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By comparing the osmolar clearance with the actual urine volume excreted per minute weight loss breakfast order orlistat cheap, it can be determined whether the water being excreted is more or less than the amount needed to maintain an osmolality the same as that of the ultrafiltrate weight loss names purchase 60 mg orlistat overnight delivery. If the value had been 0 weight loss kidney disease discount 120 mg orlistat visa, no renal concentration or dilution would be taking place; likewise weight loss pills vegetarian purchase orlistat 60mg free shipping, if the value had been +2. The calculation of the free water clearance is used to determine the ability of the kidney to respond to the state of body hydration. Based on normal hematocrit readings, reference values for the effective renal plasma flow range from 600 to 700 mL/min, making the average renal blood flow about 1200 mL/min. Also, the term "effective" is included because approximately 8% of the renal blood flow does not come into contact with the functional renal tissue. Nuclear medicine procedures using radioactive hippurate can determine renal blood flow by measuring the plasma disappearance of a single radioactive injection and at the same time provide visualization of the blood flowing through the kidneys. Impaired tubular secretory ability or inadequate presentation of the substance to the capillaries owing to decreased renal blood flow may cause an abnormal result. Titratable Acidity and Urinary Ammonia the ability of the kidney to produce an acid urine depends on the tubular secretion of hydrogen ions and production and secretion of ammonia by the cells of the distal convoluted tubule. In normal persons, a diurnal variation in urine acidity consisting of alkaline tides appears shortly after arising and postprandially at approximately 2 p. Chachati, A, et al: Rapid method for the measurement of differential renal function: Validation. The inability to produce an acid urine in the presence of metabolic acidosis is called renal tubular acidosis. This condition may result from impaired tubular secretion of hydrogen ions associated with the proximal convoluted tubule or defects in ammonia secretion associated with the distal convoluted tubule. Urine pH, titratable acidity, and urinary ammonia measurements can be used to determine the defective function. The tests can be run simultaneously on either fresh or toluenepreserved urine specimens collected at 2-hour intervals from patients who have been primed with an acid load consisting of oral ammonium chloride. By titrating the amount of free H+ (titratable acidity) and then the total acidity of the specimen, Study Questions 1. The renin-angiotensin-aldosterone system is responsible for all of the following except: A. Concentration of the tubular filtrate by the countercurrent mechanism depends on all of the following except: A. If ammonia is not produced by the distal convoluted tubule, the urine pH will be: A. Endogenous beta2-microglobulin creatinine cystatin C 125I-iothalmate 19. Given the following information, calculate the creatinine clearance: 24-hour urine volume: 1000 mL; serum creatinine: 2. Clearance tests used to determine the glomerular filtration rate must measure substances that are: A. Substances that may interfere with freezing point measurement of urine and serum osmolarity include all of the following except: A. After controlled fluid intake, the urine-to-serum osmolarity ratio should be at least: A. Calculate the free water clearance from the following results: urine volume in 6 hours: 720 mL; urine osmolarity: 225 mOsm; plasma osmolarity: 300 mOsm 31. To provide an accurate measure of renal blood flow, a test substance should be completely: A. Production of excessively acidic urine due to increased filtration of hydrogen ions B. Production of excessively acidic urine due to increased secretion of hydrogen ions C. Tests performed to detect renal tubular acidosis after administering an ammonium chloride load include all of the following except: A. Titratable acidity 56 Part One Background Case Studies and Clinical Situations 1. A 44-year-old man diagnosed with acute tubular necrosis has a blood urea nitrogen of 60 mg/dL and a blood glucose level of 100 mg/dL. Diagram the reactions that take place to ensure adequate blood pressure within the nephrons. A physician would like to prescribe a nephrotoxic antibiotic for a 60-year-old Caucasian man. How can the physician determine whether it is safe to prescribe this medication before the patient leaves the office State two additional blood tests that the physician could use to continue monitoring this patient. If the patient has a history of prostate malignancy, would both of these methods provide reliable results A laboratory is obtaining erratic serum osmolarity results on a patient who is being monitored at 6 a. Osmolarities are not performed on the night shift; therefore, the midnight specimen is run at the same time as the 6 a. If a friend were secretly bringing the patient a pint of whiskey every night, would this affect the results As mentioned in Chapter 2, early physicians based many medical decisions on the color and clarity of urine. Today, observation of these characteristics provides preliminary information concerning disorders such as glomerular bleeding, liver disease, inborn errors of metabolism, and urinary tract infection.
Clinical Significance the finding of a positive reagent strip test result for blood indicates the presence of red blood cells weight loss utah order cheap orlistat on-line, hemoglobin weight loss pills mayo clinic cheap orlistat 120mg without a prescription, or myoglobin weight loss pills under 10 buy orlistat 60 mg cheap. Reagent Strip Reactions Chemical tests for blood use the pseudoperoxidase activity of hemoglobin to catalyze a reaction between the heme component of both hemoglobin and myoglobin and the chromogen tetramethylbenzidine to produce an oxidized chromogen ez 60 weight loss pills buy generic orlistat on-line, which has a green-blue color. H2O2 + chromogen Hemoglobin Peroxidase Hematuria Hematuria is most closely related to disorders of renal or genitourinary origin in which bleeding is the result of trauma or damage to the organs of these systems. Major causes of hematuria include renal calculi, glomerular diseases, tumors, trauma, pyelonephritis, exposure to toxic chemicals, and anticoagulant therapy. The laboratory is frequently requested to perform a urinalysis when patients presenting with severe back and abdominal pain are suspected of having renal calculi. In such cases, hematuria is usually of a small to moderate degree, but its presence can be essential to the diagnosis. Hematuria of nonpathologic significance is observed following strenuous exercise and during menstruation. It also may result from intravascular hemolysis and the subsequent filtering of hemoglobin through the glomerulus. Lysis of red blood cells in the urine usually shows a mixture of hemoglobinuria and hematuria, whereas no red blood cells are seen in cases of intravascular hemolysis. Under normal conditions, the formation of large hemoglobin-haptoglobin complexes in the circulation prevents the glomerular filtration of hemoglobin. When the amount of free hemoglobin present exceeds the haptoglobin content-as occurs in hemolytic anemias, transfusion reactions, severe burns, brown recluse spider bites, infections, and strenuous exercise- hemoglobin is available for glomerular filtration. After mixing and allowing the specimen to sit for 5 minutes, the urine is filtered or centrifuged, and the supernatant is tested for a reaction for blood with a reagent strip. The principle of this screening test is based on the fact that the larger hemoglobin molecules are precipitated by the ammonium sulfate, and myoglobin remains in the supernatant. Therefore, when myoglobin is present, the supernatant retains the red color and gives a positive reagent strip test for blood. Conversely, hemoglobin produces a red precipitate and a supernatant that tests negative for blood. Sensitivity Interference Reagent strip manufacturers incorporate peroxide, and tetramethylbenzidine, into the blood testing area. In the presence of free hemoglobin/myoglobin, uniform color ranging from a negative yellow through green to a strongly positive green-blue appears on the pad. In contrast, intact red blood cells are lysed when they come in contact with the pad, and the liberated hemoglobin produces an isolated reaction that results in a speckled pattern on the pad. Reagent strip tests can detect concentrations as low as five red blood cells per microliter; however, care must be taken when comparing these figures with the actual microscopic values, because the absorbent nature of the pad attracts some of urine. The terms trace, small, moderate, and large or trace, 1+, 2+, and 3+ are used for reporting. Correlations with other tests Reaction Interference False-positive reactions due to menstrual contamination may be seen. They also occur if strong oxidizing detergents are present in the specimen container. Vegetable peroxidase and bacterial enzymes, including an Escherichia coli peroxidase, may also cause false-positive reactions. Therefore, sediments containing bacteria should be checked closely for the presence of red blood cells. Traditionally, ascorbic acid (vitamin C) has been associated with false-negative reagent strip reactions for blood. Both Multistix and Chemstrip have modified their reagent strips to reduce this interference to very high levels (25 mg/dL) of ascorbic acid. Multistix uses a peroxide that is less subject to reduction by ascorbic acid, and Chemstrip overlays the reagent pad with an iodate-impregnated mesh that oxidizes the ascorbic acid prior to its reaching the reaction pad. False-negative reactions can result when urine with a high specific gravity contains crenated red blood cells that do not lyse when they come in contact with the reagent pad. Decreased reactivity may also be seen when formalin is used as a preservative or when the hypertension medication captopril or high concentrations of nitrite (greater than 10 mg/dL) are present. Red blood cells settle to the bottom of the specimen container, and failure to mix the specimen prior to testing causes a falsely decreased reading. Bilirubin the appearance of bilirubin in the urine can provide an early indication of liver disease. Bilirubin Production Bilirubin, a highly pigmented yellow compound, is a degradation product of hemoglobin. Under normal conditions, the life span of red blood cells is approximately 120 days, at which time they are destroyed in the spleen and liver by the phagocytic cells of the reticuloendothelial system. The liberated hemoglobin is broken down into its component parts: iron, protein, and protoporphyrin. The body reuses the iron and protein, and the cells of the reticuloendothelial system convert the remaining protoporphyrin to bilirubin. The bilirubin is 86 Part Two Urinalysis then released into the circulation, where it binds with albumin and is transported to the liver. At this point, the kidneys cannot excrete the circulating bilirubin because not only is it bound to albumin, but it is also water insoluble (unconjugated bilirubin). In the liver, bilirubin is conjugated with glucuronic acid by the action of glucuronyl transferase to form water-soluble bilirubin diglucuronide (conjugated bilirubin).
The Joint Commission Patient Safety Goals require that when verbally reporting test results the information must be repeated by the person receiving the information and documented by the person giving the report weight loss breakfast ideas discount 120mg orlistat. Interpreting Results the specificity and the sensitivity for each test should be included in the procedure manual for correct interpretation of results weight loss grocery list buy orlistat with a visa. All known interfering substances should be listed for evaluation of patient test data weight loss 50 lbs before and after orlistat 60mg on-line. Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings weight loss diet 60 mg orlistat, 2007. Centers for Medicare & Medicaid Services, Department of Health and Human Services: Clinical Laboratory Improvement Amendments, Updated Regulations, Brochure #1, How do they affect my laboratory College of American Pathologists: Commission on Laboratory Accreditation, Urinalysis Checklist. Centers for Medicare & Medicaid Services, Department of Health and Human Services: Clinical Laboratory Improvement Amendments, Brochure #4: Equivalent Quality Control Procedures. In the urinalysis laboratory the primary source in the chain of infection would be: A. An employee who is accidentally exposed to a possible blood-borne pathogen should immediately: A. All of the following should be discarded in biohazardous waste containers except: A. An employer who fails to provide sufficient gloves for the employees may be fined by the: A. Centrifuging an uncapped specimen may produce a biologic hazard in the form of: A. An employee can learn the carcinogenic potential of potassium chloride by consulting the: A. All of the following are safe to do when removing the source of an electric shock except: A. During laboratory accreditation inspections, procedure manuals are examined for the presence of: A. As supervisor of the urinalysis laboratory, you have just adopted a new procedure. Indicate whether each of the following would be considered a 1) preexamination, 2) examination, or 3) postexamination factor by placing the appropriate number in the blank: Reagent expiration date Rejecting a contaminated specimen Constructing a Levy-Jennings chart Telephoning a positive Clinitest result on a newborn Calibrating the centrifuge Collecting a timed urine specimen 24 Part One Background 30. The testing of sample from an outside agency and the comparison of results with participating laboratories is called: A. State a possible reason for an accreditation team to report a deficiency in the following situations: a. An unusually high number of urine specimens are being rejected because of improper collection. As the new supervisor of the urinalysis section, you encounter the following situations. The urinalysis section is primarily staffed by personnel assigned to other departments for whom you have no personnel data. An outpatient urine specimen was delivered to the laboratory at 0800 and placed on the counter in the Urinalysis department. Where would the information concerning what should have been done with this specimen be found and the criteria for rejection References to the study of urine can be found in the drawings of cavemen and in Egyptian hieroglyphics, such as the Edwin Smith Surgical Papyrus. Pictures of early physicians commonly showed them examining a bladder-shaped flask of urine. Although these physicians lacked the sophisticated testing mechanisms now available, they were able to obtain diagnostic information from such basic observations as color, turbidity, odor, volume, viscosity, and even sweetness (by noting that certain specimens attracted ants or tasted sweet). However, modern urinalysis has expanded beyond physical examination of urine to include chemical analysis and microscopic examination of urinary sediment. These charlatans, called "pisse prophets," became the subject of a book published by Thomas Bryant in 1627. The revelations in this book inspired the passing of the first medical licensure laws in England- another contribution of urinalysis to the field of medicine. The invention of the microscope in the 17th century led to the examination of urinary sediment and to the development by Thomas Addis of methods for quantitating the microscopic sediment. By the 1930s, however, the number and complexity of the tests performed in a urinalysis had reached a point of impracticality, and urinalysis began to disappear from routine examinations. Fortunately, development of modern testing techniques rescued routine urinalysis, which has remained an integral part of the patient examination. Two unique characteristics of a urine specimen account for this continued popularity: 1. Chapter 2 Introduction to Urinalysis 29 Urea, a metabolic waste product produced in the liver from the breakdown of protein and amino acids, accounts for nearly half of the total dissolved solids in urine. The major inorganic solid dissolved in urine is chloride, followed by sodium and potassium. Dietary intake greatly influences the concentrations of these inorganic compounds, making it difficult to establish normal levels. Although not a part of the original plasma filtrate, the urine also may contain formed elements, such as cells, casts, crystals, mucus, and bacteria.
This recognition event weight loss zucchini recipes generic orlistat 120mg with amex, rapid but relatively nonspecific slim9 weight loss pills order orlistat cheap online, plays an essential role in the generation of pathogen-specific immunity through the generation of cytokines and chemokines that recruit antigenspecific cells to the site of infection and shape the ensuing adaptive immune response weight loss pills dollar tree discount 120mg orlistat overnight delivery. This section briefly details the major known receptors of the innate immune system and links the function of these receptors to antigen-specific cellular immunity weight loss pills expand in stomach order 120mg orlistat free shipping. MolecularRecognitionof MicrobialProducts Although the concept that microbial products are recognized by specific receptors of the innate immune system is not new, recent investigations have dramatically expanded our understanding of the receptors involved in this process. Several outstanding reviews provide a comprehensive overview on the molecular recognition of microbial products and its role on human susceptibility to infectious diseases. However, the role of the mannose receptor in mediating host defense through innate immune recognition remains unclear because a gene-deficient mouse strain does not appear susceptible to C. Thus, adjuvants that induce innate inflammatory responses are co-administered with some vaccines. Collectively, these studies argue that other innate immune signaling pathways provide adjuvant effects. The binding specificity for some of these receptors has been elucidated and includes fungal, bacterial, mycobacterial, viral, and parasitic ligands. Although primary active infection with these viruses is controlled, herpesviruses establish clinical latency and can cause intermittent disease or disease in the setting of impaired immunity. Although immunologic elimination of the infection is often impossible, immunologic control of intermittent reactivation is the rule. Chapter 6 Cell-Mediated Defense against Infection the diverse properties of microbial pathogens provide a challenge to the cellular immune system. Although the details of cellular immune responses to different pathogens vary substantially, some broad generalizations regarding cellular immune responses to microbial pathogens can be justified. In most cases, the subcellular anatomic location of a pathogen (extracellular, intracellular/vacuolar, intracellular cytoplasmic) predicts the arm of the cellular immune response that is necessary to contain infection by that particular pathogen. In many cases, the most definitive information about the important arms of antimicrobial defense for a particular pathogen has come from natural or acquired deficiency states, in particular, defects in immune receptors or signaling molecules. In addition, because different classes of pathogens are associated with a particular type of cellular immune response, many pathogens have developed sophisticated molecular countermeasures to avoid elimination. Because viral pathogens replicate within their host cell, their elimination by the cellular immune system involves either cytolytic destruction of the infected host cell by virus-specific lymphocytes or inhibition of viral replication in host cells. One of the most effective escape mechanisms involves entering host cells, often phagocytic cells. In this circumstance, the host cell becomes a protective barrier from extracellular microbicidal defenses. Bacterial pathogens have used many clever strategies to exploit the interior of host cells to their benefit, by manipulating intracellular trafficking pathways or targeting specific intracellular niches. The challenge facing the cell-mediated immune system is to detect and eliminate these pathogens. Multiple bacterial pathogens that parasitize phagocytic cells, such as macrophages, reside within the endosomal-phagosomal network. Some controversy exists about whether the essential macrophage effector molecules that control intracellular bacteria differ between mice and humans. This massive cohort of mycobacteria-exposed infants has revealed several inherited defects in antimycobacterial immunity. As such, it is logical to assume that pathogens of this type have evolved countermeasures to dampen or subvert effective host immunity. These pathogens secrete proteins that are essential for virulence and that destroy the vacuolar membrane, providing direct access to the host cell cytosol. Because of their cytoplasmic location, the antimicrobial effector mechanisms of phagocytic cells cannot be localized spatially to the cytoplasmic site of infection, necessitating killing of the infected cell by cytolytic T cells to eliminate the infection. Bacteria that replicate extracellularly are accessible to antibodymediated neutralization or killing by externalized microbial products of phagocytic cells. Defense against pyogenic bacteria, such as Staphylococcus aureus and Streptococcus pneumoniae, depends on adequate humoral immunity and intact neutrophil function. Th17 cells have been implicated in defense against Klebsiella infections in the lung. Although some of these alleles bind similar peptides, most, by virtue of their morphologically distinct peptide-binding grooves, bind distinct families of peptides. Positive selection occurs first through a process in which the double-positive thymocyte interacts with a thymic epithelial cell. High-affinity interaction with self-antigens results in deletion of the single positive thymocyte, providing a second opportunity to eliminate potentially autoreactive T lymphocytes. On completion of positive and negative selection, thymocytes exit the thymus in a process that is regulated by sphingosine-1phosphate. Patients with DiGeorge syndrome have a congenital absence of thymic tissue and a corresponding absence of peripheral T lymphocytes. However, adults in their 50s continue to have active thymic tissue in the mediastinum and recent thymic emigrants in the bloodstream suggest the thymus continues to function despite its relatively small size. Many forms of chemotherapy also are toxic to the thymus and result in thymic atrophy and diminished output of T lymphocytes.
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