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1.  Correlation between dipstick urinalysis and urine sediment microscopy in detecting haematuria among children with sickle cell anaemia in steady state in Ilorin, Nigeria 
Introduction
Haematuria is one of the clinical manifestations of sickle cell nephropathy. Although dipstick urinalysis detects haemoglobin and by extension haematuria; it does not confirm haematuria. Urine sediment microscopy confirms haematuria and constitutes a non-invasive “renal biopsy”. The need to correlate dipstick urinalysis and urine sediment microscopy findings becomes important because of the cheapness, quickness and simplicity of the former procedure.
Methods
Dipstick urinalysis and urine sediment microscopy were carried (both on first contact and a month after) among consecutive steady state sickle cell anaemia children attending sickle cell clinic at the University of Ilorin Teaching Hospital between October 2004 and July 2005.
Results
A total of 75 sickle cell anemia children aged between 1-17 years met the inclusion criteria. Haematuria was found in 12 children (16.0%) and persistent haematuria in 10 children 13.3%. Age and gender did not have significant relationship with haematuria both at first contact (p values 0.087 and 0.654 respectively) and at follow-up (p values 0.075 and 0.630 respectively). Eumorphic haematuria was confirmed in all the children with persistent haematuria with Pearson correlation +0.623 and significant p value of 0.000.
Conclusion
The study has revealed a direct significant correlation for haematuria detected on dipstick urinalysis and at urine sediment microscopy. It may therefore be inferred that dipstick urinalysis is an easy and readily available tool for the screening of haematuria among children with sickle cell anaemia and should therefore be done routinely at the sickle cell clinics.
doi:10.11604/pamj.2013.15.135.1854
PMCID: PMC3852513  PMID: 24319525
Sickle cell nephropathy; children; haematuria; dipstick urinalysis; urine sediment microscopy
2.  Identifying and Evaluating Field Indicators of Urogenital Schistosomiasis-Related Morbidity in Preschool-Aged Children 
PLoS Neglected Tropical Diseases  2015;9(3):e0003649.
Background
Several studies have been conducted quantifying the impact of schistosome infections on health and development in school-aged children. In contrast, relatively little is known about morbidity levels in preschool-aged children (≤5 years) who have been neglected in terms of schistosome research and control. The aim of this study was to compare the utility of available point-of-care (POC) morbidity diagnostic tools in preschool versus primary school-aged children (6–10 years) and determine markers which can be used in the field to identify and quantify Schistosoma haematobium-related morbidity.
Methods/Principal Findings
A comparative cross-sectional study was conducted to evaluate the performance of currently available POC morbidity diagnostic tools on Zimbabwean children aged 1–5 years (n=104) and 6–10 years (n=194). Morbidity was determined using the POC diagnostics questionnaire-based reporting of haematuria and dysuria, clinical examination, urinalysis by dipsticks, and urine albumin-to-creatinine ratio (UACR). Attributable fractions were used to quantify the proportion of morbidity attributable to S. haematobium infection. Based on results of attributable fractions, UACR was identified as the most reliable tool for detecting schistosome-related morbidity, followed by dipsticks, visual urine inspection, questionnaires, and lastly clinical examination. The results of urine dipstick attributes showed that proteinuria and microhaematuria accounted for most differences between schistosome egg-positive and negative children (T=-50.1; p<0.001). These observations were consistent in preschool vs. primary school-aged children.
Conclusions/Significance
Preschool-aged children in endemic areas can be effectively screened for schistosome-related morbidity using the same currently available diagnostic tools applicable to older children. UACR for detecting albuminuria is recommended as the best choice for rapid assessment of morbidity attributed to S. haematobium infection in children in the field. The use of dipstick microhaematuria and proteinuria as additional indicators of schistosome-related morbidity would improve the estimation of disease burden in young children.
Author Summary
Schistosomiasis is a major parasitic disease affecting children in Africa, with impacts on health, growth and cognitive development. Recently, the World Health Organization has recommended inclusion of preschool-aged children (≤5 years) in schistosome control programmes. However, so far the performance of available morbidity diagnostic tools has not been thoroughly evaluated in this age group. To address this knowledge gap, we conducted a study in preschool children comparing the utility of currently available point-of-care tools for diagnosing Schistosoma haematobium-related morbidity, namely: questionnaire-reported haematuria and dysuria, clinical examination, dipstick urinalysis, and measurement of urine albumin-to-creatinine ratio (UACR). We also investigated the performance of these tools in older children (6–10 years). Our study identified UACR as the most reliable tool for detecting schistosome-related morbidity in terms of the morbidity attributable to schistosome infection, followed by dipsticks, visual urine inspection, questionnaires, and lastly clinical examination The study further showed that the tools currently used in school-aged children for diagnosing schistosome-related morbidity can be extended to preschool children, allowing easier integration of this age group into treatment and monitoring programmes.
doi:10.1371/journal.pntd.0003649
PMCID: PMC4368198  PMID: 25793584
3.  Dipstick haematuria and bladder cancer in men over 60: results of a community study. 
BMJ : British Medical Journal  1989;299(6706):1010-1012.
OBJECTIVE--To investigate the prevalence and relevance of dipstick haematuria in a group of men in the community. DESIGN--Prospective study of elderly men invited to attend a health centre for urine screening as part of a health check. SETTING--An inner city health centre in Leeds. SUBJECTS--578 Of 855 men aged 60-85 responding to an invitation to participate. INTERVENTIONS--The subjects had their urine tested with a dipstick (Multistix) for the presence of blood and then tested their urine once a week for the next 10 weeks. Those with one or more positive test results were offered full urological investigation. MAIN OUTCOME MEASURE--The prevalence of urological disease in those subjects with dipstick haematuria. RESULTS--78 Men (13%) had dipstick haematuria on a single test and a further 54 (9%) had evidence of dipstick haematuria when testing their urine once a week during a subsequent 10 week period. Investigation of 87 men disclosed urological disease in 45, including four with a bladder tumour and seven with epithelial dysplasia. CONCLUSION--Dipstick haematuria is a common incidental finding in men over 60 and is associated with appreciable urological disease. The introduction of less invasive methods of investigation, particularly flexible cystoscopy and ultrasonography, has made investigation of these patients simple and safe and makes screening for bladder cancer in the community more feasible.
PMCID: PMC1837876  PMID: 2511941
4.  Patients with new onset haematuria: assessing the discriminant value of clinical information in relation to urological malignancies. 
BACKGROUND: There is little information available to assist general practitioners (GPs) in deciding which patients with haematuria are likely to have a malignancy. AIM: To derive discriminant functions for specific items or clusters of clinical history information in relation to the categorisation of patients presenting to the 'open access' haematuria clinic in Hull. DESIGN OF STUDY: Recruitment of patients via an 'open-access' haematuria clinic. SETTING: A consecutive series of 363 patients aged between 18 and 80 years who attended the clinic. METHOD: Between February 1999 and October 1999 clinical history information derived from the participating patients was compared with the patients' diagnoses. Diagnoses were established by a combination of cystoscopy and radiological assessments and rechecked against the patient records and the hospital patient administration system two to three months later. RESULTS: A number of individual variables seemed to be particularly helpful in discriminating malignancies. However, when indicants were combined using regression shrinkage techniques, only the following variables were preserved: age, sex, type of haematuria, number of episodes of haematuria, hesitancy, poor urinary stream, smoking history, and history of urinary tract infections. CONCLUSION: It is possible to generate helpful discriminant information to assist GPs in making more appropriate decisions in a difficult area of clinical practice. However, it remains a matter of judgement as to how representative the study population is likely to be compared with all haematuria patients encountered in primary care. We have reasonable confidence in the general applicability of the rules for macroscopic haematuria: however, it seems likely that the prediction rules outlined for microscopic haematuria have their greatest relevance once a patient has been referred by a GP. In developing the work further and testing out the discriminators identified in this study, we propose that a primary care-based project now needs to be undertaken focusing on microscopic haematuria with a particular emphasis on addressing selection biases. In addition, there is a more general need to assess the reliability of all the suggested items of clinical discriminant information.
PMCID: PMC1314268  PMID: 11942444
5.  A prospective study of renal disease in patients with early rheumatoid arthritis 
Annals of the Rheumatic Diseases  2001;60(4):327-331.
OBJECTIVES—This prospective study was designed to clarify the frequency, causes, and clinical course of renal disease in patients with early rheumatoid arthritis (RA).
METHODS—235 patients (185 women, mean age 49.4 years) with early RA of less than one year's duration were enrolled and assessed monthly. Proteinuria was defined as a positive dipstick result and microscopic haematuria was defined as the presence of ⩾5 red blood cells per high power field. Urinary abnormalities lasting three months or longer were defined as persistent abnormalities.
RESULTS—At entry, 40 patients exhibited haematuria, two had a raised serum creatinine concentration, and none had proteinuria. During the observation period (average 42 months), persistent haematuria was found in 43, persistent proteinuria in 17, and a raised serum creatinine concentration in 14 patients. Persistent proteinuria was caused by drugs in 14 of 17 patients and disappeared in most cases. Risk factors for drug induced proteinuria included a raised C reactive protein and erythrocyte sedimentation rate and age over 50 at entry. Drugs resulted in a raised serum creatinine concentration in eight of 14 patients. The incidence of haematuria at entry did not differ among patients who had been treated with non-steroidal anti-inflammatory drugs, disease modifying antirheumatic drugs, or no drugs. In some patients with isolated haematuria, the haematuria appeared when the activity of RA was high and resolved when it was low.
CONCLUSIONS—This study suggests that a raised serum creatinine concentration or persistent proteinuria in patients with early RA is predominantly drug related whereas, in contrast, isolated haematuria is more directly associated with the activity of the disease process.


doi:10.1136/ard.60.4.327
PMCID: PMC1753620  PMID: 11247860
6.  A study of microscopical and chemical tests for the rapid diagnosis of urinary tract infections in general practice. 
Aids to the rapid diagnosis of urinary tract infection were assessed by the examination of 325 consecutive urine samples taken in the normal course of work in a general practice. Of these samples 103 produced a pure growth of at least 10(5) organisms per ml. The appearance and smell of each sample was noted and it was then tested by simple low-power microscopy of a drop of urine and by a dipstick which measured leucocyte esterase and nitrite, together with protein, blood and pH. In addition, pus cell counts per mm3 were performed on 272 of the samples using a cytometer chamber. This method is too time-consuming for routine use in the surgery. Neither a cloudy appearance nor haematuria were sufficiently specific to be of much use in the diagnosis of urinary tract infection. In the prediction of a 'positive' culture the sensitivity and specificity of the other tests were as follows: drop method microscopy 95% and 76%, respectively; cytometer count 95% and 81%; leucocyte-esterase estimation 89% and 68%; and nitrite 57% and 96%. These figures may underestimate the true values of the tests in the diagnosis of urinary tract infection because infection may be present in some cases producing growths of less than 10(5) organisms per ml. It is concluded that the most useful aid to the diagnosis of urinary tract infection is low-power microscopy of a drop of urine.
PMCID: PMC1371381  PMID: 2271260
7.  Importance of occult haematuria found at screening. 
A retrospective study of the results of dipstick testing and microscopical examination of urine from 10 050 men undergoing health screening showed a prevalence of occult haematuria of 2.5%. Those patients with occult haematuria who were resident in the United Kingdom and registered with a general practitioner were identified and a questionnaire sent to their general practitioners asking what further investigations had been performed. The response rate was 92% (152/165 inquiries). Fifty nine general practitioners (39%) had not instigated any investigations. Among the 76 patients who underwent some further investigations abnormalities were found in 21 (28%); and among those fully investigated by examination of midstream urine, intravenous urography, and cystoscopy abnormalities were found in 12(50%). These included bladder neoplasms (two; one in a patient aged 37), epithelial dysplasia (one), staghorn calculi (one), and chronic reflux nephropathy (one). It is proposed that occult haematuria should be fully investigated regardless of the age of the patient.
PMCID: PMC1339660  PMID: 3081223
8.  Haematuria. 
Postgraduate Medical Journal  1997;73(857):129-136.
Many serious and potentially treatable diseases of the urinary tract may have haematuria as their only manifestation. However, asymptomatic microscopic haematuria detected by dipstick testing may be seen in up to 16% of screening populations. The great majority of such cases will have no sinister underlying cause, particularly in those under 40 years of age, and so the schedule of further investigations, some of which may be invasive, time-consuming and expensive, needs to be rationalised. In addition, the increasing popularity of 'fast track' clinics for the investigation of haematuria enhances the need for a clear strategy of investigation. Analysis of the epidemiology of asymptomatic haematuria and its causes combined with a consideration of the risk-benefit profile of the available investigations, makes it possible to set out an algorithm for the initial management of this common finding. Careful clinical assessment and basic laboratory tests for renal function, analysis of the urinary sediment and cytological examination of the urine are followed by ultrasound and plain radiography of the urinary tract. Flexible cystoscopy under local anaesthetic is central to the algorithm in patients of all ages. The importance of a nephrological opinion and consideration of renal biopsy, especially in younger patients with other evidence of glomerular disease, is stressed. The role of intravenous urography in excluding pathology of the upper urinary tract, especially in patients over the age of 40, is also considered.
Images
PMCID: PMC2431247  PMID: 9135826
9.  Renal screening in children after exposure to low dose melamine in Hong Kong: cross sectional study 
Objective To investigate the renal outcomes of children after exposure to low dose melamine in Hong Kong.
Design Cross sectional study.
Setting Special assessment centres, Hong Kong.
Participants 3170 children (1422 girls and 1748 boys) aged 12 years or less referred from territory-wide primary care clinics after daily consumption for one month or more of milk products tainted with melamine.
Main outcome measures Presence of renal stones and haematuria.
Results One child had a confirmed renal stone, seven were suspected of having melamine related renal deposits, and 208 (6.6%) were positive for blood in urine by reagent strip. A proportion of these children were followed up at the special assessment centre, but only 7.4% of those positive for blood on reagent strip were confirmed by microscopy, suggesting an overall estimated prevalence of less than 1% for microscopic haematuria.
Conclusions No severe adverse renal outcomes, such as acute renal failure or urinary tract obstruction, were detected in children after exposure to low dose melamine. Our results were similar to territory-wide findings in Hong Kong. Even including the seven children with suspected renal deposits, the prevalence of suspected melamine related abnormalities on ultrasonography was only 0.2%. None of these children required specific treatment. The prevalence of microscopic haematuria was probably overestimated by the reagent strip. These data suggest that large scale and urgent screening programmes may not be informative or cost effective for populations who have been exposed to low dose melamine.
doi:10.1136/bmj.a2991
PMCID: PMC2612581  PMID: 19097976
10.  New Rapid Diagnostic Tests for Neisseria meningitidis Serogroups A, W135, C, and Y 
PLoS Medicine  2006;3(9):e337.
Background
Outbreaks of meningococcal meningitis (meningitis caused by Neisseria meningitidis) are a major public health concern in the African “meningitis belt,” which includes 21 countries from Senegal to Ethiopia. Of the several species that can cause meningitis, N. meningitidis is the most important cause of epidemics in this region. In choosing the appropriate vaccine, accurate N. meningitidis serogroup determination is key. To this end, we developed and evaluated two duplex rapid diagnostic tests (RDTs) for detecting N. meningitidis polysaccharide (PS) antigens of several important serogroups.
Methods and Findings
Mouse monoclonal IgG antibodies against N. meningitidis PS A, W135/Y, Y, and C were used to develop two immunochromatography duplex RDTs, RDT1 (to detect serogroups A and W135/Y) and RDT2 (to detect serogroups C and Y). Standards for Reporting of Diagnostic Accuracy criteria were used to determine diagnostic accuracy of RDTs on reference strains and cerebrospinal fluid (CSF) samples using culture and PCR, respectively, as reference tests. The cutoffs were 105 cfu/ml for reference strains and 1 ng/ml for PS. Sensitivities and specificities were 100% for reference strains, and 93.8%–100% for CSF serogroups A, W135, and Y in CSF. For CSF serogroup A, the positive and negative likelihood ratios (± 95% confidence intervals [CIs]) were 31.867 (16.1–63.1) and 0.065 (0.04–0.104), respectively, and the diagnostic odds ratio (± 95% CI) was 492.9 (207.2–1,172.5). For CSF serogroups W135 and Y, the positive likelihood ratio was 159.6 (51.7–493.3) Both RDTs were equally reliable at 25 °C and 45 °C.
Conclusions
These RDTs are important new bedside diagnostic tools for surveillance of meningococcus serogroups A and W135, the two serogroups that are responsible for major epidemics in Africa.
There are several strains ofNeisseria meningitidis that can cause seasonal outbreaks of meningitis in Africa. Treatment of patients and containment of the epidemic through vaccination depends on which strain is responsible. The new dipstick tests described here are accurate and suitable for storage and use in resource-poor settings.
Editors' Summary
Background
Bacterial meningitis, a potentially deadly infection of tissues that line the brain and spinal cord, affects over 1 million people each year. Patients with bacterial meningitis usually have fever, headache, and stiff neck, and may become unconscious and die if the disease is not treated within hours. Most cases of bacterial meningitis occur in Africa, particularly in the arid savannah region south of the Sahara known as the Sahel, where epidemic outbreaks of meningitis occur periodically. This region, also called the “meningitis belt,” extends from Senegal and adjacent coastal countries in West Africa across the continent to Ethiopia. Although most outbreaks tend to occur in the dry season, they differ in frequency in different areas of the meningitis belt, and may involve any of several kinds of bacteria. One of the major causes of epidemic meningitis is Neisseria meningitidis, a meningococcus bacterium that exists in several different groups. Group A has been a common cause of epidemic meningitis in Africa, and some outbreaks were due to group C. More recently, group W135 has emerged as an epidemic strain. In addition to prompt diagnosis and treatment of individual cases, effective public health strategies for controlling meningococcal meningitis include rapid identification of outbreaks and determination of the type of bacteria involved, followed by mass vaccination of people in the surrounding area without delay. Vaccines are chosen on the basis of the responsible meningococcal serogroup: either the inexpensive bivalent vaccine A/C or the expensive, less readily available trivalent vaccine A/C/W135. Before the advent of W135 as an epidemic clone, bivalent vaccine was applied in the meningitis belt without identification of the serogroup. With the appearance of the W135 strain in 2003, however, the determination of serogroup before vaccination is important to select an effective vaccine and avoid misspending of limited funds.
Why Was This Study Done?
Because there are few laboratories in the affected countries and epidemiological surveillance systems are inadequate, it is difficult for health authorities to mount a rapid and effective vaccination campaign in response to an outbreak. In addition, because the two main bacteria (meningococcus and pneumococcus) that cause meningitis require different antibiotic treatments, it is important for doctors to find out quickly which bacteria is causing an individual case. The authors of this study wanted to develop a rapid and easy test that can tell whether meningococcus is the cause of a particular case of meningitis, and if so, which group of meningococcus is involved. As most outbreaks in the meningitis belt occur in rural areas that are distant from well-equipped medical laboratories, it was necessary to develop a test that can be carried out at the patient's bedside by nurses, does not require refrigeration or laboratory equipment, and is highly accurate in distinguishing among the different groups of meningococcus.
What Did the Researchers Do and Find?
The researchers have developed a rapid test to determine whether a patient's meningitis is caused by one of the four most common groups of meningococcus circulating in Africa. The test is done on the patient's spinal fluid, which is obtained by a lumbar puncture (spinal tap) as part of the usual evaluation of a patient thought to have meningitis. The test uses two paper strips, also called dipsticks (one for groups A and W135/Y, and the other for groups C and Y), that can be placed in two separate tubes of the patient's spinal fluid. After several minutes, the appearance of red lines on the dipsticks shows whether one of the four groups of meningococcus is present. The dipsticks can be produced in large quantities and relatively cheaply. The researchers showed that the test dipsticks are stable for weeks in hot weather, and are therefore practical for bedside use in resource-poor settings. They examined the test on stored spinal fluid from patients in Niger and found that the dipstick test was able to identify the correct group of meningococcus more than 95% of the time for the three groups represented in these specimens (the results were compared to a standard DNA test or culture that are highly accurate for identifying the type of bacteria present but much more complicated and expensive).
What Do These Findings Mean?
The new dipstick test for meningococcal meningitis represents a major advance for health-care workers in remote locations affected by meningitis epidemics. This test can be stored without refrigeration and used at bedside in the hot temperatures typical of the African savannah during the meningitis season. The dipsticks are easier to use than currently available test kits, give more rapid results, and are more accurate in telling the difference between group Y and the increasingly important group W135. Further research is needed to determine whether the test can be used with other clinical specimens (such as blood or urine), and whether the test is dependable for detecting group C meningococcus, which is common in Europe but rare in Africa. Nonetheless, the dipstick test promises to be an important tool for guiding individual treatment decisions as well as public health actions, including vaccine selection, against the perennial threat of epidemic meningitis.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030337.
World Health Organization fact sheet on meningococcal meningitis
PATH Meningitis Vaccine Project
US Centers for Disease Control and Prevention page on meningococcal disease
doi:10.1371/journal.pmed.0030337
PMCID: PMC1563501  PMID: 16953658
11.  The value of urinary red cell shape in the diagnosis of glomerular and post-glomerular haematuria. A meta-analysis. 
Postgraduate Medical Journal  1992;68(802):648-654.
The proportion of dysmorphic red cells (DRC) in the urinary sediment and their mean corpuscular volume (MCV) have been claimed to discriminate between glomerular and postglomerular sources of haematuria. To determine the diagnostic value of urinary DRC and MCV, we searched the literature and critically reviewed 21 published studies using a predetermined set of criteria for evaluation. All studies originated from referral centres. Interobserver variability in identifying urinary DRC was reported in four studies and found to be unacceptably large in one. Although reproducible over different samples of the same individual, urinary MCV was unreliable in cases of low-grade haematuria because of interfering debris. Weighted averages and 95% confidence limits of the sensitivity and specificity of the DRC proportion for glomerular disease were 0.88 (0.86-0.90) and 0.95 (0.93-0.97), respectively; those of a low MCV were 1.00 (0.98-1.00) for sensitivity and 0.87 (0.80-0.91) for specificity. Sensitivity and specificity values derived from in-patients were slightly higher than those in referred outpatients. No studies of urinary DRC or MCV in patients with incidentally detected microhaematuria in the primary care setting were found. We conclude that at present the diagnostic value of urinary DRC and MCV is limited. In referral centres, that is, in patients with a high probability of postglomerular haematuria, the test cannot rule out urological lesions, because its specificity for glomerular disease may be as low as 0.80. In the primary care setting, that is, in unselected patients with incidentally detected low-grade haematuria, the accuracy of the test has not been studied but may be even lower. The use of urinary DRC or MCV as an indicator of the source of haematuria is in need of further experimental development and confirmation.
PMCID: PMC2399558  PMID: 1448406
12.  The haematuria clinic--referral patterns in Northern Ireland. 
The Ulster Medical Journal  1998;67(1):25-28.
One hundred consecutive patients with haematuria were seen over a three month period at the haematuria clinic, Belfast City Hospital. 14% of patients were found to have transitional cell carcinoma of the urinary bladder; all of these presented with frank haematuria and were over 50 years of age. No malignancy was detected in the microscopic haematuria group. 14% of patients with macroscopic haematuria held back for longer than one month before seeking advice from their general practitioner. 23% with macroscopic and 30% with microscopic haematuria had their symptoms noted by the general practitioner for more than a month before they were referred for investigation. The waiting time for initial investigation at the haematuria clinic took longer than six weeks in 52% with macroscopic and 39% with microscopic haematuria. Our study has identified a high-risk group who need immediate referral and investigation. The importance of patient education, rapid referral by general practitioners and also the need to increase the capacity of the haematuria clinic are emphasized.
PMCID: PMC2448693  PMID: 9652195
13.  Performance of three rapid screening methods in the detection of Schistosoma haematobium infection in school-age children in Southeastern Nigeria 
Pathogens and Global Health  2014;108(2):111-117.
Background
A cross-sectional study of primary school children was conducted to evaluate and compare the performance of some rapid screening methods in the detection of Schistosoma haematobium infection in Nigeria Cement Factory (NigerCem) and Nike Lake areas of Southeastern Nigeria.
Methods
Urine samples of school children were examined for macro-haematuria and tested for micro-haematuria and proteinuria using reagent strips followed by egg microscopy. Self-reported haematuria was assessed using simple questionnaire. The performances of these rapid diagnoses singly and in combination were calculated using egg microscopy as gold standard.
Results
The prevalence of the infection was 26.6% in NigerCem and 5.1% in Nike Lake area, classifying these areas as moderate- and low-prevalence areas (MPA and LPA); while in the subsample used for self-reported haematuria, the prevalence was 27.2 and 4.2% in MPA and LPA, respectively. The positive predictive value (PPV) of micro-haematuria was comparable in MPA (55.26%) and LPA (57.89%). Overall PPV of macro-haematuria was 87.50% in MPA and 66.70% in LPA while in the detection of heavy infection; PPV was higher in LPA (75%) than in MPA (66.67%). In LPA and MPA, combination of micro-haematuria and proteinuria, and concomitant presence of macro-haematuria, micro-haematuria, and proteinuria had PPV of 83.33 and 63.16%, and 100 versus 66.67%, respectively. Generally, the rapid screening tests had lower negative predictive values (NPVs) in MPA than in LPA. The use of simple questionnaire increased the PPV of heavy infection in MPA (77.78%). This was further increased to 80% when self-reported haematuria was combined with micro-haematuria.
Conclusion
The result suggests that in MPA with chronic infections, combination of self-reported haematuria and micro-haematuria may reduce the chance of missing those who should be treated.
doi:10.1179/2047773214Y.0000000128
PMCID: PMC4005590  PMID: 24593687
Schistosoma haematobium; Macro-haematuria; Reagent strip; Questionnaire method; Predictive values
14.  Phase contrast microscopic examination of urinary erythrocytes to localise source of bleeding: an overlooked technique? 
Journal of Clinical Pathology  1993;46(7):642-645.
AIMS--To localise the source of bleeding in the urinary tract in patients presenting with haematuria. METHODS--Urine samples were obtained from 109 patients with symptoms referable to the urinary tract. The sample was examined for the presence of red blood cells by phase contrast microscopy (PCM) and the proportion of dysmorphic and isomorphic red blood cells was determined. If more than 20% of the red blood cells were dysmorphic a glomerular origin for the site of bleeding was suspected; if less than 20% of the red blood cells were isomorphic a non-glomerular origin was suspected. Phase contrast microscopy and clinical findings were correlated. RESULTS--The correct bleeding site was shown in 27 of 30 (90%) patients with glomerulopathy and in all 17 patients with bleeding from the lower urinary tract, indicating that this method of analysis has a sensitivity of 90% and specificity of 100% for detecting the glomerular source of bleeding. CONCLUSIONS--The examination of urine for dysmorphic and isomorphic red blood cells by phase contrast microscopy is strongly recommended in routine clinical practice for the detection of glomerular and non-glomerular lesions. This technique may avoid unnecessary investigations for the diagnosis of the site of bleeding in patients with haematuria.
Images
PMCID: PMC501394  PMID: 8157752
15.  Urinary red-cell morphology during exercise. 
Midstream urine samples were examined by phase-contrast microscopy before and immediately after 48 subjects participated in a long-distance run. Minor abnormalities were found in six samples before exercise. Eighteen subjects developed proteinuria and five haematuria on dipstick testing after exercise. Forty-four subjects had increased urinary red-cell counts after exercise; of these, 33 had counts above the normal range (800/ml). In all subjects urinary red cells were dysmorphic both before and after exercise, indicating a glomerular source. Ten subjects developed red-cell casts and 42 showed an increase in hyaline and hyaline-granular casts after exercise. There were modest increases in urinary white-cell counts in 35 subjects but little change in urine pH or osmolality with exercise. This study confirms that urinary red-cell counts commonly increase appreciably after exercise. The dysmorphic appearance of the red cells together with the presence of red-cell casts indicates a glomerular source for this common form of exercise haematuria.
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PMCID: PMC1500573  PMID: 6814599
16.  Can urine dipstick testing for urinary tract infection at point of care reduce laboratory workload? 
Journal of Clinical Pathology  2005;58(9):951-954.
Aim: The University Hospitals of Leicester NHS Trust microbiology laboratory receives 150 000 urine samples each year, approximately 80% of which prove to be culture negative. The aim of this study was to reduce the proportion of culture negative urines arriving in the laboratory, by producing local evidence based guidelines for the use of urine dipstick testing at point of care within the trust’s three acute hospitals.
Methods: One thousand and seventy six unborated urine samples were dipstick tested at the point of care using an automatic strip reader. Quantitative results for the four infection associated markers—leucocyte esterase, nitrite, blood, and protein—were compared with the results of conventional laboratory microscopy and culture.
Results: The performance of different marker combinations was calculated against the routine laboratory methods. One hundred and seventy five (16.3%) samples were negative for all four markers. Of these dipstick negative samples, only three (1.7% of all true positives) were positive by culture. The absence of all four infection associated markers was found to have a greater than 98% negative predictive value and a sensitivity and specificity of 98.3% and 19.2%, respectively.
Conclusions: A urinary dipstick testing algorithm for infection associated markers was derived for use in hospital patients to screen out negative urines. Two years after distributing the algorithm and promoting access to reagent strips and strip readers, a reduction in the urine workload has been seen against an otherwise increasing laboratory specimen load.
doi:10.1136/jcp.2004.025429
PMCID: PMC1770822  PMID: 16126876
algorithm; infection associated markers; urinary tract infection; urine dipstick testing; workload
17.  Circulating antigen tests and urine reagent strips for diagnosis of active schistosomiasis in endemic areas 
Background
Point-of-care (POC) tests for diagnosing schistosomiasis include tests based on circulating antigen detection and urine reagent strip tests. If they had sufficient diagnostic accuracy they could replace conventional microscopy as they provide a quicker answer and are easier to use.
Objectives
To summarise the diagnostic accuracy of: a) urine reagent strip tests in detecting active Schistosoma haematobium infection, with microscopy as the reference standard; and b) circulating antigen tests for detecting active Schistosoma infection in geographical regions endemic for Schistosoma mansoni or S. haematobium or both, with microscopy as the reference standard.
Search methods
We searched the electronic databases MEDLINE, EMBASE, BIOSIS, MEDION, and Health Technology Assessment (HTA) without language restriction up to 30 June 2014.
Selection criteria
We included studies that used microscopy as the reference standard: for S. haematobium, microscopy of urine prepared by filtration, centrifugation, or sedimentation methods; and for S. mansoni, microscopy of stool by Kato-Katz thick smear. We included studies on participants residing in endemic areas only.
Data collection and analysis
Two review authors independently extracted data, assessed quality of the data using QUADAS-2, and performed meta-analysis where appropriate. Using the variability of test thresholds, we used the hierarchical summary receiver operating characteristic (HSROC) model for all eligible tests (except the circulating cathodic antigen (CCA) POC for S. mansoni, where the bivariate random-effects model was more appropriate). We investigated heterogeneity, and carried out indirect comparisons where data were sufficient. Results for sensitivity and specificity are presented as percentages with 95% confidence intervals (CI).
Main results
We included 90 studies; 88 from field settings in Africa. The median S. haematobium infection prevalence was 41% (range 1% to 89%) and 36% for S. mansoni (range 8% to 95%). Study design and conduct were poorly reported against current standards.
Tests for S. haematobium
Urine reagent test strips versus microscopy
Compared to microscopy, the detection of microhaematuria on test strips had the highest sensitivity and specificity (sensitivity 75%, 95% CI 71% to 79%; specificity 87%, 95% CI 84% to 90%; 74 studies, 102,447 participants). For proteinuria, sensitivity was 61% and specificity was 82% (82,113 participants); and for leukocyturia, sensitivity was 58% and specificity 61% (1532 participants). However, the difference in overall test accuracy between the urine reagent strips for microhaematuria and proteinuria was not found to be different when we compared separate populations (P = 0.25), or when direct comparisons within the same individuals were performed (paired studies; P = 0.21).
When tests were evaluated against the higher quality reference standard (when multiple samples were analysed), sensitivity was marginally lower for microhaematuria (71% vs 75%) and for proteinuria (49% vs 61%). The specificity of these tests was comparable.
Antigen assay
Compared to microscopy, the CCA test showed considerable heterogeneity; meta-analytic sensitivity estimate was 39%, 95% CI 6% to 73%; specificity 78%, 95% CI 55% to 100% (four studies, 901 participants).
Tests for S. mansoni
Compared to microscopy, the CCA test meta-analytic estimates for detecting S. mansoni at a single threshold of trace positive were: sensitivity 89% (95% CI 86% to 92%); and specificity 55% (95% CI 46% to 65%; 15 studies, 6091 participants) Against a higher quality reference standard, the sensitivity results were comparable (89% vs 88%) but specificity was higher (66% vs 55%). For the CAA test, sensitivity ranged from 47% to 94%, and specificity from 8% to 100% (4 studies, 1583 participants).
Authors' conclusions
Among the evaluated tests for S. haematobium infection, microhaematuria correctly detected the largest proportions of infections and non-infections identified by microscopy.
The CCA POC test for S. mansoni detects a very large proportion of infections identified by microscopy, but it misclassifies a large proportion of microscopy negatives as positives in endemic areas with a moderate to high prevalence of infection, possibly because the test is potentially more sensitive than microscopy.
Plain Language Summary
How well do point-of-care tests detect Schistosoma infections in people living inendemic areas?
Schistosomiasis, also known as bilharzia, is a parasitic disease common in the tropical and subtropics. Point-of-care tests and urine reagent strip tests are quicker and easier to use than microscopy. We estimate how well these point-of-care tests are able to detect schistosomiasis infections compared with microscopy.
We searched for studies published in any language up to 30 June 2014, and we considered the study’s risk of providing biased results.
What do the results say?
We included 90 studies involving almost 200,000 people, with 88 of these studies carried out in Africa in field settings. Study design and conduct were poorly reported against current expectations. Based on our statistical model, we found:
• Among the urine strips for detecting urinary schistosomiasis, the strips for detecting blood were better than those detecting protein or white cells (sensitivity and specificity for blood 75% and 87%; for protein 61% and 82%; and for white cells 58% and 61%, respectively).
• For urinary schistosomiasis, the parasite antigen test performance was worse (sensitivity, 39% and specificity, 78%) than urine strips for detecting blood.
• For intestinal schistosomiasis, the parasite antigen urine test, detected many infections identified by microscopy but wrongly labelled many uninfected people as sick (sensitivity, 89% and specificity, 55%).
What are the consequences of using these tests?
If we take 1000 people, of which 410 have urinary schistosomiasis on microscopy testing, then using the strip detecting blood in the urine would misclassify 77 uninfected people as infected, and thus may receive unnecessary treatment; and it would wrongly classify 102 infected people as uninfected, who thus may not receive treatment.
If we take 1000 people, of which 360 have intestinal schistosomiasis on microscopy testing, then the antigen test would misclassify 288 uninfected people as infected. These people may be given unnecessary treatment. This test also would wrongly classify 40 infected people as uninfected who thus may not receive treatment.
Conclusion of review
For urinary schistosomiasis, the urine strip for detecting blood leads to some infected people being missed and some non-infected people being diagnosed with the condition, but is better than the protein or white cell tests. The parasite antigen test is not accurate.
For intestinal schistosomiasis, the parasite antigen urine test can wrongly classify many uninfected people as infected.
doi:10.1002/14651858.CD009579.pub2
PMCID: PMC4455231  PMID: 25758180
18.  Management of macroscopic haematuria in the emergency department 
Emergency Medicine Journal : EMJ  2007;24(6):385-390.
Macroscopic haematuria is a commonly seen condition in the emergency department (ED), which has a variety of causes. However, most importantly, macroscopic haematuria has a high diagnostic yield for urological malignancy. 30% of patients presenting with painless haematuria are found to have a malignancy. The majority of these patients can be managed in the outpatient setting. This review of current literature suggests a management pathway that can be used in the ED. A literature search was done using Medline, PubMed and Google. In men aged >60 years, the positive predictive value of macroscopic haematuria for urological malignancy is 22.1%, and in women of the same age it is 8.3%. In terms of the need for follow‐up investigation, a single episode of haematuria is equally important as recurrent episodes. Baseline investigation in the ED includes full blood count, urea and electrolyte levels, midstream urine dipstick, β human chorionic gonadotrophin, and formal microscopy, culture and sensitivities. Treatment of macroscopic haematuria aims at RESP—Resuscitation, Ensuring, Safe and Prompt. Indications for admission include clot retention, cardiovascular instability, uncontrolled pain, sepsis, acute renal failure, coagulopathy, severe comorbidity, heavy haematuria or social restrictions. Discharged patients should drink plenty of clear fluids and return for further medical attention if the following occur: clot retention, worsening haematuria despite adequate fluid intake, uncontrolled pain or fever, or inability to cope at home. Follow‐up by a urological team should be promptly arranged, ideally within the 2‐week cancer referral target.
doi:10.1136/emj.2006.042457
PMCID: PMC2658267  PMID: 17513531
19.  Low quality of routine microscopy for malaria at different levels of the health system in Dar es Salaam 
Malaria Journal  2011;10:332.
Background
Laboratory capacity to confirm malaria cases in Tanzania is low and presumptive treatment of malaria is being practiced widely. In malaria endemic areas WHO now recommends systematic laboratory testing when suspecting malaria. Currently, the use of Rapid Diagnostic Tests (RDTs) is recommended for the diagnosis of malaria in lower level peripheral facilities, but not in health centres and hospitals. In this study, the following parameters were evaluated: (1) the quality of routine microscopy, and (2) the effects of RDT implementation on the positivity rate of malaria test results at three levels of the health system in Dar es Salaam, Tanzania.
Methods
During a baseline cross-sectional survey, routine blood slides were randomly picked from 12 urban public health facilities in Dar es Salaam, Tanzania. Sensitivity and specificity of routine slides were assessed against expert microscopy. In March 2007, following training of health workers, RDTs were introduced in nine public health facilities (three hospitals, three health centres and three dispensaries) in a near-to-programmatic way, while three control health facilities continued using microscopy. The monthly malaria positivity rates (PR) recorded in health statistics registers were collected before (routine microscopy) and after (routine RDTs) the intervention in all facilities.
Results
At baseline, 53% of blood slides were reported as positive by the routine laboratories, whereas only 2% were positive by expert microscopy. Sensitivity of routine microscopy was 71.4% and specificity was 47.3%. Positive and negative predictive values were 2.8% and 98.7%, respectively. Median parasitaemia was only three parasites per 200 white blood cells (WBC) by routine microscopy compared to 1226 parasites per 200 WBC by expert microscopy. Before RDT implementation, the mean test positivity rates using routine microscopy were 43% in hospitals, 62% in health centres and 58% in dispensaries. After RDT implementation, mean positivity rates using routine RDTs were 6%, 7% and 8%, respectively. The sensitivity and specificity of RDTs using expert microscopy as reference were 97.0% and 96.8%. The positivity rate of routine microscopy remained the same in the three control facilities: 71% before versus 72% after. Two cross-sectional health facility surveys confirmed that the parasite rate in febrile patients was low in Dar es Salaam during both the rainy season (13.6%) and the dry season (3.3%).
Conclusions
The quality of routine microscopy was poor in all health facilities, regardless of their level. Over-diagnosis was massive, with many false positive results reported as very low parasitaemia (1 to 5 parasites per 200 WBC). RDTs should replace microscopy as first-line diagnostic tool for malaria in all settings, especially in hospitals where the potential for saving lives is greatest.
doi:10.1186/1475-2875-10-332
PMCID: PMC3217957  PMID: 22047131
20.  Danish general practitioners' estimation of urinary albumin concentration in the detection of proteinuria and microalbuminuria. 
BACKGROUND. Microalbuminuria may predict proteinuria and increased mortality in non-insulin dependent diabetic patients. Early detection of microalbuminuria may therefore be essential. AIM. The primary objective of this study was to describe the association between the presence of albuminuria in diabetic patients as detected by general practitioners using conventional reagent strip dipstick tests for albumin, and the urinary albumin concentration as measured in a hospital laboratory. METHOD. A total of 675 newly diagnosed diabetic patients aged 40 years or over were included in the Danish study, diabetes care in general practice. Data for urinary albumin concentration from a morning urine sample and the results of three consecutive dipstick tests for albumin were collected for 417 patients. RESULTS. When defining elevated urinary albumin concentration as 200 mg l-1 or more (proteinuria) the finding of at least one positive test out of the three dipstick tests for albumin had a diagnostic sensitivity of 73% and a specificity of 89%. When the microalbuminuric range (15.0 to 199.9 mg l-1) was added to the definition of renal involvement, the sensitivity of the dipstick test became as low as 28% with a specificity of 96%. CONCLUSION. It is essential for general practitioners to be able to identify proteinuric patients. To achieve this by means of the conventional dipstick test, general practice procedures need to be improved. As it is becoming increasingly well-documented that microalbuminuric non-insulin dependent diabetic patients may benefit from pharmacological treatment of even slight arterial hypertension and heart failure, it seems reasonable to suggest that the use of dipsticks for albumin in general practice be replaced by laboratory quantitative determination of urinary albumin concentration in a morning urine sample.
PMCID: PMC1239138  PMID: 7702885
21.  Significance of microhaematuria in young adults. 
The medical records of 1000 asymptomatic male air force personnel were examined retrospectively for the results of 15 yearly examinations of urinary sediment. The study covered the period 1968-82, beginning with the subjects aged 18-33 years. The cumulative incidence of two to four or more red blood cells per high power field found at one or more examinations was 38.7% after an average of 12.2 yearly examinations per person. In 161 subjects two to four or more red blood cells per high power field were found at two or more yearly examinations within a five year period. Intravenous pyelography in 58 cases disclosed asymptomatic nephrolithiasis in six. Cystoscopy performed in 11 cases identified one patient with urethritis, one with a vesical calculus, and one with transitional cell carcinoma of the bladder. Two years before diagnosis the patient with carcinoma had had a single transient finding of 10-12 red blood cells per high power field which was not investigated further. Cystoscopy was performed after an episode of macroscopic haematuria. Renal biopsy in one subject with recurrent microhaematuria and trace proteinuria disclosed focal glomerulonephritis. None of the remaining subjects with microhaematuria developed hypertension or proteinuria, and at the end of the study period all were active and free of urinary symptoms. The observed cumulative incidence of urological neoplasms at 15 years (0.1%) was consistent with that expected in Israeli men aged 18-40 (0.09%). Hence microhaematuria detected during a screening examination probably should not be regarded as a specific sign of a significant lesion and does not of itself warrant urological investigation in adults aged 40 or less.
PMCID: PMC1444134  PMID: 6418299
22.  Detection of Parasite-Specific DNA in Urine Sediment Obtained by Filtration Differentiates between Single and Mixed Infections of Schistosoma mansoni and S. haematobium from Endemic Areas in Ghana 
PLoS ONE  2014;9(3):e91144.
Differential diagnosis of Schistosoma mansoni and S. haematobium, which often occur sympatrically in Africa, requires both urine and stool and the procedures are low in sensitivity. The standard diagnostic tests, such as Kato-Katz (KK) for S. mansoni eggs and presence of haematuria for S. haematobium both lack sensitivity, produce false-negative results and show reduced accuracy with decreasing intensity of infection. The need for a single diagnostic test with high sensitivity and specificity for both parasites is important as many African countries are implementing Mass Drug Administration (MDA) following recommendations of the World Health Organization (WHO). Eighty-six samples of urine sediment obtained by filtration were collected from a group of 5–23 years old people from an endemic area of southern Ghana. DNA was extracted from the urine sediment on filter paper from which a species-specific repeat fragment was amplified by polymerase chain reaction (PCR) with specific primers for S. mansoni and for S. haematobium. Additionally, all participants were tested by KK (stool) and dipstick for haematuria. Diagnostic parameters for all three tests were analyzed statistically. Amplification of species-specific DNA by PCR showed much higher sensitivity (99%–100%) and specificity (100%) compared to KK and haematuria (sensitivity: 76% and 30% respectively) for both schistosome species. The same pattern was observed when the data were stratified for age group and sex specific analysis. In addition PCR amplification detected DNA from 11 individuals infected with both parasites who were negative by KK and haematuria. This approach of detecting parasite specific DNA from either or both species in a single urine specimen is a practical advantage that avoids the need for two specimens and is more effective than standard tests including those based on serology. This promises to improve the effectiveness of surveillance of MDA control programs of schistosomiasis.
doi:10.1371/journal.pone.0091144
PMCID: PMC3954594  PMID: 24632992
23.  Ultrasonography compared with intravenous urography in the investigation of adults with haematuria. 
BMJ : British Medical Journal  1990;301(6760):1074-1076.
OBJECTIVE--To compare ultrasonography with intravenous urography in the investigation of adults with haematuria. DESIGN--Prospective study entailing the examination of all patients with both investigations concurrently. The investigations were performed independently on routine lists by different duty radiologists. Each was aware of the details of the request form but not of the findings of the other investigation. SETTING--Radiology department of a teaching hospital. PATIENTS--155 Consecutive adult patients (aged 18-93) referred from general practitioners and hospital outpatient clinics with a history of haematuria. FOLLOW UP--When results of both examinations proved normal no clinical or radiological follow up was sought. All abnormal findings of either investigation were correlated with results of subsequent imaging studies or operative findings. RESULTS--81 Patients (52%) had normal findings on urography and ultrasonography. Overall, the findings of ultrasonography concurred with those of urography in 144 cases (93%). Among the discrepant findings of the two investigations ultrasonography missed two ureteric calculi; one was in a non-dilated ureter, and in the other case ultrasonography detected the secondary ureteric dilatation. Ultrasound examination alone detected four bladder tumours not visible on urography with sizes ranging from 5 to 21 mm, representing one fifth of the 20 cystoscopically proved bladder tumours detected in the series. Ultrasonography detected all the 22 neoplastic lesions discovered in the study (20 bladder, two renal). Ultrasonography clarified the nature of renal masses evident in three urograms (simple cysts). CONCLUSIONS--Ultrasonography is a safe and accurate method of investigating the urinary tract in adults with haematuria. When combined with a single plain abdominal radiograph it proved to be superior to urography as the primary imaging study in this series. Ultrasonography should certainly be preferred to urography if cystoscopy is not planned. No urothelial tumours of the upper urinary tract were found in the series, reflecting their rarity. For those patients in whom ultrasonography and plain radiography have shown no abnormality and in whom cystoscopic appearances are normal urography would be advisable to exclude urothelial tumours of the upper urinary tract.
PMCID: PMC1664237  PMID: 2249070
24.  Renal function in men with lower urinary tract symptoms at first presentation to urology out-patient department. 
AIM: Current national guidelines state that it is mandatory to perform an estimation of renal function in all males with lower urinary tract symptoms (LUTS). As national audit evidence suggests this is not general practice, we have carried out a study to assess the value of routine testing of renal function in this group. PATIENTS AND METHODS: Serum creatinine or urea was measured in 213 consecutive men presenting to the urology out-patient department with lower urinary tract symptoms. Risk factors for renal dysfunction such as large post-void residual volume, proteinuria, microscopic haematuria, diabetes mellitus and cardiovascular disease were noted. RESULTS: Twelve of 213 patients had abnormal results. One 90-year-old had a raised serum urea but was found to have a normal creatinine level. Ten of the remaining 11 patients would have had their renal dysfunction predicted by history, examination or bedside tests. CONCLUSIONS: Routine measurement of creatinine or urea in men presenting with LUTS with no other risk factors could be considered purely a health screening test. It is suggested that it should no longer be considered as mandatory, in this situation, but used only if specifically indicated. A urine flow rate would be a more useful test in reaching a diagnosis and planning treatment.
doi:10.1308/003588404323043319
PMCID: PMC1964183  PMID: 15140303
25.  Sensitivities and specificities of diagnostic tests and infection prevalence of Schistosoma haematobium estimated from data on adults in villages northwest of Accra in Ghana 
Substantial uncertainties surround the sensitivities and specificities of diagnostic techniques for urinary schistosomiasis. We used Latent Class (LC) modeling to address this problem. In this study 220 adults in three villages northwest of Accra in Ghana were examined using five Schistosoma haematobium diagnostic measures: microscopic examination of urine for detection of S. haematobium eggs, dipsticks for detection of haematuria, tests for circulating antigens, serological antibody tests and ultrasound scans of the urinary system. Testing of the LC model indicated non-invariance of the performance of the diagnostic tests across different age groups while measurement invariance held for males and females and for the three villages. We therefore recommend the use of LC models for comparison between, and the identification of, the most accurate schistosomiasis diagnostic tests. Furthermore, microscopy and haematuria dipsticks were indicated through these models as the most appropriate techniques for detection of S. haematobium infection.
PMCID: PMC2726788  PMID: 19270295

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