41 0
450
530
580 nm
0.6 .------------------------------.
0.5 1-----7'i'l"-<:----:------l
0.4 """"=-=Ã==++----++--...,._
____________ __,
w
0
z
<(
ro
a:
0
(/')
ro
<(
B
350 365
41 0
450
530
580 nm
Figure 1 7-5.
Spectrophotometric scan of amn iotic fluid ind icat-
ing bilirubin and oxyhemog lobin pea ks. Note the near linearity of the
normal cu rve i n (A). In (B), note the elevated bilirubin pea k (at 450 nm)
and the oxyhemoglobin peak (at 41 0 nm). The base is drawn from 550 nm
to 365 nm. (From B u rtis CA, Ashwood ER. Tietz Textbook of Clinical
Chemistry. 2nd ed. Phi ladelphia, PA: WB Sau nders Company; 1 994 )
maintain the foam in greater concentrations of ethanol and
more fetal lung surfactant is needed to support fetal lung
function at birth. An index of 0.47 or higher is considered to
indicate enough fetal lung surfactant for fetal lung maturity.
Lamellar Bodies
Fetal lung surfactants are produced by fetal type II pneu-
mocytes of the fetal lung and are stored as lamellar bod-
ies after about 20 weeks of gestation. Lamellar bodies are
about the size of small platelets. Lamellar bodies are storage
forms of lung phospholipids and they enter the fetal lungs
and the amniotic fluid at about 20 to 24 weeks of gestation.
They reach levels of about 50,000 to 200,000 lamellar bodies/
microliter of amniotic fluid by the third trimester of preg-
nancy. Amniotic fluid samples must be free of blood, hemo-
globin, and meconium for accurate lamellar body testing.
Lamellar bodies affect the optical density of amniotic fluid
and a measurement of the optical density of 0. 150 at 650 nm
has been shown to correlate with an LIS ratio of 2.0 and to
correlate with the presence of phosphatidylglycerol.
Lamellar body counts provide a reliable estimate of fetal
lung maturity. Lamellar body counts can be performed eas-
ily with many hematology analyzers using the platelet count
channel. As the methods employed by each hematology
system vary considerably, sample preparation and lamellar
body count cut -off values vary for assessment of fetal lung
maturity. Lamellar body counts of approximately 50,000 per
·A450
0.5
0.4
0.3
0.2
0.1
0.09
0.08
0.07
0.06
0.05
0.04
0.03
0.02
Chapter 1 7
Amniotic Fluid
251
microliter correspond to adequate fetal lung surfactant lev-
els and 15,000 per milliliter correspond to inadequate sur-
factant levels, however these lung maturity thresholds need
to be established in your laboratory with your instrument.
The CLSI final document, Assessment of Fetal Lung Maturity
by the Lamellar Body Count (C58-A), published in Novem-
ber 201 1, provides guidelines for the use of automated lamel-
lar body counting and establishing your testing verification
1 . Reasons for analyzing amniotic fluid include the
following EXCEPT:
a. To diagnose genetic and congenital neural tube
disorders
b. To assess fetal liver maturity
c. To assess fetal lung maturity
d. To detect fetal distress from hemolytic disease of the
newborn
2. The following is true about amniotic fluid specimen
collection and handling:
a. Fifty milliliters of amniotic fluid is typically collected
b. Glass containers are used for cytogenetic studies
c. Typical amniotic fluid is colorless to pale yellow and
slightly cloudy
d. Amniotic fluid is always refrigerated
3. Bilirubin is detected spectrophotometrically in amniotic
fluid at:
a. 365 nm
b. 550 nm
c. 410 nm
d. 450 nm
4. A potential complication caused by early delivery of the
premature newborn:
a. Hemolytic disease of the newborn
b. Neural tube defects
c. Respiratory distress syndrome
d. Excess lamellar bodies
5. All of these phospholipids have a role in fetal lung
maturity EXCEPT:
a. Lecithin
b. Sphingomyelin
c. Phosphatidylglycerol
d. Lamellar bodies
6. A M450 value that falls into zone I indicates:
a. A normal finding without significant hemolysis
b. Moderate hemolysis
c. Severe hemolysis
d. High fetal risk
7. Decreased fetal swallowing can result in:
a. Hydraminos
b. Hydronephosis
c. Oligohydramnios
d. Oligohyponephrosis
8. Amniocentesis is performed:
a. Through the umbilicus
b. Transabdominally
c. Transvaginally
9. Which test is most specific for neural tube disorders?
a. Acetylcholinesterase
b. Alpha fetoprotein
c. Phosphatidyl glycerol
BIBLIOGRAPHY
Brunzel MS, Nancy A. Fundamentals of Urine and Body Fluid Analysis. 3rd ed.
Philadelphia, PA: Saunders; 2013:Chapter 12.
DiGiulio DB, Roberto RR, Amogan HP, et al. Microbial prevalence, diver-
sity and abundance in amniotic fluid during preterm labor: A molecular
and culture-based investigation. PLoS One. 2008;3(8):e3056. Available at:
http://www. pubmedcen tral. n ih. gov I articlerender. fcgi? artid=25 1 6597
CLSI. Assessment of Fetal Lung Matu rity by the Lamella r Body Count; App roved
Guideline. Wayne, PA: Clinical and Laboratory Standards Institute; 20 1 1 .
CLSI document C58-A.
Chapter 1 7
Amniotic Fluid
253
Liley AW. Liquor amnii analysis in the management of the pregnancy compli-
cated by rhesus sensitization. Am J O bstetric Gynecol. 1961;82: 1 359- 1 370.
McBride LJ. Textbook of Urinalysis and Body Fluids: A Clinical App roach. Phil-
adelphia, PA: Lippincott; 1 998:Chapter 13.
Neerhof MG, Dohnal JC, Ashwood ER, et al. Lamellar body counts a consen-
sus on protocol. O bstet Gynecol. 200 1 ;97:3 18.
Sbarra AJ, Michlewitz H, Selvaraj RJ, et al. Correlation between amniotic fluid
optical density and LIS ratio. O bstet Gynecol. 1 976;48(5) :613-615.
Strasinger SK, Di Lorenzo MS. Urinalysis and Body Fluid Analysis. 6th ed.
Philadelphia, PA: FA Davis; 20 1 4:Chapter 1 3 .
KEY TERMS
Amine or Whiff Test
Atrophic Vaginitis
Bacterial Vaginosis
Candidiasis
Chorion
Clue Cells
Decidua
Fern Test
Fetal Fibronectin
KOH Preparation
Placental Alpha Microglobulin-1
Rupture of Fetal Membranes (ROM}
Trichomoniasis
Vaginitis
Wet Mount
254
LEARNING
OBJECTIVES
1. Explain the procedure collection and handling of vaginal secretion specimens.
2. Discuss the origin of substances present in amniotic fluid used in the diagnosing
of rupture of fetal membrane (ROM).
3. Describe tests for detecting amniotic fluid in vaginal secretions.
4. Differentiate among various forms of vaginitis.
5. Describe laboratory tests for detection of atrophic vaginitis, desquamative
inflammatory vaginitis, bacterial vaginosis, trichomoniasis, and candidiasis.
6. Summarize laboratory findings in normal vaginal secretions, atrophic vaginitis,
desquamative inflammatory vaginitis, bacterial vaginosis, trichomoniasis, and
candidiasis.
7. Recognize sources of error when performing laboratory testing of vaginal
secretions.
G
lands in the cervix normally produce a clear mucus
that may turn slightly white or pale yellow upon expo-
sure to air. The amount of vaginal secretions may vary
throughout the menstrual cycle. Noticeable changes in the
color, consistency, or amount of vaginal secretions may be
linked to various conditions and infections. Vaginal secretions
are also examined for the presence of amniotic fluid as evidence
of fetal membrane rupture.
Specimen Collection
an d H an dlin g
Vaginal secretions are collected by a healthcare provider during
a pelvic examination. The method of collection and con-
tainer used is specific for the testing that is to be performed.
A warmed speculum is used to visualize the vaginal fornices
and the specimen is collected by swabbing the area required for
testing-vaginal pool, vaginal wall, or cervical os (or cervical
opening to the uterus) (Fig. 18- 1).
The swab used is dependent upon the test to be performed.
If the specimen is for bacterial culture, polyester-tipped swabs
on a plastic shafts should be used as other substances are toxic
to certain pathogens (Table 18-1).
Swabs must be placed immediately into a properly labeled
tube or container, containing transport media appropriate for
the test to be performed, and be stored and transported at the
correct temperature.
Rupture of Fetal Membran es
The rupture of fetal membranes (ROM), tearing of the amni-
otic sac with release of amniotic fluid, normally occurs at
the onset of labor once the fetus has arrived to full-term at
A
8
Figure 1 8-1 .
A: A warmed speculum allows for visual ization
and insertion of swab. B: The swab is used to sample the vag inal pool
and nontraumatically " scrape" the cervica l os and walls of the vagina
(depending on test req u i rements) .
Chapter 1 8
Vaginal Secretions
255
/_
Table 1 8-1
Toxicity of Swabs
to Microorganisms
MATERIAL
Cotton swab
Wooden shaft
Calcium alginate swab
ORGANISM AFFECTED
Neisseria gonorrhoeae
Chlamydia trachomatis
256
Graft's Textbook of Urinalysis and Body Fluids
is present only at very low levels in cervicovaginal secre-
tions when fetal membranes are intact. PAMG- 1 is present in
amniotic fluid throughout all three trimesters of pregnancy,
and appears in vaginal secretions after the ROM.
Traditional procedures for the diagnosis of ROM include
pooling of amniotic fluid observed during speculum examina-
tion, nitrazine test, and a ferning test. A more current test used
by healthcare professionals to aid in the detection of ROM is
AmniSure. This test can be performed when pregnant women
report signs, symptoms, or complaints suggestive of such a
rupture. A positive AmniSure test is indicative of amniotic
fluid in vaginal secretions, meaning there is a rupture of the
amniotic membranes.
AmniSure is a one-step immunochromatographic assay
using monoclonal antibodies to detect PAMG- 1 . During the
test procedure, PAMG- 1 from the sample sequentially binds
to a monoclonal antibody conjugated with labeled particles
and is carried to the test area where the complex is bound by
a second monoclonal antibody, resulting in a positive result
line. If no PAMG- 1 is present, the test area will not display
a line. A line in the control area must be present for either a
positive or negative result to be valid.
PROCEDURE. A vaginal swab is used non-invasively to
take a sample of vaginal secretions. The swab is then imme-
diately placed into a vial with solvent to extract the PAMG- 1
from the swab. To perform the test, the test strip (dipstick) is
inserted into the vial and the result is read after 10 minutes.
See Box 18- 1 . (Note: Please see instructions for use for full
details on the test procedure and limitations.)
PERFORMANCE
RESULTS. According to the FDA-
cleared package insert, AmniSure has a sensitivity of 98.9%
and a specificity of 98. 1 %.
Insulin-like Growth Factor Binding Protein-1
Insulin-like growth factor binding protein- 1 (IGFBP- 1) is
secreted by the decidual cells of placenta and is present in
amniotic fluid in high concentration. When fetal membranes
rupture, IGFBP- 1 is present in vaginal secretions. The Actim
PROM test detects IGFBP- 1 using the principle of lateral flow
immunochromatography that is visually interpreted.
Fetal Fibronectin
Fetal Fibronectin (fFN) is an adhesive glycoprotein produced by
fetal cells and is found in the space between the chorion (fetal
sac) and the decidua (uterine lining). fFN binds the fetal sac to
the uterine lining and begins to break down toward the end of
pregnancy. The presence of fFN that has leaked into the vagina
may indicate that a preterm delivery is likely to occur, although
a positive result is often inconclusive.
fFN is tested on patients between 22 and 34 weeks of ges-
BOX 1 8- 1
AmniSure Procedu-re _ _
_
Chapter 1 8
Vaginal Secretions
257
NOTE: You must follow all directions to get an accurate reading of the results.
The test should not be used earlier than 6 hours after the removal of any disinfectant solutions or
medicines from the vagina.
Placenta previa and performing digital exams prior to sample collection can lead to inaccurate test
results.
1 . Take the solvent vial by its cap and shake well to make sure all
liquid in the vial has dropped to the bottom. Open the solvent
vial and put it in a vertical position.
2. To collect a sample from the surface of the vagina use the
sterile Polyester swab provided. Remove the sterile swab from
its package following the instructions on the package. The
Polyester top should not touch anything, prior to its insertion
into the vagina. Hold the swab in the middle of the stick and,
while the patient is lying flat on her back carefully insert the
Polyester top of the swap into the vagina until the fingers
contact skin (no more than 5-7 cm deep). Withdraw the
swab from the vagina after 1 minute.
3. Place the Polyester tip into the vial and rinse the swab in the
solvent by rotating for one minute.
4. Remove and dispose of the swab.
5. Tear open the foil pouch at the notches and remove the
Amnisure ROM Test strip.
6. Dip the white end of the test strip (marked with arrows) into the
vial with solvent. Strong leakage of amniotic fluid may make
the results visible early (within 5 minutes), while a very small
leak will take the full 1 0 minutes.
7. Remove the Test Strip if two stripes are clearly visible in the
vial or after 1 0 minutes sharp. Read the results by placing the
test on a clean, dry, flat surface. Do not read or interpret the
results after 1 5 minutes have passed since dipping the Test
Strip into the vial.
Two lines: There is a rupture
One line: No membranes ruptured
No lines: Test is invalid ;
take another test
l l lltl
I
El
-
11:1
Control fine _j L Test line
Control fine _j
The darkness of the stripes may vary. The Test is valid even if the stripes are faint or uneven. Do not
try to interpret the test result based on the darkness of the stripes. © QIAGEN, all rights reserved.
Vagin itis
258
Graft's Textbook of Urinalysis and Body Fluids
Figure 1 8-4.
I m matu re epithelial cells (parabasal cel ls) as wel l as
mature squamous epithelial cells. The i mmature cells are smaller and
round. (Wet mou nt)
round and smaller than parabasal cells, and may be confused
with leukocytes. See Figure 18-4 for the appearance of mature
and immature epithelial cells.
Squamous epithelial cells slough off and can be seen in
vaginal secretions. During childbearing years, vaginal secre-
tions contain a predominance of squamous epithelial cells.
The normal process of epithelial glycogen conversion to lactic
acid helps maintain a pathogen-free environment.
ATROPHIC VAGINITIS
Atrophic vaginitis is a condition caused by physiologic and
structural changes that occur to the vulvovaginal mucosa
primarily as a result of a decrease in estrogen levels at meno-
pause. Symptoms of atrophic vaginitis include vulvovaginal
dryness, vulvar itching or pain, recurring urinary tract infec-
tions, and abnormal vaginal discharge. As estrogen decreases
after menopause, so do the number of squamous cells. The
resultant rise in pH provides an environment in which pathogens
can overgrow.
After menopause vaginal secretions will contain a pre-
dominance of parabasal cells and can even be acellular in
severe cases of estrogen deficiency (Fig. 18-5). Quantitation
of parabasal cell numbers can be used as an assessment of
genital atrophy and evaluation of hormonal therapy.
DESQUAMATION INFLAMMATORY
DISEASE
Desquamative inflammatory vaginitis is a sterile vaginitis. It
can be found in women of any age and is displayed as vir-
ginal discomfort, irritation, increased vaginal discharge, and
painful sexual intercourse. Vaginal secretions demonstrate an
abnormal pH of 7.4 and show a high number of white blood
Figure 1 8-5.
A predomi nance of parabasal cells in vaginal secre-
tions is consistent with estrogen deficiency. In severely estrogen-defi-
cient women, the vag inal fl uid is al most ace l l u lar. (Wet mou nt)
cells (WBCs) and an increased number of parabasal cells
(Fig. 18-6). Gram stains show an absence of Lactobacilli; and
bacterial, viral, and fungal cultures are negative.
Desquamative inflammatory vaginitis must be differen-
tiated from mucosal blistering disorders and all infectious
forms of vaginitis.
BACTERIAL VAGINOSIS
Bacterial vaginosis is the most common vaginal infection in
women. In bacterial vaginosis, the vaginal flora is altered. Nor-
mally, Lactobacillus predominates in the healthy vaginal flora
(Fig. 18-7). In vaginosis, other bacteria such as Gardnerella
/
-
Figure 1 8-7.
G ram stain (1 ,OOOx). Lactobaci l l us predom inati ng in a
healthy vagina with squamous epithelial cells. (C DC, PHIL i mage, http://
phil.cdc.gov/phil i mage 1 Og0029_1ores.jpg.).
vagina/is, or Mobiluncus species, or the anaerobic Prevotella
species predominate.
The overgrowth of other anaerobic bacteria is also asso-
ciated with bacterial vaginosis. Studies of women with vag-
inosis have shown a correlation of bacterial vaginosis with
an increased risk for premature birth and low-birth-weight
infants.
In bacterial vaginosis, the vaginal discharge is gray or off-
white and thin, with characteristics of a transudate. There is
a characteristic lack of WBCs as there is no invasion of the
subepithelial tissue, but there is an increase in exfoliation
of epithelial cells. To diagnose bacterial vaginosis, three of
the following characteristics should be seen: (a) "clue cells;'
sloughed off squamous epithelial cells covered with numer-
ous small thin, curved gram-variable bacilli, (b) a vaginal pH
greater than 4.5, (c) a positive amine or "whiff" tests (detec-
tion of a characteristic odor upon exposure to KOH), and
(d) a malodorous, homogeneous vaginal discharge. Of these
tests, the most reliable indicator of bacterial vaginosis is the
characteristic microscopic appearance of "clue cells;' together
with an altered microbial flora, with a reduction in the typical
long, thin Lactobacillus, and an overgrowth of the small, thin,
curved gram-variable bacilli of species such as Gardnerella,
Mobiluncus, and Prevotella (Fig. 18-8).
TRICHOMONIASIS
Trichomoniasis is a common parasitic infection of the vag-
inal mucosa in females and of the urogenital tract of males
that is cause by Trichomonas vagina/is. Women usually com-
plain of yellow-green vaginal discharge, although women
can be asymptomatic and men are usually asymptomatic. In
pregnant women, Trichomoniasis is a risk factor for preterm
rupture of membranes and preterm labor and delivery. The
Chapter 1 8
Vaginal Secretions
259
Figure 1 8-8. A: Wet mount and (B) G ram stain of "clue cells. "
These are squamous epithelial cells that are l iterally covered with
numerous small curved baci l l i . These cells slough off because of bac-
terial a lteration in bacterial vaginosis. (From Sweet RL, G i bbs RS. Atlas
of Infectious Diseases of the Female Genital Tract. Philadelphia, PA:
Lippincott Will iams & Wil kins; 2005, Asset 55832 c1 Of1 0.)
wet mount (microscopic examination of a drop of freshly
collected fluid) is helpful to detect the majority of cases of
Trichomoniasis. Culture and/or DNA probe for Trichomonas
are useful when the wet mount is negative and trichomoni-
260
Graft's Textbook of Urinalysis and Body Fluids
Figure 1 8-9.
Trophozoites of Trichomonas vagina/is obta ined from
in vitro culture, stained with G iemsa. (C DC, DpDx Laboratory Diagnosis
of Parasites of Public Health Concern Parasite Image Li brary, http://
www.dpd .cdc.gov/dpdx/HTM Uimage_Library. htm.).
normal bacterial flora and the normal vaginal environment.
While C. albicans can be found normally in the vagina, it is
generally in small numbers but greatly overgrows in candidi-
asis. This is frequently caused by antibiotic treatment and can
occur in celibate as well as sexually active women. It is also
more common in immunosuppressed patients. Women with
candidiasis frequently complain of a whitish, curd-like vagi-
nal discharge. Microscopic examination reveals an increased
number of yeast cells and pseudohyphae with a concomitant
increase in WBCs (Fig. 18-10).
Figure 1 8-1 0.
Wet preparation o f Candida albicans yeast a n d
pseudohyphae with WBCs. Yeast (incl uding pseudohyphae), RBCs, a n d
W B C s (200x). (From McBride LJ . Textbook o f Urinalysis and Body Fluids.
A Clinical Approach. Philadelphia, PA: Lippincott; 1 998.)
OTHER DISORDERS
Other tests that are performed for the diagnosis of female
genital disorders, such as microbial cultures and molecular
testing for Chlamydia trachomatis, Neisseria gonorrhoeae, and
herpes, and cytology for cervical cancer, are beyond the scope
of this chapter. These tests usually require cervical swabs
(rather than vaginal secretions) be collected that are appro-
priate for the methods being performed in the laboratory.
LABORATORY EXAMINATION OF
VAGINAL SECRETIONS
Physical Characteristics
APPEARANCE. Normal vaginal fluid appears white and
may have a flocculent discharge containing a few WBCs.
If the patient is menstruating, the discharge will be reddish
due to the presence of red blood cells. Abnormal appearance
of vaginal secretions includes a thin, white/gray or gray dis-
charge that is associated with bacterial vaginosis. A "cottage
cheese" appearance to the vaginal discharge is seen in Can-
dida infections. Infection with Trichomonas may produce
a yellow-green frothy discharge; and Chlamydia infections
present with yellow opaque discharge.
pH. Normally, vaginal secretions have a pH of 3.8 to 4.5, due
to the growth of Lactobacillus species and its acidic byprod-
ucts. With the alterations of bacterial flora that occur in bac-
terial vaginosis and infection with Trichomonas, the pH rises
and Lactobacillus numbers decrease. The vaginal pH also
rises in postmenopausal women due to decreased Lactobacillus
species that can occur with atrophic vaginosis. In candidiasis,
the pH is largely unchanged, between 3.8 and 4.5.
1 . Which of the following materials is known to be toxic to
specific microorganisms? (choose all that apply)
a. Calcium alginate
b. Cotton
c. Dacron
d. Wood
2. The decidual cells of placenta produce this substance
found primarily in amniotic fluid. (choose all that apply)
a. Placental alpha microglobulin - 1
b. Insulin -like growth factor binding protein - 1
c. Fetal fibronectin
d. Murine monoclonal anti-fFN antibody
3. Which substance functions as an adhesive between the
chorion and decidua? (choose all that apply)
a. Placental alpha microglobulin - 1
b. Insulin -like growth factor binding protein - 1
c. Fetal fibronectin
d. Murine monoclonal anti-fFN antibody
4. The fern test is performed by:
a. Fluorescence
b. Immunochromatography
c. Latex agglutination
d. Microscopic examination
5. This cell is an abnormal finding indicating bacterial vaginosis:
a. "Clue cells"
b. Parabasal cells
c. Red blood cells
d. White blood cells
6. In bacterial vaginosis, in trichomoniasis, and in post-
menopausal women, the vaginal pH is:
a. Above 4.5
b. Between 3.8 and 4.5
c . Below 3.8
Chapter 18
Vaginal Secretions
261
d. It is above 4.5 in some of these and below 3.8 in others
7. Organisms associated with premature birth include:
(select all that apply)
a. Gardnerella
b. Lactobacillus
c. Mobiluncus species
d. Prevotella
8. A predominance of these cells in vaginal secretion is
indicative of a postmenopausal vaginitis:
a. "Clue cells"
b. Parabasal cells
c. Red blood cells
d. Squamous epithelial cells
9. "Clue cells" are indicative of all of these EXCEPT:
a. Gardnerella vagina/is
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Graft's Textbook of Urinalysis and Body Fluids
1 . What infection does this patient have?
2. What risks does this infection pose to the developing fetus,
if any?
3. What techniques are used to detect this organism?
4. What are the expected vaginal pH and amine test results in
this case and why is the pH altered?
BIBLIOGRAPHY
Abdelazim lA. Fetal fibronectin (Quick Check fFN test®) for detection of pre-
mature rupture of fetal membranes. A rch O bstetric Gynecol. 20 13;287:205-
2 10.
Abdelazim lA, Makhlouf HH. Placental alpha macroglobulin- ! (AmniSure
test) versus insulin-like growth factor binding protein-! (Actim PROM
test) for detection of premature rupture of fetal membranes. ] O bstetric
Gynecol Res. 20 1 3;39( 6): l l29- l 1 36.
Brunzel MS, Nancy A. Fundamentals of Urine and Body Fluid Analysis. 3rd ed.
Philadelphia, PA: Saunders; 2013:Chapter 16.
DiGiulio DB, Roberto RR, Amogan HP, et al. Microbial prevalence, diver-
sity and abundance in amniotic fluid during preterm labor: A molecular
and culture-based investigation. PLoS One. 2008;3 (8):e3056. Avail-
able at http:/ /www.pubmedcentral.nih.gov/articlerender.fcgi?artid
=
25 1 6597.
Goa L, Zhang JP, Chen H, et al. Fetal fibronectin detection for preterm birth
prediction. Genet Mol Res. 20 14; 1 3 ( 1 ) : 1 323- 1 328.
Hainer BL, Gibson MV Vaginitis: Diagnosis and treatment. Am Fam Physi-
cian. 20 1 1 ;83(7):807-8 1 5 .
Lee SM, Lee J , Seong H S , e t al. The clinical significance o f a positive Amnisure
Test in women with term labor with intact membranes. ] Mate rn Fetal
Neonatal Med. 2009;22(4):305-3 10.
Liley AW. Liquor amnii analysis in the management of the pregnancy compli-
cated by rhesus sensitization. Am ] O bstetric Gynecol. 1 96 1 ;82: 1 359- 1 370.
McBride LJ. Textbook of Urinalysis and Body Fluids: A Clinical App roach. Phil-
adelphia, PA: Lippincott; 1 998:227.
Mcgregor JA, French Jl, Parker R. Prevention of premature birth by screening
and treatment for common genital tract infections: Results of a prospec-
tive controlled evaluation. Am f O bstet Gynecol. 1995 ; 1 73 ( 1 ) : 1 57- 1 67.
Murphy R. Desquamative inflammatory vaginitis. De rmatol Ther. 2004;1 7:47-49.
Riboni F, Virulo A, Dell'avanzo M, et al. Biochemical markers predicting pre-
term delivery in symptomatic patients: Phosphorylated insulin-like growth
factor binding protein - 1 and fetal fibronectin. A rch O bstetric Gynecol. 20 l l :
284; 1 325- 1 329.
Sbarra AJ, Michlewitz H, Selvaraj RJ, et al. Correlation between amniotic fluid
optical density and LIS ratio. O bstet Gynecol. 1 976;48(5) :613-615.
Stika CS. Atrophic vaginitis. De rmatol The r. 20 1 0;23:514-522.
Strasinger SK, Di Lorenzo MS. Urinalysis and Body Fluid Analysis. 6th ed.
Philadelphia, PA: FA Davis; 2014:Chapter 15.
KEY TERMS
Acute Interstitial Nephritis (AIN}
Bronchoalveolar Lavage (BAL}
Bronchial Washings
Beta-Human Chorionic Gonadotropin
Hormone (13-hCG}
Calcofluor White
Middle Ear Effusion
Otitis Media with Effusion
Pregnancy Testing
Sterile Pyuria
Urine Eosinophils
Vitreous Fluid
LEARNING
OBJECTIVES
1. Explain what is detected in a pregnancy test and what may affect test results.
2. Explain the importance of testing for urine eosinophils.
3. Describe the collection of bronchial washings and the bronchoalveolar lavage.
4. Describe normal and abnormal findings for tests performed on bronchial
specimens.
5. Describe methods for detection and identification of various microorganisms
found in bronchial specimens from patients with various conditions.
6. Describe testing of middle ear effusions.
7. Describe the procedure for collection of vitreous fluid.
8. Suggest testing that may be performed on vitreous fluid.
9. Suggest reasons for which other body fluids may be tested.
263
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Graft's Textbook of Urinalysis and Body Fluids
T
he clinical laboratory has a role in providing clinicians
with critical test results from a variety of body fluids.
This chapter covers miscellaneous urine testing and
body fluids that have not been covered previously, or that
are currently tested less frequently, but that yield crucial evi-
dence of the patient's status. Laboratory medicine is constantly
expanding its capabilities and thus, continually adding new
tests and new types of specimens.
Additional Urin e Tests
URINE PREGNANCY
Pregnancy testing may be performed on urine or on blood.
The substance tested in pregnancy is beta-human chorionic
gonadotropin hormone (B-hCG), a hormone that is secreted
in urine within 2 to 3 days after implantation of the embryo
(or approximately 8 to 10 days after fertilization). Levels of this
hormone rise rapidly after conception and remain elevated in
pregnancy, peaking in the first trimester of pregnancy. Some
tests performed on serum can detect pregnancy much ear-
lier, within days of conception. One reason that serum is able
to detect pregnancy earlier is that the levels of the hormone
B-hCG vary a great deal due to the concentration of the urine,
yet the levels are relatively stable in serum. Still, collecting
a urine specimen is easier and urine pregnancy test kits are
available over the counter. The best specimen for urine preg-
nancy testing is the first morning urine, which is the most
concentrated specimen. For optimal results, urine-specific
gravity should be 1.015 or higher. False results may occur
with large amounts of blood, protein, or bacterial contam-
ination. Enzyme immunoassays are the most popular type
of test kit (Fig. 19-1), but whatever the method, follow the
c
T
s
·
·
·
·
·
·
8ECKMAN
COUI.IER
Figure 1 9-1 .
ICON pregnancy test cartridge. (Image courtesy of
Beckman Cou lter, Inc.)
manufacturer's guideline. Results are reported as B-hCG neg-
ative or B-hCG positive. Test kits may show a positive result
in a urine sample in as little as 10 days after conception.
URINE EOSINOPHILS
DISEASE CORRELATIONS
BAL is particularly helpful in the diagnosis of fungi such as
Pneumocystis jiroveci or Aspergillus species or other fungi in the
alveolar cellular layer of immunocompromised patients. Immu-
nocompromised hosts are susceptible to many organisms that
normally do not cause infection as well as being susceptible to
the generally recognized pathogens of the lower respiratory tract.
BAL has been found to be more sensitive for detecting
infectious organisms such as Pneumocystis carinii or Aspergillus
species than traditional biopsy procedures. In addition, bron-
chial washings are less likely to contain material from the
alveoli, where Pneumocystis exudate is found, and are therefore
less effective in recovering the organism, compared with BAL.
SPECIMEN COLLECTION
These specimens are obtained in surgery. A lighted optical
instrument, the bronchoscope, is used to examine the tracheo-
bronchial tree and can help detect obstructions, pneumo-
nia, carcinoma, hemoptysis, foreign bodies, or abscesses. These
instruments can be equipped with suction catheters, brushes,
or biopsy attachments for specimen collection. The broncho-
scope consists of fiber optics (flexible tube using specialized glass
fibers) that form a bidirectional light system through which light
enters the interior of the bronchi and returns a magnified image.
The bronchoscope is advanced into a bronchial segment
until it occludes the lumen. For washings, 20 to 60 mL of saline
are infused and then recollected by aspiration. Bronchial
washings obtain material from the more proximal areas of
the bronchoalveolar tree. The BAL is used at more distal sites
to retrieve cellular alveolar material, which is more represen-
tative of the alveoli (Fig. 19-3).
Figure 1 9-3.
This bronchoalveolar lavage is being performed with a
protected catheter, but without the aid of a bronchoscope. (From Marino
PL. Marino's the ICU Book. Philadelphia, PA: Wolters Kl uwer, 201 3.)
Chapter 1 9
Miscellaneous Urine and Body Fluid Tests
265
LABORATORY EXAMINATION
BAL specimens are obtained for routine bacterial, fungal, and
mycobacterial examination and culture, and for cytological
studies. In the laboratory, the fluid volume of each specimen
is measured and analyses conducted.
Microscopic Evaluation
CELL COUNTS AND SPECIAL STAINS. Cell counts
are performed using a hemocytometer; and cytocentrifuga-
tion gives best cellular preparations for staining for cellular
differentiation. Although Wright stain could be used on these
specimens, cytological stains (Gomori methenamine sil-
ver [GMS] and Papanicolaou [PAP] ) and microbiological
stains (calcofluor white) are more commonly used on these
specimens.
266
Graft's Textbook of Urinalysis and Body Fluids
Figure 1 9-5.
Squamous cell carcinoma in a bronchial brush specimen.
Highly atypical squamous cells show marked variation in size and shape.
The nuclei are hyperchromatic and irregular. (Papanicolaou stain) (From
Rubin R, Strayer DS. Rubin's Pathology: Clinicopathologic Foundations of
Medicine. 5th ed . Philadelphia: Lippincott Williams & Wilkins, 2008.)
WET MOUNTS AND CALCOFLUOR WHITE STAIN.
Wet mounts are useful to detect fungal elements and cells
that may be present in these samples. Stains can be used
along with wet mounts or stains can be used on smears. A
technique that is particularly helpful to detect P. jiroveci,
Candida albicans, and other fungi is the calcofluor white wet
preparation. The calcofluor white stain is a fluorescent stain
that has increased sensitivity in the detection of these organ-
isms and detection of fungi. It can be combined with KOH
to dissolve cells in order to see fungal structures more easily
(Fig. 19- 1 1).
Ear Fluid
The middle ear lies between the tympanic membrane and the
internal ear (Fig. 19-12). Middle ear effusion (MME) (excess
fluid in the tympanic cavity) is often seen during chronic
otitis media with effusion (OME). The effusions that are pres-
ent in the ear display a complex composition that includes
secreted mucus glycoproteins, protein, lipid, and many
Figure 1 9-7.
Pneumocystis
jiroveci pneumonia. A: The alveol i
are fil led with a foamy exudate,
and the interstiti um is th ickened
and contains a chron ic i nflam-
matory infi ltrate (Hematoxyl i n
& Eosin stain). B: A centrifuged
bronchoalveolar lavage specimen
impregnated with si lver shows
a cl uster of Pneumocystis cysts.
(From Rubin E MD, Reisner H .
Essentials of Rubin's Pathology
6th ed. Phi ladelphia: Wolters
Kl uwer, 201 3.)
Figure 1 9-6.
Adenocarcinoma cells in bronchial brush specimen. A
cl uster of epithelial cells with highly atypical nuclei, prominent nucleoli,
and cytoplasmic vacuoles is seen. (Papanicolaou stain) (From Rubin R,
Strayer DS. Rubin's Pathology: Clinicopathologic Foundations of Medicine.
5th ed. Philadelphia: Lippincott Williams & Wil kins, 2008.)
inflammatory substances. OME can be caused by anatomical
factors, obstruction of the eustachian tubes, ear infections,
allergic reactions, and impaired immunologic status. Some
researchers suggest that gastroesophageal reflux may also
Figure 1 9-8.
Cytomega lovirus (C MV) infection in bronch ial wash-
ings. Note the large basoph i l ic n uclear incl usions surrou nded by a halo
and marginated chromati n, form ing the typical target-shaped appear-
ance. (Papan icolaou sta in) (From Rubin E MD, Farber JL. Pathology. 3rd
ed. Phi ladelphia: Lippi ncott Will iams & Wilkins, 1 999.)
Figure 1 9-9.
Cell block preparation of BAL showing cysts of P jiroveci,
G MS-P stain (1 ,OOOx). (From McBride U. Textbook of Urinalysis and Body
Fluids. A Clinical Approach. Philadelphia, PA Lippi ncott; 1 998 264.)
Figure 1 9-10.
Cell block preparation of BAL showing cysts of P jiroveci,
GMS-P stain (1 ,OOOx). (From McBride U. Textbook of Urinalysis and Body
Fluids.· A Clinical Approach. Philadelphia, PA Lippincott; 1 998:265 )
Chapter 1 9
Miscellaneous Urine and Body Fluid Tests
267
Figure 1 9-1 1 .
Candida albicans with germ tube development in a
calcofl uor wh ite preparation . (C DC, PHIL i mage, http://phil .cdc. gov/phil
image 295 )
= Tympanic cavity
= Bony labyrinth
= Membranous labyrinth
Dura mater
l Endolymphatic sac
..,_,===-=-,_.,._
Vestibular aqueduct
·
containing endo-
Base of stapes in A4 .
oval window
'
Stapes
Incus
·
Malleus
·
-
Temporal bone ;;;;:;<B=UP<:
lymphatic duct
Cochlear
aqueduct
Ä Duct of
·'-.
cochlea
;:
1 . Which statements regarding pregnancy testing are true?
(select all that apply)
a. Dilute urine is the preferred specimen.
b. Serum tests are more reliable than urine tests.
c. Beta-human chorionic gonadotropin hormone is
increased during early stages of pregnancy.
d. For urine pregnancy tests, the specific gravity should
be less than 1.015.
2 . Urine eosinophils may be present in urine during which
of these disorders? (select all that apply)
a. Cystitis
b. Glomerulonephritis
c. Pyelonephritis
d. Prostatitis
3. Which of these specimens is best for the detection of
Pneumocystis jiroveci?
a. Bronchoalveolar lavage
b. Vaginal secretions
c. Bronchial washings
d. Amniotic fluid
4. Normal bronchial epithelial cells:
a. are ciliated columnar cells with uniform and basally
located nuclei.
b. have basophilic nuclear inclusions surrounded by a
halo and marginated chromatin.
c. show marked variation in size and shape and nuclei
are hyperchromatic and irregular.
5. The effusions that are present in the ear comprise
secreted substances that include all of the following
EXCEPT:
a. Enzymes
b. Mucus
c. Lipid
d. Protein
6. Otitis media with effusion can be caused by any of these
conditions. (select all that apply)
a. Abnormalities in ear anatomy
b. Gastroesophageal reflux
c. Infections of the ear
d. Obstruction in the eustachian tubes
7. A vitrectomy is used to collect fluid from the:
a. Alveoli
b. Ear
c. Eye
d. Nasopharynx
8. Test that can be performed on any body fluid include:
(select all that apply)
a. Cell counts
b. Chemistries
c. Cultures
d. Cytology
Figure 1 9-14.
This image depicts histopatholog ic changes
ind icating asperg i l losis of the lung caused by Aspergillus fumigatus.
Methenamine si lver stain reveals hyphae of A. fumigatus. Inhalation of
a i rborne con idia of A. fumigatus can cause asperg i l losis i n immu nosup-
pressed hosts. (C DC, PHIL image, httpl/phil.cdc.gov/phil image 3952 )
Figure 1 9-1 5.
Methenamine si lver sta i n . Disseminated infection in
an immu ne-compromised host with the opportunistic fung us, A. fumi-
gatus. Note the characteristic dichotomous branching of the hyphae.
(C DC, PHIL i mage, httpl/p h i l .cdc.gov/phil image 4228 )
Case 19·2
A 5 1 -year-old man was complaining of a 30-lb
weight loss i n the past month, coug h , fever, shortness of breath,
abdom inal pain, chest pa i n , decreased appetite, and feeling weak
and fai nt when ambulatory. X-rays showed pul monary lesions.
He had been traveling i n Africa, so his physician ordered tests
for malaria, which were negative. A slig htly elevated wh ite blood
cel l count was noted. The patient underwent a bronchoscopy
with bronchoalveolar lavage and bronchial wash i ngs. A calcofl uor
white with KOH was performed and bacterial, fungal, and myco-
bacterial cultures were ordered as well as histolog ic exami nation
using special stains. The calcofl uor white preparation showed smal l
encapsu lated i ntracellular yeast. Figures 1 9-1 6 t o 1 9- 1 8 are from
this patient.
Chapter 19
Miscellaneous Urine and Body Fluid Tests
269
Figure 1 9-16.
Bronchial washing cel l block. H&E stain (1 ,OOOx)
(From McBride U. Textbook of Urinalysis and Body Fluids. A Clinical
Approach. Philadelph ia, PA: Lippincott; 1 998:263.)
Figure 1 9-1 7. Bronchial washing cel l block. G M S-C stain (1 ,000x).
(From McBride LJ . Textbook of Urinalysis and Body Fluids: A Clinical
Approach. Phi ladelphia, PA: Lippincott; 1 998 263 )
Figure 1 9-18.
Bronchial washing cel l block. PAP stain (1 ,OOOx).
(From McBride U. Textbook of Urinalysis and Body Fluids: A Clinical
Approach. Philadelph ia, PA: Lippincott; 1 998 263.)
270
Graft's Textbook of Urinalysis and Body Fluids
1 . What types of conditions can be detected using bronchos-
copy with bronchial washings and BAL collections?
2. What group of organisms is causing this patient's condition-
bacteria, fungi, or mycobacteria?
BIBLIOGRAPHY
Abdel-Rehim A, Abdel-Rehim M. Screening and determination of drugs
in human saliva utilizing microextraction by packed sorbent and liquid
chromatography-tandem mass spectrometry. Biomed Ch romatog r. 2013;
27: 1 188- 1 1 9 1 .
Baker RJ, Pusey CD. Th e changing profile o f acute tubulointerstitial nephritis.
Neph rol Dial T ransplant. 2004; 1 9:8.
Bertram KM, Bula DV, Pulido JS, et al. Amino-acid levels in subretinal and
vitreous fluid of patients with retinal detachment. Eye. 2008;22(4):582-589.
Brunzel NA. Fundamentals of Urine and Body Fluid Analysis. 3rd ed. Philadel-
phia, PA: Saunders; 20 1 3 .
Davis JL, Ruiz P, Shah M , e t al. Evaluation o f the reactive T-cell infiltrate in
uveitis and intraocular lymphoma with flow cytometry of vitreous fluid.
Trans Am Ophthalmol Soc. 20 12; 1 1 0: 1 1 7- 1 29.
Manoop S, Bhutani MS, Gupta V, et al. Pancreatic cyst fluid analysis - a review.
J Gastrointestin Live r Dis. 20 1 1 ;20(2): 1 7 5- 1 80.
McBride LJ. Textbook of Urinalysis and Body Fluids: A Clinical App roach. Phil-
adelphia, PA: Lippincott; 1 998.
Monkemiiller KE, Harewood GC, Curioso WH, et al. Biochemical analysis
of pancreatic fluid collections predicts bacterial infection. 1 Gastroente rol
Hepatol. 2005;20: 1 667- 1 673.
Servat OS, Hernandez CH, Simo R. Usefulness of the vitreous fluid analysis
in the translational research of diabetic retinopathy. Mediato rs Inflamm.
20 12;20 12:872978.
Sosa-Jurad F, Hernandez-Galindo VL, Mendoza-Torres MA, et al. Detec-
tion of hepatitis C virus RNA in saliva of patients with active infection
not associated with periodontal or liver disease severity. BMC Infect Dis.
20 14;14:72. Online article accessed at http://www.biomedcentral.com
Strasinger S. Urinalysis and Body Fluids. 6th ed. Philadelphia, PA: FA Davis;
2014.
Toros SZ, Toros AB, Ozel L, et al. Investigation of gastric pepsinogen in mid-
dle ear fluid of children with glue ear. Acta Otola ryngol. 20 1 0 ; 1 3 0 : 1 220-
1 224.
Turgeon M. Linne & Rings rud's Clinical La bo rato ry Science: The Basics and
Routine Techniques. 5th ed. St. Louis, MO: Mosby; 2007.
KEY TERMS
Automated Urine Sediment Analyzers
Barcode-Labeled Specimen
Completely Automated Urine Analyzers
Semiautomatic Strip Readers
LEARNING
OBJECTIVES
1. State the rationales for using automated systems for urinalysis and body fluids
examination.
2. List and describe the available automated urinalysis systems.
3. List and describe the available automated body fluid analysis systems.
271
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Graft's Textbook of Urinalysis and Body Fluids
T
ime-saving equipment and equipment that can accom-
modate large numbers of samples have been developed
for every area of the clinical laboratory. Automating
laboratory procedures allow for better standardization of test
performance and reduce not only the turnaround time but
also transcription errors. In addition, many automated instru-
ments interface with laboratory information systems, provid-
ing for quick entry of data into patients' electronic medical
records.
The use of automation in the urine and body fluids analy-
sis helps reduce technologist's interpretation variability. Auto-
mated equipment for performing urine and body fluid anal-
ysis takes the form of semiautomated or automated. Nearly
each manufacturer of reagent strips has developed its own
instrument. Some manufacturers have also developed auto-
mated systems for performing microscopic analysis on urine
and/or body fluids. This chapter contains a brief explanation
of the basic principles of some of these instruments.
Rationale for Automatin g
Urin alysis an d Body Fluids
Significant sediment findings may be missed if laboratory
protocols direct laboratory personnel to skip microscopic
evaluation when negative reagent strips findings are obtained.
Crystals, renal tubular epithelial cells, parasites, and yeast do
not have chemical indicators present on reagent strips cur-
rently in use. These findings also do not always have other
abnormalities present that would lead to the performance of
a microscopic evaluation. In addition, interfering substances
still do play a role in occasionally masking the presence of red
and white blood cells.
Automation of the microscopic portion of the urinaly-
sis not only helps detect unexpected sediment but also helps
standardize the identification and enumeration of urinary
sediment. Eliminating inaccuracies in manual timing of
reactions and visual subjectivity of reagent pad color inter-
pretation helps make urinalysis more reliable and less depen-
dent on the technologist. With automation, not much time
is needed to perform a complete urinalysis than a dipstick
screening only. Some laboratories do not perform a micro-
scopic examination when dipstick findings are normal. This
policy may be helpful in managing workflow in understaffed
laboratories, but some significant microscopic findings may
be missed.
Automated Urin alysis Systems
Several brands of urinalysis automation are currently available.
The current choices available include strip readers, semiauto-
matic strip readers, automated urine sediment analyzers, and
completely automated urine analyzers with both chemical and
Chapter 20
Automation of Urinalysis and Body Fluids Examination
273
Figure 20-1 .
Iris Automated Urinalysis i RICELL workce l l . Product
I mages © 2009 IRIS International, Inc. All rig hts reserved. I RIS, the Iris
logo, iC hem, iQ, i RIC ELL, and Velocity are trademarks of IRIS Interna-
tional, Inc. and are registered in the USPTO .
The Velocity reads the specimen's barcode, aspirates the
sample, and dispenses urine onto each pad of the reagent strip.
Color assessment of each reaction uses the same principle of
reflectance as described previously. Timing remains consistent
from sample to sample. The Velocity is capable of assessing the
color of a specimen by using wavelengths of light to obtain the
tone and hue of a urine specimen. Light scatter is used to deter-
mine the turbidity of the specimen. Specific gravity is measured
by assessing refractive index of LED-emitted light as it passes
through the specimen. The Velocity uses dual wavelength reflec-
tance to measure the pH and chemical constituents of urine.
The iQ200 series reads the specimen's barcode, aspirates the
sample, and performs urine sediment identification. The iden-
tification is done by enveloping a lamina of the sample with
a suspension fluid that moves past the objective lens of the
microscope. A digital camera, illuminated by a strobe lamp,
captures 500 frames per sample. The Auto-Particle Recog-
nition software uses size, shape, contrast, and texture to clas-
sify images. Digital images are reviewed by a technologist and
correlated to chemical and physical findings before reporting.
Electronic archiving of results allows results to be reviewed by
multiple users for confirmation of results, quality control, or
used in training sessions.
'ms
I
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·
Figure 20-2.
Iris Automated Urinalysis i RICELL workcel l with
iQ200ELITE. Product Images © 2009 I RIS I nternational, Inc. All rig hts
reserved. I RIS, the Iris logo, iC hem, iQ, iRICELL, and Velocity are trade-
marks of I RIS International, Inc. and are reg istered in the USPTO .
q
..".,â
Figure 20-3.
Iris Automated Urinalysis i RICELL workcel l with
iQ200SELECT. Product I mages © 2009 IRIS International, Inc. All rig hts
reserved. I RIS, the Iris logo, iC hem, iQ, iRICELL, and Velocity are trade-
marks of I RIS International, Inc. and are reg istered in the USPTO .
The combination of Velocity and an iQ200 provides a fully
automated urinalysis workcell, the iRICELL (Fig. 20- 1). The
iRICELL is available in three speeds: at 101 samples per hour
(Fig. 20-2), at 70 samples per hour (Fig. 20-3), and at 40 sam-
274
Graft's Textbook of Urinalysis and Body Fluids
Figure 20-5.
C lose-up of the iQ barcode reader and tube carrier.
Figure 20-6.
CLIN ITE K® Status. (Used with permission from
Siemens Med ical Solutions Diagnostics.)
Figure 20-7.
CLINITEK Advantus® Analyzer. (Cou rtesy of Siemens
Med ical Solutions Diag nostics.)
---
Figure 20-8.
CLINITEK Atlas® Automated U rine C hem istry Ana-
lyzer with rack. (Cou rtesy of Siemens Med ical Solutions Diag nostics.)
Siemens Medical Solutions Diagnostics' fully automated
instrument, the CLINITEK Atlas Automated Urine Chem-
istry Analyzer is available with rack (Fig. 20-8) or carou-
sel (Fig. 20-9), which provide walkaway convenience. The
CLINITEK Advantus is designed for high-volume urine
testing, using Siemens' proven technology in dry-pad urine
chemistry analysis and continuous reagent roll for simplified
loading and reduced interruptions. The CLINITEK Advantus
features a built-in liquid level sensing for simplified sample
preparation and has a modular design for compatibility with
laboratory automation systems. The CLINITEK Advantus
may be combined with the Sysmex UF- IOOOi Urine Cell
Analyzer to provide complete automation of both chemical
and microscopic aspects of the urinalysis procedure.
Figure 20-9.
C LINITEK Atlas® Automated Urine C hem istry Analyzer
with carousel. (Courtesy of Siemens Medical Solutions Diagnostics.)
Chapter 20
Automation of Urinalysis and Body Fluids Examination
275
Figure 20-1 0.
Fully Automated Urine Cell Analyzer UF-1 000 i .
(Image courtesy o f Sysmex America, I ne)
SYSMEX
The Sysmex Fully Automated Urine Cell Analyzer UF- lOOOi
(Fig. 20- 10) uses flow cytometry technology to classify and
quantitate the cellular elements found in the urine sediment.
After the cells are mixed with fluorescent stains, heated
and placed in suspension, they are covered in sheath fluid
and ejected through a nozzle into the flowcell. Here each
urine cell is illuminated by a focused semiconductor laser
beam, causing the individual cells to fluoresce and scatter
light. The forward and lateral-scattered light reflects the size
and surface characteristics of the cell. The fluorescent light
emitted reflects the more detail of the cell surface and high-
lights the internal structures, and the specific fluorescent
antibodies in the different stains reflect the DNA and/or RNA
properties of the cell nucleus. The forward scattered light,
lateral scattered light, and fluorescent light released by the
cells are captured by the detector block, then converted into
Cell suspension fluid
Sheath ll2i l il"'th ll"id
1
1
Optical
signal
Scattered light
Analysis
(V
-
Flourescent
-
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101
lig ht
electrical signals, which are then analyzed for height, ampli-
tude, and intensity. The cells are classified by an algorithm
based on these signal waveform patterns, and the cell counts
are quantified by adaptive cluster analysis. See Figure 20- 1 1
for an illustration of this process.
Automated Urin alysis
Systems Images
Most automated instruments that classify and enumerate urine
sediment display digital images for laboratory personnel to
evaluate.
Figures 20- 12 to 20-23 show digital images, produced by
these instruments, of various form of urinary sediment. The
276
Graft's Textbook of Urinalysis and Body Fluids
Figure 20-1 2.
Dig ital i mages of urine sed iment; white blood cells.
Figure 20-1 3.
Dig ital i mages of urine sed iment; red blood cells.
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Figure 20-14.
Dig ital i mages of urine sed iment; transitional cells.
·I
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Figure 20-1 5.
Dig ital i mages of urine sed iment; hya l i ne casts.
Figure 20-1 6.
Dig ital i mages of urine sed iment; granular casts.
Figure 20-1 7.
Dig ital i mages of urine sed iment; ca lcium oxalate
crystals.
Figure 20-1 8.
Dig ital i mages of urine sed iment; triple phosphate
crystals.
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Chapter 20
Automation of Urinalysis and Body Fluids Examination
277
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Dig ital i mages of urine sed iment; these sperm were
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Figure 20·21 .
Dig ital i mages of urine sed iment; yeast
Figure 20-22.
Squamous epithelial cells are not usua l ly reported
and are identified as " u nclassified " urinary sed i ment
eosinophils. Automated cell counters use larger numbers of
cells, enhancing precision and accuracy. Table 20-2 lists auto-
mated systems available for body fluid cell counting.
IRIS INTERNATIONAL, INC.
The Iris iQ Body Fluid Module adapts the iQ200 (Fig. 20-24)
for identification and enumeration of cells in most body fluids
including cerebrospinal, pleural, peritoneal, peritoneal lavage,
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