October-November
Shelly has shown the pictures to colleagues at Exeter, but has urgent family issues to deal with. So I'll be waiting a while.

October
Have had a quick look at the reports and pictures with Shelly, and she intends to take them to her work colleagues for further views. Thence we will look at the slides.

September 19th
Spoke to Shelly and will call her when I get the piccies.

September 17th
Spoke to Laura and she said the loan of the slides is to avoid them lending me the microscope etc.

September 16th
Yesterday I paid to have pictures taken of the dodgy cells in my June tests.

The option will be to:

• Take more pictures of the slides: Must check my compact flash cards are viable.
• Take the slides to Exeter for further analysis.
• Do another cytology test. Have to chase up the staining procedure.

From : Roger Lovejoy
User-Agent: Thunderbird 2.0.0.14 (Windows/20080421)
To: plamkom@labcore.com
Subject: cytology and haematuria

Hi. Matthew

I just spoke to you from the UK about the ability to assess the origin of red blood cells by microscopic analysis. I had found this option via an associated website of yours: http://www.carepathonline.com/Topic.aspx?Nav=0&Rel=166

"If red blood cells are present in your urine sample, the pathologist will examine them closely with a high-powered microscope to observe their shape. The shape of the cells tells the pathologist whether they came from the kidney or from another part of your urinary tract."

As I mentioned the common options available to the punter, here is rather sketchy and it has taken me some months to get this far. Even the medical professionals seem to be bemused at my discoveries. (BTAStat, NMP22) and now this. The only view on cytology that I have extracted locally is being used to find cancer cells. My query is to know where the blood is coming from at this stage.

My queries are:

1. Is the analysis by an optical microscope or it some other higher tech. apparatus needed.
2. Can you provide me with any examples of how you discover the source, i.e. the differences in red blood cells. A description and/or images would be great. If it is done using an optical microscope I am thinking of buying one and doing regular checks myself.

Please let me know you get this so I can confirm I have the correct email address.

All the best

Roger Lovejoy

Subject: Haematuria and Cytology
From: Roger Lovejoy
Date: Fri, 06 Jun 2008 13:16:34 +0100
To: martina.hornby@phnt.swest.nhs.uk
User-Agent: Thunderbird 2.0.0.14 (Windows/20080421)

Dear Martina Hornby

Thank you for the time you spent helping me with my cytology queries regarding haematuria.

Re: Recommended Procedure for samples
You mentioned the recommended procedure is for three samples be taken, mid-morning, on consecutive days.
As the local surgery has samples collected at 11am I'm wondering what
condition the samples need to be in when they arrive at Derriford. Do
they have to arrive separately each day, so they are 'fresh' or can
they be stored locally, refrigerated or otherwise and then sent as a
batch?

On the subject of 'screening' for types of red blood cells
I can refer you to two web site pages. I have emailed the second and am about to call the first:

On reading the first again, I note doesn't specifically say that the cytology is the method for assessing the source of blood, its just the way its written in the same paragraph. It was very useful talking to you as it became clearer that using cytology to find the source of
haematuria may be a red-herring

1. From: http://www.carepathonline.com/Topic.aspx?Nav=0&Rel=166

"Your doctor may order urine cytology if you have blood in
your urine and a definite cause of the bleeding has not been identified. The medical name for blood in the urine is hematuria. It has many causes, including strenuous exercise, too much stress, infection, kidney and bladder stones, and even cancer. When there is blood in your urine, it is important to identify what part of your urinary tract the blood is coming from so any problems can be properly diagnosed and treated."

2. From: http://www.wisegeek.com/what-is-cytology.htm

"Another important aspect in the discipline of
cytology is
examining
cell interaction. By studying how cells relate to other cells or to the
environment, cytologists can predict problems or examine environmental
dangers to cells, such as toxic or cancer-causing substances. In humans
and other multi-cellular structures, cytology can examine the presence
of too many of one kind of cell, or the lack of enough of a certain
kind of cell. In a simple test like a complete blood count, a
laboratory can look at white blood cells and identify the presence of
an infection, or it may examine a low level of certain types
of red blood cells and diagnose anemia."

All the best

Roger Lovejoy

Well I've pretty much decided to have the cytology as I am now in a position to find out what I want rather than being a mindless consumer of the NHS.

I have just, 13:00, been talking to Martina Hornby, Chief Bio-technician at Derriford Cytology. She was not aware of cytology being used to test for blood cells as a way of finding the source of haematuria. This made me read the info I had more carefully. See my email to her, which also queries the procedure for supply samples of urine.

However I have just revisited the site where I thought cytology was mentioned in relation to types of blood cells, thinking I was mistaken only to find this.
From: CarePathOnLine.com

If There Is Blood in Your Urine
If red blood cells are present in your urine sample, the pathologist will examine them closely with a high-powered microscope to observe their shape. The shape of the cells tells the pathologist whether they came from the kidney or from another part of your urinary tract. The pathologist also will study the physical appearance, acidity (pH), and chemical makeup of your urine and determine whether any casts are present in your urine (see below). All this will be helpful in identifying the nature of your problem.

So I hardly need to call to confirm, but will. They may be my best option. CarePath Online is the support feature for 'Dianon'. a Labcorp Company. 200 Watson Boulevard Stratford, CT 06615 Phone: 001-203-381-4000

-:- 14:20 Have just called Dianon and had to leave a message for Matthew Plamkoodin. I have also email him there via plamkom@labcore.com

-:- 17:05 have just emailed Dr Mccormick with my latest findings re: assessing red blood cell origin and the three shots procedure for the cytology at Derriford as per Martina's reference. About to call Dianon again.

-:- 17:20 Have just spoken to Matthew Plamkoodin and he has confirmed that they can tell if blood source in the urine is from the kidney, urinary tract or bladder. He will get back to me on how its done and how to get them to do it for me if its not available in the UK. -:- 17:38 Just sent email.

-:- 17:39 Have also just received a reply from wisegeek.com, which directs me to leave a message for other users. Not going to follow this up, as the issue is resolved in communications with Matthew Plamkoodin.

27th June 14:50
I've just about given up on Plamkoodin and co. I've sent yet another email and have no reply. I'm thinking they can only differentiate between blood from the kidneys as the cells are somewhat squashed together other than any other part of the urinary system.

Dr McCormick replied at 11:41:10 +0100. Reply in green, my next in black.

Hi Doctor

I'm still subconsciously juggling with the purpose of the cytology as its propensity for not finding a positive being high, is not very useful. That it may find a positive may be useful, but I'm not sure about that if there's little or nothing I can envisage doing about it.

However I am getting closer to having the cytology if only for curiosity of the process and outcome.
To that end I think it better to provide a sample where there is clearly a substantial haem count or preferably, well not that I want it, urine that is at least pink. I do a stick test daily and some days are negative so a sample then would be all but useless. Also the more haem there is the more a visual examination will have to study.

Overall things have plateaued out, things are not as 'bad' as when I came to see you, my urine is less often obviously discoloured. I'm not sure if that means any possible tumour is just getting its feet under the table or its being squeezed out of home.

One thing I didn't mention was that when I went to get copies of the U-scan and X-ray I had a shock as when I went for a pee in the hospital my pee was so red I almost fainted. It was so red it was like paint and stained the bowl. I went to A & E and felt very dizzy and out of it. The reason I mention it is that it was extreme and yet the only such time. There were a few times of light pink but most of those were weeks ago. I just wonder what could have been the source of such an amount of blood whereas normally, well, its not like that.

Since we don't know the exact cause of the bleeding it is difficult to draw any conclusions about why you pass more blood on some days than others-this would certainly be not unusual for a tumour.

I thought that was the way, as I had been reading, but it still prompts the query as to why so different. What exactly happens?

In fact, how much and when you pass blood doesn't help us at all , although it does make me worry that you may become anaemic in due course if it continues.

Well luckily the only time was that once, all the other times are no where near the same. I gather that "As little as 1 milliliter (0.03 ounces) of blood will turn the urine red." http://www.urologychannel.com/hematuria/index.shtml so I don't I have any concerns about anaemia at the moment. If I was to bleed a lot I would worry

There is also the possibility that an infection could ensue causing more bleeding-this is unlikely if it goes away again, and if it is not associated with any new symptoms such as pain or fever.

No pain, no fever but I do get a little tired or confused. I'm not sure but my thinking slows down and I can't respond or pat attention to things as well. It happens now and then and is usually followed by either a +++ reading on the sticks or visibly coloured pee.

Back to the cytology option. Is it possible for me to pick up a sample bottle and keep it until I am ready, and then presumably bring it in before 11am one morning, although if it just so happens that I have a pink or red pee at any time maybe I should bring it it immediately. I don't have a fridge to store anything and I imagine that keeping it for any length of time may facilitate degradation of the sample.

I think as regards when you provide the sample-in fact too many red blood cells could make it harder for the cytologist to see any tumour cells, so I think that you should actually avoid a sample on a day when you can see blood.Ideally I would like to send it to the lab the same day but the cells will last a few days before they degrade ,after that it is up to the cytologist when it is screened, so we may not get an answer for several weeks-I don't know as it is not a routine test.

My understanding of the cytology test was that it was looking for a specific type of red blood cell which will define where the blood comes from, no so much looking for cancerous cells. I must read up on that again as otherwise your suggestion makes far more sense. In fact in that case I may go jogging first to loosen up some bit

I will arrange for a pot and a cytology form to be left at Reception for you next week.

Ok that's it for now

Thanks

Roger Lovejoy

I have managed to secure the offer of a cytology test via my GP: Quote the email

"You can certainly have the cytology screen done on the urine. Mr Hammonds' (the Urologist) opinion is that it is too insensitive to be reliable, apart from in very highly malignant cases. This means essentially that whilst a positive test is likely to be significant, a negative test does not reassure either of us that there is not a cancer there."

There are a few things I want to address before deciding whether to have one. Some of these are technical issues, others philosophical. The later need addressing first, else there's no test. However as the technical issues have finite goals and outcomes they can actively be resolved and so take the focus and action. The philosophical issues will resolve themselves automatically by sitting back and relaxing, they cannot be resolved by analysis but more by weight of feeling.

Technical:

• Timing: Take a sample that has a lot of blood and is cloudy and has bits. I note from the initial blood sample there were no casts in the specimen.
• Find data on results relative to stages etc.
• Find data on the specifics of the test. Can it be a DIY process?

Philosophical:
The main issues here are as to the reason for having the test.

• Curiosity
• What would happen next
• What to family think as I'm under pressure to act to their desires and 'benefit'

30th May 09:24 Well I've heard Vyaj has had her final exam plus I'm feeling more positive so I'm inclined to have the cytology just for curiosity. However I will no doubt mull over this change and see what underlies it and consider the consequences. Most of such will be done subconsciously.

31st May 09:50 Have emailed Dr McCormick

6th June 09:33
From: carepathonline.com

Your doctor may order urine cytology if you have blood in your urine and a definite cause of the bleeding has not been identified. The medical name for blood in the urine is hematuria. It has many causes, including strenuous exercise, too much stress, infection, kidney and bladder stones, and even cancer. When there is blood in your urine, it is important to identify what part of your urinary tract the blood is coming from so any problems can be properly diagnosed and treated.

From: wisegeek.com

Another important aspect in the discipline of cytology is examining cell interaction. By studying how cells relate to other cells or to the environment, cytologists can predict problems or examine environmental dangers to cells, such as toxic or cancer-causing substances. In humans and other multi-cellular structures, cytology can examine the presence of too many of one kind of cell, or the lack of enough of a certain kind of cell. In a simple test like a complete blood count, a laboratory can look at white blood cells and identify the presence of an infection, or it may examine a low level of certain types of red blood cells and diagnose anemia.

-:- 10:05 Just emailed the above as follows:
"Hi. I'm about to have a cytology examination of urine to assess if I have cancer of the bladder, as I have haematuria. My 'Doctor' is under the impression that only cancer cells will be looked for.

I found that
"it is important to identify what part of your urinary tract the blood is coming from" from http://www.carepathonline.com/Topic.aspx?Nav=0&Rel=166 and
"of certain types of red blood cells" from your web site.

Accordingly, checking for cancer cells is not the only or better option.

If no cancer cells are found, then knowing where the blood comes form is very significant.

The fact that there is this option to check the red blood cell type means I can provide two samples.

One with obvious (gross) haematuria so that the blood cells can be easily available for analysis and a second, clear sample, as my Dr said the blood may interfere and obscure the cytologist in the search for cancer cells.

Can you please confirm that there are different types of red blood cells and direct me to any on-line or other reference, so I can present such to my Dr.

Thank you"