- Email: [email protected]
ROUTINE URINE TESTS IN GENERAL PRACTICE
1167
patients have been screened in respect of one item, urine testing. 461 were male, 659 female. 17% of the practice is of pensionable age. 1120
Views of General Practice ROUTINE URINE TESTS IN GENERAL PRACTICE MURDO MACLEOD
Wallasey, Cheshire In the absence of an agreed policy on screening for disease, the responsibility lies with general practitioner, public-health department and hospitals. A screening programme in a singlehanded practice of 2555 patients is described. In a two-year period about 1000 patients have responded to a tape-recorded request, played at intervals in the waiting-room, or to postal or health visitor follow-up if they had not visited the surgery. 33 cases of glycosuria, 20 of albuminuria, and 26 of hæmaturia were detected, and 42 patients are benefiting from treatment given as a result of screening. Among the major lesions picked up were diabetes (15), carcinoma of the bladder (1), papilloma of the bladder (2), and renal stone (1). The screening programme was amply justified by the results: it thus seems unfortunate that Department of Health and Social Security supplies
Sum ary
other sections of the Health Service with the tool for screening but refuses to provide diagnostic strips free of charge to general practitioners. INTRODUCTION
" PREVENTIVE medicine tends to be seen by everyone Where does as the responsibility of someone else."’ the responsibility lie-with the general practitioner, public-health department, or hospitals ? Until a corporate policy can be agreed upon, surely it rests with all three. Very often a general practitioner will send a patient to a hospital outpatient department, assuming that the staff will do a routine urine test. But do many outpatient departments test the urine of every new patient? Most of them only test urines routinely in medical clinics, and other clinical staff do so only to confirm their clinical suspicions. This hit-or-miss attitude persists despite the fact that " hospital patients in general, whether in- or out-patients, constitute a specially high-risk group of the population and are likely to give a high yield for conditions such as diabetes mellitus, cancer of the cervix, etc.".2 Recently, a Scottish hospital decided to test the urine of every patient, regardless of the clinic they were attending, and discovered 6 new diabetics in the ear, nose, and throat clinic alone.3 Normally these patients would not have had their urine tested routinely, and their condition might have remained undetected until one or more of the complications of diabetes
developed. Two years ago I launched a routine screening programme in my single-handed practice. The aim was to test the height, weight, blood-pressure, and smoking habits in those over forty; I do about 150 cervical smears each year, and encourage self-examination of the breast; haemoglobin is tested in those at risk; and urine tests are done routinely. To date
METHOD
Doctor-to-patient communication was a problem. A large notice displayed in the waiting-room and explaining the survey, evoked little or no response, so I decided to convey the message by means of a tape-recorded request for cooperation which was repeated every four minutes against a background of music. The message ran as follows: " This is the doctor speaking. At the present moment I am undertaking a survey of patients over 40 years of age and in particular testing a sample of urine for early diabetes. The test is simple, but it depends on your help-that is-a sample of water passed into a clean bottle li/2 to 2 hours after the main meal of the day, and presented, labelled with the name of the patient, the following day, if possible. Some people are in the habit of handing in the first morning specimen, but this is incorrect unless it is particularly asked for. The whole object is in diagnosing disease in the early stages, and thus preventing serious complications later on in life." The response was most gratifying, and it seemed that once it had been explained to them why their cooperation was needed, the patients were happy to participate. 770 patients presented urine for testing, leaving 350 patients who had not been to the surgery since the scheme started. The local executive council kindly helped by sending a circular letter to these 350 patients explaining the object of the exercise, but their response was poor. Eventually, however, except for a hard core of about 100 patients (1 of whom died of diabetes in hospital), all were tested. With the help of health visitor follow-up this gave a response-rate of 91%. Clean bottles and instructions were issued to the cooperating patients, and urine samples were deposited by them in a box by the front door of the surgery or handed directly to the doctor or nurse/receptionist who did the urine tests. Since urine testing with dip-and-read tests is so quick and easy it was decided that it would be squandering an opportunity to test for only one abnormality (i.e., glucose) when it would be as simple to test for four or five, so’Hema-Combistix’ (Ames) were used, which measure urinary pH, glucose, albumin, and blood in urine, all in thirty seconds. We have progressed to ’Labstix ’ (Ames) which are basically the same as hema-combistix but have the added advantage of an extra section which detects ketones. These strips are simple to use, and sensitive to detect clinically abnormal amounts of the substances for which we are searching.
pH results
have not been included as most of these between 5 and 6. Alkaline urines outside this range were found in patients with urinary-tract infections. Male patients tended to have urines of about pH 6 or below, unless infected, and many female patients tended to have values above pH 6. 15 new diabetics were discovered, only 1 of whom had clinical symptoms. This fact alone is a sufficient answer to the school of thought that says that sooner If a or later patients will present with symptoms. were
1168 so present the questions that must be asked are: How long have they had the symptoms ? Have they any sign of complications and if so, could earlier detection have prevented these? Besides the newly diagnosed diabetics, 12 patients are under surveillance because of glycosuria. These patients have a fasting blood-glucose carried out periodically either at the hospital laboratory or with ’Dextrostix ’ (Ames) at the surgery. Unfortunately only 50% cooperated. The remaining 6, though with persistent glycosuria had normal fasting blood-sugars or normal
patient does
glucose-tolerance tests. Of the 20 patients with albuminuria, 5 had congestive cardiac failure, 3 chronic renal disease, and 12 were known hypertensives. Most patients, being with disease processes several elderly, presented this the of blurring survey. Out of the total, aspect 6 had recurrent urinary-tract infection. This does not mean there were no other patients with urinary
Service are provided with the tools for screening, the general practitioner who is anxious to practice preventive medicine is discouraged by the Department’s refusal to supply diagnostic strips as used in the survey free of charge. I thank the clerk to the Wallasey Executive Council, the medical officer of health for Wallasey, the practice nursing sister and my wife (a former health visitor) for help and advice. Requests for reprints should be addressed to 30 Seabank Road, Wallasey, Cheshire L45 7PE. REFERENCES 1. Lancet, 1967, i, 83. 2. Wilson, J. M. G., Jumgner, G. Principles and Practice of Screening for Disease; p. 19. Geneva, 1968. 3. McIlwaine, C. L. K., Smith, A. M. W. Scot. med. J. 1966, 11, 208. 4. Wallace, D. M., Harris, D. L. Lancet, 1965, ii, 332. 5. Sanders, C. Practitioner, 1963, 191, 192. 6. Jameson, R. M. Lancet, 1969, i, 1164.
Round the World
infections
as not all present with albuminuria. For 20 example, pus cells per high-power field will not a cause change of colour in the reagent strip. Tests for haematuria proved most interesting, the most significant findings being: carcinoma of bladder (1), papilloma of bladder (2), and renal stone (1). Each of these patients was symptom-free and the amount of blood present was microscopic, which was detected by the strip tests and confirmed by microscopy. In each case the urine contained no protein. 1 female with haematuria was later found to have a cervical polyp. It is not generally realised that 90% of all cases of bladder tumours present with painless hasmaturia, and that one month’s delay in detection 4 can halve their chances of survival. Microscopic haematuria is more common than has previously been assumed.1i Indeed one hospital recently had referred to it 6 cases of symptomatic microscopic haematuria, discovered by routine testing, that were subsequently diagnosed as tumour in the urinary tract.6 My survey revealed 8 cases of haematuria, confirmed by microscopy, where investigation showed no obvious disease. Several explanations have been offered-local traumatic causes, senile vaginitis, " urethral caruncle or burnt-out glomerulonephritis ". These patients have been labelled " occult lesion " and more detailed follow-up study may reveal the significance of painless haematuria with a negative intravenous pyelogram.
CONCLUSION
It should be
equipment,
possible, given sufficient staff and whole populations every five or
to screen
for such diseases as diabetes, cervical carrenal disease, iron-deficiency anaemia, and cinoma, This would encourage doctors anxious hypertension. to do preventive medicine; the patients would benefit enormously and, if organised with the aid of computers, the programme could be based on properly staffed and equipped health centres within easy reach of district general hospitals. In the absence of a uniform policy, this practice accepts its share of the responsibility and undertakes continuous screening of patients. It seems, however, unforgivable that while other sections of the Health ten years
United States WELFARE CHAOS
In this sombre week, lit by burning R.O.T.C. buildings, there was a minor but significant tragic mishap to the administration’s welfare proposals which had passed the House by a large majority. It was expected that the Senate, rather more liberal than the House in these matters, would accept the proposals-the main foreseen danger being that the benefits might be increased by the Senate to such a point that the President would veto the proposal on financial grounds. However, things turned out differently. The opposition in the Senate turned on two main grounds. The first was that the " incentives " to work were inadequate, and the second that by various means recipients of welfare could, in certain areas, and by various devices, obtain an income that was greater than that of working families. The reason for this is, of course, the great diversity of federal welfare funding agencies and their counterparts in the individual States. Many of the federal welfare schemes do not come under the umbrella of the Department of Health, Education, and Welfare which is to administer the guaranteed-income scheme. By obtaining the maximum benefits from this scheme, by obtaining federal food stamps and other federal benefits, and various State and other allowances, the welfare recipient could, under various if rather peculiar circumstances, boost his income to a considerable extent. Mr. Finch pleaded vainly that he could only control the activities of H.E.W., and that other agencies and what they did were things for which he could not answer. No matter, the Senate sent the proposals back to be reconsidered. Clearly these matters will have to be resolved before the Senate again gets to work on the proposals, but lines of solution are not easy to see. We are faced with a considerable increase in the number of unemployed, further increases are predicted, and a further flood of schoolleavers will aggravate the situation. Summer jobs for students are not easy to find. But apart from this, H.E.W. faces an almost insoluble task unless there is an upheaval in administration at the federal level. Considering that it is responsible for health, education, and welfare, it is already an administrative colossus, and yet in every one of these fields-surely large enough for each to be a separate department-it has to share responsibilities with other federal agencies which it cannot control and which are not
always ready
to cooperate. Not so many years ago, the federal Government’s responsibilities in all these fields were minimal ; now they are enormous, and a crazy patchwork of agencies and funding have been set up-by Congress.
patients have been screened in respect of one item, urine testing. 461 were male, 659 female. 17% of the practice is of pensionable age. 1120
Views of General Practice ROUTINE URINE TESTS IN GENERAL PRACTICE MURDO MACLEOD
Wallasey, Cheshire In the absence of an agreed policy on screening for disease, the responsibility lies with general practitioner, public-health department and hospitals. A screening programme in a singlehanded practice of 2555 patients is described. In a two-year period about 1000 patients have responded to a tape-recorded request, played at intervals in the waiting-room, or to postal or health visitor follow-up if they had not visited the surgery. 33 cases of glycosuria, 20 of albuminuria, and 26 of hæmaturia were detected, and 42 patients are benefiting from treatment given as a result of screening. Among the major lesions picked up were diabetes (15), carcinoma of the bladder (1), papilloma of the bladder (2), and renal stone (1). The screening programme was amply justified by the results: it thus seems unfortunate that Department of Health and Social Security supplies
Sum ary
other sections of the Health Service with the tool for screening but refuses to provide diagnostic strips free of charge to general practitioners. INTRODUCTION
" PREVENTIVE medicine tends to be seen by everyone Where does as the responsibility of someone else."’ the responsibility lie-with the general practitioner, public-health department, or hospitals ? Until a corporate policy can be agreed upon, surely it rests with all three. Very often a general practitioner will send a patient to a hospital outpatient department, assuming that the staff will do a routine urine test. But do many outpatient departments test the urine of every new patient? Most of them only test urines routinely in medical clinics, and other clinical staff do so only to confirm their clinical suspicions. This hit-or-miss attitude persists despite the fact that " hospital patients in general, whether in- or out-patients, constitute a specially high-risk group of the population and are likely to give a high yield for conditions such as diabetes mellitus, cancer of the cervix, etc.".2 Recently, a Scottish hospital decided to test the urine of every patient, regardless of the clinic they were attending, and discovered 6 new diabetics in the ear, nose, and throat clinic alone.3 Normally these patients would not have had their urine tested routinely, and their condition might have remained undetected until one or more of the complications of diabetes
developed. Two years ago I launched a routine screening programme in my single-handed practice. The aim was to test the height, weight, blood-pressure, and smoking habits in those over forty; I do about 150 cervical smears each year, and encourage self-examination of the breast; haemoglobin is tested in those at risk; and urine tests are done routinely. To date
METHOD
Doctor-to-patient communication was a problem. A large notice displayed in the waiting-room and explaining the survey, evoked little or no response, so I decided to convey the message by means of a tape-recorded request for cooperation which was repeated every four minutes against a background of music. The message ran as follows: " This is the doctor speaking. At the present moment I am undertaking a survey of patients over 40 years of age and in particular testing a sample of urine for early diabetes. The test is simple, but it depends on your help-that is-a sample of water passed into a clean bottle li/2 to 2 hours after the main meal of the day, and presented, labelled with the name of the patient, the following day, if possible. Some people are in the habit of handing in the first morning specimen, but this is incorrect unless it is particularly asked for. The whole object is in diagnosing disease in the early stages, and thus preventing serious complications later on in life." The response was most gratifying, and it seemed that once it had been explained to them why their cooperation was needed, the patients were happy to participate. 770 patients presented urine for testing, leaving 350 patients who had not been to the surgery since the scheme started. The local executive council kindly helped by sending a circular letter to these 350 patients explaining the object of the exercise, but their response was poor. Eventually, however, except for a hard core of about 100 patients (1 of whom died of diabetes in hospital), all were tested. With the help of health visitor follow-up this gave a response-rate of 91%. Clean bottles and instructions were issued to the cooperating patients, and urine samples were deposited by them in a box by the front door of the surgery or handed directly to the doctor or nurse/receptionist who did the urine tests. Since urine testing with dip-and-read tests is so quick and easy it was decided that it would be squandering an opportunity to test for only one abnormality (i.e., glucose) when it would be as simple to test for four or five, so’Hema-Combistix’ (Ames) were used, which measure urinary pH, glucose, albumin, and blood in urine, all in thirty seconds. We have progressed to ’Labstix ’ (Ames) which are basically the same as hema-combistix but have the added advantage of an extra section which detects ketones. These strips are simple to use, and sensitive to detect clinically abnormal amounts of the substances for which we are searching.
pH results
have not been included as most of these between 5 and 6. Alkaline urines outside this range were found in patients with urinary-tract infections. Male patients tended to have urines of about pH 6 or below, unless infected, and many female patients tended to have values above pH 6. 15 new diabetics were discovered, only 1 of whom had clinical symptoms. This fact alone is a sufficient answer to the school of thought that says that sooner If a or later patients will present with symptoms. were
1168 so present the questions that must be asked are: How long have they had the symptoms ? Have they any sign of complications and if so, could earlier detection have prevented these? Besides the newly diagnosed diabetics, 12 patients are under surveillance because of glycosuria. These patients have a fasting blood-glucose carried out periodically either at the hospital laboratory or with ’Dextrostix ’ (Ames) at the surgery. Unfortunately only 50% cooperated. The remaining 6, though with persistent glycosuria had normal fasting blood-sugars or normal
patient does
glucose-tolerance tests. Of the 20 patients with albuminuria, 5 had congestive cardiac failure, 3 chronic renal disease, and 12 were known hypertensives. Most patients, being with disease processes several elderly, presented this the of blurring survey. Out of the total, aspect 6 had recurrent urinary-tract infection. This does not mean there were no other patients with urinary
Service are provided with the tools for screening, the general practitioner who is anxious to practice preventive medicine is discouraged by the Department’s refusal to supply diagnostic strips as used in the survey free of charge. I thank the clerk to the Wallasey Executive Council, the medical officer of health for Wallasey, the practice nursing sister and my wife (a former health visitor) for help and advice. Requests for reprints should be addressed to 30 Seabank Road, Wallasey, Cheshire L45 7PE. REFERENCES 1. Lancet, 1967, i, 83. 2. Wilson, J. M. G., Jumgner, G. Principles and Practice of Screening for Disease; p. 19. Geneva, 1968. 3. McIlwaine, C. L. K., Smith, A. M. W. Scot. med. J. 1966, 11, 208. 4. Wallace, D. M., Harris, D. L. Lancet, 1965, ii, 332. 5. Sanders, C. Practitioner, 1963, 191, 192. 6. Jameson, R. M. Lancet, 1969, i, 1164.
Round the World
infections
as not all present with albuminuria. For 20 example, pus cells per high-power field will not a cause change of colour in the reagent strip. Tests for haematuria proved most interesting, the most significant findings being: carcinoma of bladder (1), papilloma of bladder (2), and renal stone (1). Each of these patients was symptom-free and the amount of blood present was microscopic, which was detected by the strip tests and confirmed by microscopy. In each case the urine contained no protein. 1 female with haematuria was later found to have a cervical polyp. It is not generally realised that 90% of all cases of bladder tumours present with painless hasmaturia, and that one month’s delay in detection 4 can halve their chances of survival. Microscopic haematuria is more common than has previously been assumed.1i Indeed one hospital recently had referred to it 6 cases of symptomatic microscopic haematuria, discovered by routine testing, that were subsequently diagnosed as tumour in the urinary tract.6 My survey revealed 8 cases of haematuria, confirmed by microscopy, where investigation showed no obvious disease. Several explanations have been offered-local traumatic causes, senile vaginitis, " urethral caruncle or burnt-out glomerulonephritis ". These patients have been labelled " occult lesion " and more detailed follow-up study may reveal the significance of painless haematuria with a negative intravenous pyelogram.
CONCLUSION
It should be
equipment,
possible, given sufficient staff and whole populations every five or
to screen
for such diseases as diabetes, cervical carrenal disease, iron-deficiency anaemia, and cinoma, This would encourage doctors anxious hypertension. to do preventive medicine; the patients would benefit enormously and, if organised with the aid of computers, the programme could be based on properly staffed and equipped health centres within easy reach of district general hospitals. In the absence of a uniform policy, this practice accepts its share of the responsibility and undertakes continuous screening of patients. It seems, however, unforgivable that while other sections of the Health ten years
United States WELFARE CHAOS
In this sombre week, lit by burning R.O.T.C. buildings, there was a minor but significant tragic mishap to the administration’s welfare proposals which had passed the House by a large majority. It was expected that the Senate, rather more liberal than the House in these matters, would accept the proposals-the main foreseen danger being that the benefits might be increased by the Senate to such a point that the President would veto the proposal on financial grounds. However, things turned out differently. The opposition in the Senate turned on two main grounds. The first was that the " incentives " to work were inadequate, and the second that by various means recipients of welfare could, in certain areas, and by various devices, obtain an income that was greater than that of working families. The reason for this is, of course, the great diversity of federal welfare funding agencies and their counterparts in the individual States. Many of the federal welfare schemes do not come under the umbrella of the Department of Health, Education, and Welfare which is to administer the guaranteed-income scheme. By obtaining the maximum benefits from this scheme, by obtaining federal food stamps and other federal benefits, and various State and other allowances, the welfare recipient could, under various if rather peculiar circumstances, boost his income to a considerable extent. Mr. Finch pleaded vainly that he could only control the activities of H.E.W., and that other agencies and what they did were things for which he could not answer. No matter, the Senate sent the proposals back to be reconsidered. Clearly these matters will have to be resolved before the Senate again gets to work on the proposals, but lines of solution are not easy to see. We are faced with a considerable increase in the number of unemployed, further increases are predicted, and a further flood of schoolleavers will aggravate the situation. Summer jobs for students are not easy to find. But apart from this, H.E.W. faces an almost insoluble task unless there is an upheaval in administration at the federal level. Considering that it is responsible for health, education, and welfare, it is already an administrative colossus, and yet in every one of these fields-surely large enough for each to be a separate department-it has to share responsibilities with other federal agencies which it cannot control and which are not
always ready
to cooperate. Not so many years ago, the federal Government’s responsibilities in all these fields were minimal ; now they are enormous, and a crazy patchwork of agencies and funding have been set up-by Congress.