During a health centre screening programme for men aged 60 years and over, the urinary dipstick results of 58 patients found to have microscopic haematuria were compared with the results of immediate microscopy at the health centre and routine microscopy by a hospital laboratory. There was agreement between a positive dipstick test for haematuria and the presence of red cells at routine microscopy reported by the hospital laboratory in only 18 cases (31%). Routine urine microscopy results requested from general practice should not be taken as the criterion for deciding whether further investigation is needed in cases of microscopic haematuria.
Hematuria is one of the most common findings on urinalysis in patients encountered by primary care physicians. In many instances it can also be the first presentation of a serious urological problem. As such, we sought to evaluate current practices adopted by primary care physicians in the workup and screening of hematuria.
Questionnaires were mailed to all registered primary care physicians across Quebec. Questions covered each physician’s personal approach to men and postmenopausal women with painless gross hematuria or with asymptomatic microscopic hematuria, as well as screening techniques, general knowledge with regards to urine collection and sampling, and referral patterns.
Of the surveys mailed, 599 were returned. Annual routine screening urinalysis on all adult male and female patients was performed by 47% of respondents, regardless of age or risk factors. Of all the respondents, 95% stated microscopic hematuria was associated with bladder cancer. However, in an older male with painless gross hematuria, only 64% of respondents recommended further evaluation by urology. On the other hand, in a postmenopausal woman with 2 consecutive events of significant microscopic hematuria, only 48.6% recommended referral to urology. Findings were not associated with the gender of the respondent, experience or geographic location of practice (urban vs. rural).
There seems to be reluctance amongst primary care physicians to refer patients with gross or significant microscopic hematuria to urology for further investigation. A higher level of suspicion and further education should be implemented to detect serious conditions and to offer earlier intervention when possible.
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.
Few studies have evaluated dipstick urinalysis for elderly and practically none present confidence intervals. Furthermore, most previous studies combine all bacteria species in a "positive culture". Thus, their evaluation may be inappropriate due to Yule-Simpson's paradox. The aim of this study was to evaluate diagnostic accuracy of dipstick urinalysis for the elderly in nursing homes.
In this cross-sectional study voided urine specimens were collected from 651 elderly individuals in nursing homes. Dipstick urinalysis for nitrite, leukocyte esterase and urine culture were performed. Sensitivity, specificity, positive and negative predictive values with 95% confidence intervals were calculated. Visual readings were compared to readings with a urine chemistry analyzer.
207/651 (32%) of urine cultures showed growth of a potentially pathogenic bacterium. Combining the two dipsticks improved test characteristics slightly compared to using only one of the dipsticks. When both dipsticks are negative, presence of potentially pathogenic bacteria can be ruled out with a negative predictive value of 88 (84–92)%. Visual and analyzer readings had acceptable agreement.
When investigating for bacteriuria in elderly people at nursing homes we suggest nitrite and leukocyte esterase dipstick be combined. There are no clinically relevant differences between visual and analyzer dipstick readings. When dipstick urinalysis for nitrite and leukocyte esterase are both negative it is unlikely that the urine culture will show growth of potentially pathogenic bacteria and in a patient with an uncomplicated illness further testing is unnecessary.
Suspected urinary tract infection (UTI) is one of the most common presentations in primary care. Systematic reviews have not documented any adequately powered studies in primary care that assess independent predictors of laboratory diagnosis.
To estimate independent clinical and dipstick predictors of infection and to develop clinical decision rules.
Design of study
Validation study of clinical and dipstick findings compared with laboratory testing.
General practices in the south of England.
Laboratory diagnosis of 427 women with suspected UTI was assessed using European urinalysis guidelines. Independent clinical and dipstick predictors of diagnosis were estimated.
UTI was confirmed in 62.5% of women with suspected UTI. Only nitrite, leucocyte esterase (+ or greater), and blood (haemolysed trace or greater) independently predicted diagnosis (adjusted odds ratios 6.36, 4.52, 2.23 respectively). A dipstick decision rule, based on having nitrite, or both leucocytes and blood, was moderately sensitive (77%) and specific (70%); positive predictive value (PPV) was 81% and negative predictive value (NPV) was 65%. Predictive values were improved by varying the cut-off point: NPV was 73% for all three dipstick results being negative, and PPV was 92% for having nitrite and either blood or leucocyte esterase. A clinical decision rule, based on having two of the following: urine cloudiness, offensive smell, and dysuria and/or nocturia of moderate severity, was less sensitive (65%) (specificity 69%; PPV 77%, NPV 54%). NPV was 71% for none of the four clinical features, and the PPV was 84% for three or more features.
Simple decision rules could improve targeting of investigation and treatment. Strategies to use such rules need to take into account limited negative predictive value, which is lower than expected from previous research.
clinical scoring algorithms; diagnosis, urinary tract infection; dipsticks
Mass urinary screening is a useful tool to identify children with asymptomatic progressive renal diseases. A dipstick urinalysis screening was conducted to detect such prevalence and to set up a more effective screening program for children.
Patients and Methods:
A cross sectional study was carried out in seven nurseries and primary schools in different regions of Lebanon (Beirut, North Lebanon, and Valley of Bekaa) between February 2010 and March 2010. Eight hundred seventy asymptomatic children were enrolled in this study. First morning mid steam urine samples were obtained from students and were tested by dipstick method. Children with abnormal findings were re-tested after fifteen days.
Twenty five (2.9%) children had urinary abnormalities at the first screening; Eighteen (72%) of them still had abnormal results at the second screening. Among all the students, hematuria was the most common abnormality found with a prevalence of 1.5%, followed by nitrituria (0.45%), combined hematuria and nitrituria (0.45%) and proteinuria (0.1%). Urinary abnormalities were more common in females than in males. With respect to age, most positive results were detected at 6 years of age. Hematuria and proteinuria were mainly present in the North of Lebanon.
Asymptomatic urinary abnormalities might be detected by urine screening program at school age. Further work-up should be offered to define the exact etiology of any abnormal finding and to determine whether early detection of renal disorders in childhood will lead to effective interventions and reduction in the number of individuals who develop end-stage renal disease.
Dipstick urine analysis; renal failure in school aged children; urine analysis screening
International comparisons of sickness absence rates are difficult to make because of different national social security arrangements or recording procedures. Therefore a cross national study of sickness absence in Belgium, West Germany, and the Netherlands focused firstly on "contextual" aspects of sickness absence such as work incapacity benefit schemes, job security regulations, and the role of occupational physicians. Substantial differences were observed in regulations, local definitions, and available data. Those differences provide hypotheses for possibly divergent absence levels as well. For instance, Belgium shows the most diversified control procedures, the lowest level of sickness benefits, and the most rigid qualifying criteria for invalidity benefits. Sickness absence data were obtained from companies of four different clusters, each consisting of a comparable Belgian, German, and Dutch organisation. Conceptual, administrative, and statistical sources of bias were accounted for by selecting companies which resemble each other as to their product, production process, size, and geographical location: by using standardised definitions, absence data, and indices (observation period 1 January 1980 to 1 January 1982); and by measuring population variables to eliminate obvious explanations in terms of workforce composition. Controlled comparisons in these multiple clusters showed considerable and consistent differences in sickness absence rates. Whereas Belgian employees had 20.3 days of sickness absence (standardised for sex, age, and occupation) a year, German and Dutch employees had 28.5 and 39.1 days off a year respectively. Factors that might account for these differences are discussed.
Dipsticks are one of the most commonly used near-patient tests in primary care, but few clinical or dipstick algorithms have been rigorously developed.
To confirm whether previously documented clinical and dipstick variables and algorithms predict laboratory diagnosis of urinary tract infection (UTI).
Design of study
A total of 434 adult females with suspected lower UTI had bacteriuria assessed using the European Urinalysis Guidelines.
Sixty-six per cent of patients had confirmed UTI. The predictive values of nitrite, leucocyte esterase (+ or greater), and blood (haemolysed trace or greater) were confirmed (independent multivariate odds ratios = 5.6, 3.5, and 2.1 respectively). The previously developed dipstick rule — based on presence of nitrite, or both leucocytes and blood — was moderately sensitive (75%) but less specific (66%; positive predictive value [PPV] 81%, negative predictive value [NPV] 57%). Predictive values were improved by varying the cut-off point: NPV was 76% for all three dipstick results being negative; the PPV was 92% for having nitrite and either blood or leucocyte esterase. Urine offensive smell was not found to be predictive in this sample; for a clinical score using the remaining three predictive clinical features (urine cloudiness, dysuria, and nocturia), NPV was 67% for none of the features, and PPV was 82% for three features.
A clinical score is of limited value in increasing diagnostic precision. Dipstick results can modestly improve diagnostic precision but poorly rule out infection. Clinicians need strategies to take account of poor NPVs.
algorithms, clinical scoring; diagnosis, urinary tract infection; primary care; urinalysis
Chinese immigrants in the United States are broadly affected by cancer health disparities. We examined the cancer screening attitudes and practices of physicians serving Chinese immigrants in the New York City (NYC) area by mailing a cancer screening survey, based on current guidelines, to a random sample of physicians serving this population. Fifty three physicians (44%) completed the survey. Seventy-two percent reported following the guidelines for breast cancer, 35% for cervical cancer screening, and 45% for all colorectal cancer screening tests. Sixty-eight percent of physicians were satisfied with their current rates of cancer screening with their Chinese immigrant patient population. Physicians serving the Chinese community in NYC follow cancer screening guidelines inadequately. Cancer screening rates in this population could likely be increased by interventions that target physicians and improve awareness of guidelines and recommended best practices.
Chinese; immigrants; cancer screening; physician practices; primary care
It is known that there is significant morbidity associated with urinary tract infection and with renal dysfunction in sickle cell disease (SCD). However, it is not known if there are potential adverse outcomes associated with asymptomatic bacteriuria (ASB) infections in sickle cell disease if left untreated. This study was undertaken to determine the prevalence of ASB, in a cohort of patients with SCD.
This is a cross-sectional study of patients in the Jamaican Sickle Cell Cohort. Aseptically collected mid-stream urine (MSU) samples were obtained from 266 patients for urinalysis, culture and sensitivity analysis. Proteinuria was measured by urine dipsticks. Individuals with abnormal urine culture results had repeat urine culture. Serum creatinine was measured and steady state haematology and uric acid concentrations were obtained from clinical records. This was completed at a primary care health clinic dedicated to sickle cell diseases in Kingston, Jamaica. There were 133 males and 133 females in the sample studied. The mean age (mean ± sd) of participants was 26.6 ± 2.5 years. The main outcome measures were the culture of ≥ 105 colony forming units of a urinary tract pathogen per milliliter of urine from a MSU specimen on a single occasion (probable ASB) or on consecutive occasions (confirmed ASB).
Of the 266 urines collected, 234 were sterile and 29 had significant bacteriuria yielding a prevalence of probable ASB of 10.9% (29/266). Fourteen patients had confirmed ASB (prevalence 5.3%) of which 13 had pyuria. Controlling for genotype, females were 14.7 times more likely to have confirmed ASB compared to males (95%CI 1.8 to 121.0). The number of recorded visits for symptomatic UTI was increased by a factor of 2.5 (95% CI 1.4 to 4.5, p < 0.005) but serum creatinine, uric acid and haematology values were not different in patients with confirmed ASB compared with those with sterile urine. There was no association with history of gram negative sepsis.
ASB is a significant problem in individuals with SCD and may be the source of pathogens in UTI. However, further research is needed to determine the clinical significance of ASB in SCD.
Little information is available on physician characteristics and patient presentations that may influence compliance with evidence-based guidelines for acute low back pain.
To assess whether physicians' management decisions are consistent with the Agency for Health Research Quality's guideline and whether responses varied with the presentation of sciatica or by physician characteristics.
Cross-sectional study using a mailed survey.
Participants were randomly selected from internal medicine, family practice, general practice, emergency medicine, and occupational medicine specialties.
A questionnaire asked for recommendations for 2 case scenarios, representing patients without and with sciatica, respectively.
Seven hundred and twenty surveys were completed (response rate=25%). In cases 1 (without sciatica) and 2 (with sciatica), 26.9% and 4.3% of physicians fully complied with the guideline, respectively. For each year in practice, the odds of guideline noncompliance increased 1.03 times (95% confidence interval [CI]=1.01 to 1.05) for case 1. With occupational medicine as the referent specialty, general practice had the greatest odds of noncompliance (3.60, 95% CI=1.75 to 7.40) in case 1, followed by internal medicine and emergency medicine. Results for case 2 reflected the influence of sciatica with internal medicine having substantially higher odds (vs case 1) and the greatest odds of noncompliance of any specialty (6.93, 95% CI=1.47 to 32.78), followed by family practice and emergency medicine.
A majority of primary care physicians continue to be noncompliant with evidence-based back pain guidelines. Sciatica dramatically influenced clinical decision-making, increasing the extent of noncompliance, particularly for internal medicine and family practice. Physicians' misunderstanding of sciatica's natural history and belief that more intensive initial management is indicated may be factors underlying the observed influence of sciatica.
back pain; guidelines; practice variation; clinical vignette; decision making
Objective: To assess the quality and quantity of communication and cooperation between Dutch rheumatologists and occupational physicians.
Methods: A postal survey among 187 Dutch rheumatologists.
Results: 153/187 rheumatologists (82%) returned the questionnaire. They considered reducing pain and fatigue to be their major responsibility in the process of occupational rehabilitation, followed by improving work participation (68/153 (44%)) and quality of work (55/153 (36%)). Although 112/153 (73%) of the rheumatologists judged the communication and cooperation with occupational physicians as reasonable to good, 119/153 (78%) of them were willing to improve the collaboration. Perceived bottlenecks mentioned were a lack of clarity about the occupational physician's position and activities, and the absence of practice guidelines. The most important prerequisites for improvement were found to be guarantees about the occupational physician's professional independence and more clarity about the competence of the occupational physicians and how they used the information provided.
Conclusion: Dutch rheumatologists are willing to improve cooperation and communication with occupational physicians. The perceived lack of clarity about their mutual tasks appears to be a major obstacle. Thus the development of a joint education programme and a guideline for occupational rehabilitation in rheumatic diseases may be appropriate first steps towards improvement.
To determine whether high risk patients with hematuria receive evaluation according to guideline recommendations.
Materials and Methods
We recently performed a screening study for bladder cancer using a urine-based tumor marker in 1502 subjects at high risk based on age over 50, ≥10-year smoking history, and/or a 15 year or more environmental exposure. We evaluated use of urinalysis (UA) within 3 years preceding the screening study. Chart review was performed to determine if this subset with microhematuria received any additional evaluation.
Of 1502 study participants, routine urinalysis was performed in 73.2% and 164 (14.9%) subjects had documented hematuria (>3 RBCs/HPF) prior to inclusion. Of these, 42.1% had no further evaluation. Additional testing included repeat urinalysis (36%), urine culture (15.2%), cytology (10.4%), imaging (22.6% overall: 15.9% CT, 4.3% IVP; 2.4% MRI) and cystoscopy (12.8%).
Three subjects with microscopic hematuria (2%) were subsequently found to have bladder cancer during the screening study but were not referred for evaluation based on their hematuria. The source of hematuria was unknown in 65%, infection in 22%, benign prostatic enlargement in 10% and renal stone disease in 4% but these results are based on incomplete evaluation since only 12.8% underwent cystoscopy.
Subjects at high risk for bladder cancer based on ≥10 years of smoking or environmental exposure with microscopic hematuria are rarely evaluated thoroughly and only 12.8% were referred for urologic evaluation. Further studies are needed to evaluate both the utilization and effectiveness of guidelines for hematuria.
Hematuria; Guidelines Recommendations; bladder cancer
A positive dipstick urinalysis (i.e., leukocyte esterase test and/or nitrite test) did not reliably detect significant bacteriuria in 479 ambulatory women with suspected uncomplicated urinary tract infection; 18.9% of the urine samples that demonstrated significant bacteriuria would have been rejected by the laboratory based on a negative urinalysis screen.
Occupational health service (OHS) for small-scale enterprises (SSEs) is still limited in many countries. Both Japan and the Netherlands have universal OHS systems for all employees. The objective of this survey was to examine the activities of occupational physicians (OPs) in the two countries for SSEs and to investigate their proposals for the improvement of service.
Questionnaires on types and sizes of the industries they serve, allocation of service hours (current and desired), sources of information for occupational health activities etc. were mailed in 2006 to 461 and 335 Japanese and Dutch OPs, respectively, who have served in small- and medium-scale enterprises. In practice, 107 Japanese (23%) and 106 Dutch physicians (32%) replied, respectively.
Results and Conclusions
Total service time per month was longer for OPs in the Netherlands than OPs in Japan. Japanese OPs spent more hours for health and safety meetings, worksite rounds, and prevention of overwork-induced ill health (14–16% each). Dutch OPs used much more hours for the guidance of absent workers (48%). Thus, service conditions were not the same for OPs in the two countries. Nevertheless, both groups of OPs unanimously considered that employers are the key persons for the improvement of OHS especially in SSEs and their education is important for better OHS. The conclusions should be taken as preliminary, however, due to study limitations including low response rates in both groups of physicians.
Education; Employer; Occupational physician; Occupational health services; Small-scale enterprises
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.
The Netherlands, Belgium, and Luxembourg have adopted laws decriminalizing euthanasia under strict conditions of prudent practice. These laws stipulate, among other things, that the attending physician should consult an independent colleague to judge whether the substantive criteria of due care have been met. In this context initiatives were taken in the Netherlands and Belgium to establish specialized services providing such consultants: Support and Consultation for Euthanasia in the Netherlands (SCEN) and Life End Information Forum (LEIF) in Belgium. The aim of this study is to describe and compare these initiatives.
We studied and compared relevant documents concerning the Dutch and Belgian consultation service (e.g. articles of bye-laws, inventories of activities, training books, consultation protocols).
In both countries, the consultation services are delivered by trained physicians who can be consulted in cases of a request for euthanasia and who offer support and information to attending physicians. The context in which the two organisations were founded, as well as the way they are organised and regulated, is different in each country. By providing information on all end-of-life care matters, the Belgian LEIF seems to have a broader consultation role than the Dutch SCEN. SCEN on the other hand has a longer history, is more regulated and organised on a larger scale and receives more government funding than LEIF. The number of training hours for physicians is equal. However, SCEN-training puts more emphasis on the consultation report, whereas LEIF-training primarily emphasizes the ethical framework of end-of-life decisions.
In case of a request for euthanasia, in the Netherlands as well as in Belgium similar consultation services by independent qualified physicians have been developed. In countries where legalising physician-assisted death is being contemplated, the development of such a consultation provision could also be considered in order to safeguard the practice of euthanasia (as it can provide safeguards to adequate performance of euthanasia and assisted suicide).
In Europe, a comparable scope of training in GP can be observed especially in the field of knowledge. This feasibility study determines if a knowledge test is suitable in the context of a neighboring country.
A Dutch knowledge multiple choice test was used after validation of its content in Flanders (Belgium) in the academic year 2010–2011. Satisfaction with the test format was assessed. The test was taken by general practice trainees and trainers. Group scores of trainees in year 1, 2 and 3 and their trainers were compared to Dutch participants as a control group.
80 percent of the items in the Dutch test were transferable to Flanders (Belgium). Flemish participants (Belgium) liked the test format. The scores of all Belgian participants groups were lower than the Dutch participants.
The results among 1278 participants show that the use of the Dutch knowledge multiple-choice test is feasible in a neighboring country. At present, the individual scores can not be used for high stake decisions for trainees in Flanders (Belgium). If countries collaborate in the area of assessing GPs trainees, there would be an economical benefit due to increased efficiency. It would also lead to greater international integration of the discipline.
General practice/family medicine; Quality; Postgraduate training; Guidelines; International
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.
Objectives To determine whether data on proteinuria are useful for refining estimates of risk based on kidney function alone, and whether the results of kidney function tests can be a useful adjunct to data on proteinuria.
Design Analysis of data from a randomised trial. Impaired kidney function was defined as low glomerular filtration rate (< 60 ml/min/1.73 m2) and proteinuria (≥ 1+ protein) on dipstick urinalysis.
Setting Study of cholesterol and recurrent events: a randomised trial of pravastatin 40 mg daily versus placebo.
Participants 4098 men and women with previous myocardial infarction.
Main outcome measures All cause mortality and cardiovascular events.
Results 371 participants died in nearly 60 months of follow-up. Compared with participants without proteinuria or impaired kidney function, patients with both characteristics were at high risk (hazard ratio 2.39, 95% confidence interval 1.72 to 3.30), and those with only proteinuria or only impaired kidney function were at intermediate risk (1.69, 1.32 to 2.16; 1.41, 1.12 to 1.79, respectively) of dying from any cause. The results were similar for cardiovascular outcomes, including new cases of heart failure, stroke, and coronary death or non-fatal myocardial infarction. A graded increase in the risk of all cause mortality was seen for severity of renal impairment and degree of proteinuria by dipstick.
Conclusions The presence or absence of proteinuria on dipstick urinalysis may be used to refine estimates of risk based on kidney function alone.
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.
algorithm; infection associated markers; urinary tract infection; urine dipstick testing; workload
Chronic kidney disease (CKD) is a significant public health problem. Strategy for its early detection is still controversial. This study aims to assess the cost-effectiveness of population strategy, i.e. mass screening, and Japan’s health checkup reform.
Cost-effectiveness analysis was carried out to compare test modalities in the context of reforming Japan’s mandatory annual health checkup for adults. A decision tree and Markov model with societal perspective were constructed to compare dipstick test to check proteinuria only, serum creatinine (Cr) assay only, or both.
Incremental cost-effectiveness ratios (ICERs) of mass screening compared with do-nothing were calculated as ¥1,139,399/QALY (US $12,660/QALY) for dipstick test only, ¥8,122,492/QALY (US $90,250/QALY) for serum Cr assay only and ¥8,235,431/QALY (US $91,505/QALY) for both. ICERs associated with the reform were calculated as ¥9,325,663/QALY (US $103,618/QALY) for mandating serum Cr assay in addition to the currently used mandatory dipstick test, and ¥9,001,414/QALY (US $100,016/QALY) for mandating serum Cr assay and applying dipstick test at discretion.
Taking a threshold to judge cost-effectiveness according to World Health Organization’s recommendation, i.e. three times gross domestic product per capita of ¥11.5 million/QALY (US $128 thousand/QALY), a policy that mandates serum Cr assay is cost-effective. The choice of continuing the current policy which mandates dipstick test only is also cost-effective. Our results suggest that a population strategy for CKD detection such as mass screening using dipstick test and/or serum Cr assay can be justified as an efficient use of health care resources in a population with high prevalence of the disease such as in Japan and Asian countries.
Chronic kidney disease; Cost-effectiveness; Dipstick test; Mass screening; Proteinuria; Serum creatinine
Occupational health professionals may play an important role in preventive health promotion activities for employees. However, due to a lack of knowledge and evidence- and practice based methods and strategies, interventions are hardly being implemented by occupational physicians to date. The aim of the Balance@Work project is to develop, evaluate, and implement an occupational health guideline aimed at the prevention of weight gain among employees.
Following the guideline development protocol of the Netherlands Society of Occupational Medicine and the Intervention Mapping protocol, the guideline was developed based on literature, interviews with relevant stakeholders, and consensus among an expert group. The guideline consists of an individual and an environmental component. The individual component includes recommendations for occupational physicians on how to promote physical activity and healthy dietary behavior based on principles of motivational interviewing. The environmental component contains an obesogenic environment assessment tool. The guideline is evaluated in a randomised controlled trial among 20 occupational physicians. Occupational physicians in the intervention group apply the guideline to eligible workers during 6 months. Occupational physicians in the control group provide care as usual. Measurements take place at baseline and 6, 12, and 18 months thereafter. Primary outcome measures include waist circumference, daily physical activity and dietary behavior. Secondary outcome measures include sedentary behavior, determinants of behavior change, body weight and body mass index, cardiovascular disease risk profile, and quality of life. Additionally, productivity, absenteeism, and cost-effectiveness are assessed.
Improving workers' daily physical activity and dietary behavior may prevent weight gain and subsequently improve workers' health, increase productivity, and reduce absenteeism. After an effect- and process evaluation the guideline will be adjusted and, after authorisation, published. Together with several implementation aids, the published guideline will be disseminated broadly by the Netherlands Society of Occupational Medicine.
We investigated relationship between job stress and self-rated health among Japanese nese full-time occupational physicians (OPs).
In 2000, we mailed self-administrated questionnaires to 716 OPs. Of these OPs, 349 (49%) returned sufficiently completed questionnaires for analyses. oblique-rotated principal factor analysis of the job stress questionnaire extracted three components; low understanding of occupational health services in companies (low understanding), conflicts between occupational physicians and their coworkers (conflicts), and discrepancies between occupational physicians’ routine work and occupational health services (discrepancies).
The model, in which low understanding contributed to self-rated health through job satisfaction and self-rated health was influenced by job satisfaction and discrepancies, provided a good fit to the data.
We found that a potential relationship between job stress and self-rated health among Japanese full-time OPs. The present results implied that among full-time OPs, low understanding contributed negatively to self-rated health through job satisfaction, and that self-rated health was influenced positively by job satisfaction and negatively by discrepancies.
job stress; job satisfaction; self-rated health; occupational physicians; structural equation model
In the working population, back disorders are an important reason for sick leave and permanent work inability. In the context of fitting the job to the worker, one of the primary tasks of the occupational health physician is to evaluate the balance between work-related and individual variables. Since this evaluation of work capacity often consists of a physical examination of the back, the objective of this study was to investigate whether a physical examination of the low back, which is routinely performed in occupational medicine, predicts the development of low back pain (LBP).
This study is part of the Belgian Low Back Cohort (BelCoBack) Study, a prospective study to identify risk factors for the development of low back disorders in occupational settings. The study population for this paper were 692 young healthcare or distribution workers (mean age of 26 years) with no or limited back antecedents in the year before inclusion. At baseline, these workers underwent a standardised physical examination of the low back. One year later, they completed a questionnaire on the occurrence of LBP and some of its characteristics. To study the respective role of predictors at baseline on the occurrence of LBP, we opted for Cox regression with a constant risk period. Analyses were performed separately for workers without any back antecedents in the year before inclusion ('asymptomatic' workers) and for workers with limited back antecedents in the year before inclusion ('mildly symptomatic' workers).
In the group of 'asymptomatic' workers, obese workers showed a more than twofold-increased risk on the development of LBP as compared to non-obese colleagues (RR 2.57, 95%CI: 1.09 – 6.09). In the group of 'mildly symptomatic' workers, the self-reports of pain before the examination turned out to be most predictive (RR 3.89, 95%CI: 1.20 – 12.64).
This study showed that, in a population of young workers wh no or limited antecedents of LBP at baseline, physical examinations, as routinely assessed in occupational medicine, are not useful to predict workers at risk for the development of back disorders one year later.