Early Morning Specimens Research Articles

Spot specimen testing with GeneXpert MTB/RIF results compared to morning specimen in a programmatic setting in Cotonou, Benin

BackgroundThe diagnosis of tuberculosis (TB) using smear microscopy has been based on testing two specimens: one spot and one early morning sputa. Recently, the World Health Organization (WHO) has recommended to replace, whenever possible, microscopy with GeneXpert® MTB/RIF performed on a single specimen. However, as the bacterial load is higher in early morning specimens than in spot specimens, one could expect lower sensitivity of GeneXpert® MTB/RIF performed only on spot specimens. In this study, we compared results of GeneXpert® MTB/RIF on spot specimens versus early morning specimens, under programmatic conditions in Cotonou, Benin.MethodsFrom June to September 2018, all sputa received from presumptive TB patients at the Supranational Reference Laboratory for Tuberculosis of Cotonou were included in the study. From each patient, two specimens were collected (one spot and one early morning) and GeneXpert® MTB/RIF was performed on both specimens.ResultsIn total, 886 participants were included in the study, of whom 737 provided both sputa and 149 (16.8%) gave only the spot specimen. For the 737 participants who provided both sputa, GeneXpert® MTB/RIF was positive for both specimens in 152 participants; for three participants GeneXpert® MTB/RIF was positive on spot specimen but negative on morning specimen while for another three, the test was positive on morning specimen but negative on spot specimen. The overall percentage of agreement was excellent (99.2%) with a positive and negative percent agreement greater than 98%.ConclusionFor TB diagnosis under programmatic conditions in Cotonou, GeneXpert® MTB/RIF in spot specimens gave similar results with the test in morning specimens. Performing GeneXpert® MTB/RIF in both specimens did not significantly increase the number of cases detected. To avoid losing patients from the diagnostic cascade, it is preferable to test sputa produced at the time of the first visit at the health center.

Early-Morning vs Spot Posterior Oropharyngeal Saliva for Diagnosis of SARS-CoV-2 Infection: Implication of Timing of Specimen Collection for Community-Wide Screening.

BackgroundPosterior oropharyngeal saliva is increasingly recognized as a valid respiratory specimen for SARS-CoV-2 diagnosis. It is easy to collect and suitable for community-wide screening. The optimal timing of collection is currently unknown, and we speculate that an early-morning specimen before oral hygiene and breakfast would increase the diagnostic yield.MethodsPosterior oropharyngeal saliva was collected at 5 different time points within the same day from 18 patients with previously confirmed SARS-CoV-2 infection by molecular testing. Cycle threshold (Ct) values were compared.ResultsThere was an overall trend of lower Ct values from specimens collected in the early morning, with a gradual decrease of viral load towards nighttime, but reaching statistical significance only when compared with the specimens collected at bedtime. Eight out of 13 subjects had a higher viral load in the early morning than the rest of the 4 time points (before lunch, before teatime at 3 pm, before dinner, before bedtime).ConclusionsThe result suggests a diurnal variation of viral shedding from the upper respiratory tract with a trend showing higher viral load in the early morning. For community screening purposes, posterior oropharyngeal saliva could be taken throughout the day, but preferably in the early morning to maximize the yield.

Decreased glomerular filtration rate in patients with at least 5 years of type 2 diabetes in Ho Chi Minh City, Vietnam: Prevalence and associated factors

AimsThis study determined the prevalence and associated factors of decreased estimated glomerular filtration rate (eGFR) in patients who had type 2 diabetes for at least 5 years. MethodsA cohort study was conducted in 467 outpatients in a community-based hospital in Ho Chi Minh City, Vietnam. Serum creatinine were tested twice, at two occasions at least 3 months apart. The confirmatory eGFR was the average of the two eGFR of which the difference was ≤20%. The mean urine albumin-to-creatinine ratio was calculated from two consecutive early morning specimens. ResultsMost patients were female with a mean age of 61.7 (8.0) years. Albuminuria was found in 40% of participants, and the prevalence of decreased eGFR was 7.5% (n=35). Individuals with declined eGFR were older (p<0.001), had duration of diabetes longer (p=0.025), higher systolic blood pressure (p=0.010) and higher acid uric level (p<0.001), increased albumin excretion (p=0.009), and more proliferative retinopathy (p=0.011) than those with non-declined eGFR. ConclusionsAlthough decreased eGFR in type 2 diabetes patients was not prevalent, the strategies to prevent the progressive decline of GFR should be done to prevent patients from progressing to advanced renal disease.

Baseline Study of Sputum Microscopy for Diagnosis of Tuberculosis in Western Region of Nepal

Introduction: Tuberculosis is a major health issue in Nepal. Early detection of tuberculosis is essential to identify the case which limits the transmission of tuberculosis and builds an effective approach of tuberculosis control policy. Therefore, the present study is aimed to assess the case of tuberculosis by sputum smear examination.Methods: A prospective study was conducted in a tertiary care hospital of Western Nepal. Two sputum samples were collected from each suspect – spot specimen on the first day and one early morning specimen on the second day. The standard protocol of Ziehl Neelsen stain was applied to detect the acid fast bacilli.Results: Out of 280 smears from suspected patients, only 30 showed smear positivity (10.7%). Among the total identified positive case of tuberculosis (30/280), the highest rate was observed in the age group of 56-65 years. Males (56.7%) were highly affected by tuberculosis than females (43.3%). The minimum age of the suspects was two years and maximum age was of 105 years with mean age of 53.6 years.Conclusions: It is concluded that prevalence of tuberculosis is high in patients attending tertiary care hospital in Western region of Nepal, which is slightly higher than the annual report of National Tuberculosis Program 2017. Incidence of pulmonary tuberculosis is higher in males as compared to females.

Microalbuminuria screening in diabetes

Microalbuminuria screening in diabetes

Feasibility and cost analysis of programmatic implementation of microscopic-observation drug susceptibility (MODS) assay in Nigeria

Detection of Multi-drug resistant tuberculosis in Nigeria still remains a challenge. We evaluated the feasibility of programmatic implementation of the Microscopic-Observation Drug Susceptibility (MODS) assay, a rapid culture and drug susceptibility testing technique for drug susceptibility testing in a low resource setting.In a novel laboratory setting in Nigeria, we obtained data from the market on the cost of materials necessary for MODS assay. Three routinely collected sputum specimens from 160 tuberculosis suspects were evaluated by smear microscopy while only the early morning specimen was used for MODS culture.MODS assay detected M. tuberculosis in 97.7% (42/43) of smear positive and 6.0% (7/117) of smear negative TB suspects. There was a statistically significant advantage of a single MODS culture over 3 smear microscopies (P=0.019). The modal time from culture of specimen to detection of M. tuberculosis and availability of drug susceptibility result for MODS was 7days with a mean of 8.4 days (Range= 5-13 days). Culture and susceptibility result was available in 18.4% (9/49) of patients within 5days of culture. Turnaround time for smear microscopy in the centers was 3 days. Cost of processing one specimen by MODS assay in the study was USD2.65. Multi-Drug resistant tuberculosis (MDR-TB) was detected in 4.1% (2/49) while Isoniazid mono-resistance was detected in 2.0% (1/49) of the culture positive cases. All the drug resistant isolates were from re-treatment cases with a statistically significant association (P=0.005).The MODS technique is simple, and its implementation in this novel setting was feasible. MODS can be scaled up to meet the demand for MDR-TB confirmation in XpertMTB/Rif deployed sites in Nigeria.

Preworking hour reporting of inpatient blood tests with early morning specimen collection

Preworking hour reporting of inpatient blood tests with early morning specimen collection

Feasibility for Same Day Tuberculosis Diagnosis Using the Smear Microscopy Approach in Rural South Western Uganda

Background: WHO recently recommended the collection of two sputum smears and that these specimens can be collected in an accelerated scheme called front-loaded or same-day microscopy. We studied the feasibility of same day sputum smear microscopy in rural refugee settlement in South Western Uganda. Methods: Sputum specimens were collected from tuberculosis suspects at two health centers in Nakivale refugee settlement in South Western Uganda. Patients submitted 2 spot samples one hour apart and an early morning sample was submitted the next day. All samples were stained by Ziehl-Nielsen stain. Results for the two spot samples were given on day one and the morning sample results were given on day 2. Patients found to have TB were referred for treatment on reception of their results. Short Research Article Bazira et al.; AIR, 4(3): xxx-xxx, 2015; Article no.AIR.2015.070 152 Results: Of the 316 TB suspects, 190(60.1%) were males and 126(39.9%) were females. The mean age of the TB suspects was 40 years. Overall smear positivity rate was 46/316(15.0%). Of the 40 smear positive TB cases, 38(95.0%) were positive on the spot1, 35 (92.5%), on spot 2 while 31(85.0%) were positive on the early morning specimen. Only one TB suspect had negative sport1 sample that was positive with spot2 and early morning. Three TB suspects who had positive spot1 result did not return with spot2 sample. Six (15%) patients with a positive spot 1 did not bring the early morning sample. Though the bacillary load differed on the spot2 and morning samples the difference was not significant p-value > 0.05, all samples that were positive on morning sample were also positive on the spot 2. There was no association between HIV and TB infection. Conclusion: Same day smear microscopy for diagnosing tuberculosis is feasible in a rural setup by examining two spot samples.

Operational research: Yield of sputum smear positivity for early morning and spot sputum specimen in follow-up patients on DOTS

Operational research: Yield of sputum smear positivity for early morning and spot sputum specimen in follow-up patients on DOTS

Comparing Same Day Sputum Microscopy with Conventional Sputum Microscopy for the Diagnosis of Tuberculosis – Chhattisgarh, India

BackgroundThe World Health Organization (WHO) recommends same day sputum microscopy (spot-spot) in preference to conventional strategy (spot-morning) for the diagnosis of smear positive tuberculosis with the view that completing diagnosis on a single day may be more convenient to the patients and reduce pre-treatment losses to follow-up.MethodsWe conducted a cross-sectional study in seven selected district level hospitals of Chhattisgarh State, India. During October 2012 – March 2013, two sputum specimens (spot-early morning) were collected from consecutively enrolled adult (≥18 years) presumptive TB patients as per current national guidelines. In addition, a second sample was collected (one hour after the collection of first spot sample) from the same patients. All the samples were examined by ziehl-Neelsen (ZN) microscopy. McNemar’s test was used to compare statistical differences in the proportion smear positive between the two approaches (spot-spot versus spot-morning).ResultsOf 2551 presumptive TB patients, 69% were male. All patients provided the first spot specimen, 2361 (93%) provided the second spot specimen, and 2435 (96%) provided an early morning specimen. 72% of specimens were mucopurulent in conventional strategy as compared to 60% in same day strategy. The proportion of smear-positive patients diagnosed by same day microscopy was 14%, as compared to 17% by the conventional method (p<0.001). A total of 73 (16.9%) potential cases were missed by the same day method compared to only 2 (0.5%) by the conventional method.ConclusionSame-day microscopy method missed 17% of smear-positive cases and contrary to prior perception, did not increase the proportion of suspects providing the second sample. These findings call for an urgent need to revisit the WHO recommendation of switching to same-day diagnosis over the current policy.

Spatum smear positive tuberculosis among tuberculosis patients in a sub-urban hospital in Northeastern Nigeria

Background: The global tuberculosis control strategy recommended by the World Health Organization. (WHO) directly observed therapy short Course (DOTS), is based on identification of sputum smear-positive pulmonary tuberculosis cases. The rate of sputum smear- positive tuberculosis has never been reported from this part of the country. Aim: To determine the prevalence of sputum smear positive tuberculosis. Materials and Methods: The study group comprised patients aged 14 years and above admitted either into the Infectious diseases or medical wards of the Federal Medical Centre, Nguru northeastern Nigeria from 1st January 2002 to 31st December 2002. Diagnosis of TB was based either on the detection of acid- and alcohol-fast bacilli on the sputum of suspected cases or the non-resolution of radiographic features following a course of broad spectrum antibiotic. All cases had sputum smear examination of three early morning specimens (5-10 ml each) by the Ziehl-Neelsen technique for the detection of tubercle bacilli. Results: Fifty five patients with TB comprising 37 (67.3%) males and 18 (32.7%) females qualified for the study out of which one (1.8%) had extra pulmonary TB. Their ages ranged between 14 and 75 years with a mean of 35.6 ± 12.4 years. Thirty five patients (63.6%) had positive sputum smears for Mycobacterium tuberculosis, out of which 26(74.3%) were males. Twenty (36.4%) had negative smears. Conclusion: There is a high rate of sputum smear positive tuberculosis among patients seen in this hospital and this may pose some risk to close contacts and care givers. Nigerian Journal of Health and Biomedical Sciences Vol. 7 (1) 2008 pp. 72-5

Improvement of tuberculosis case detection and reduction of discrepancies between men and women by simple sputum-submission instructions: a pragmatic randomised controlled trial

In several settings, women with suspected tuberculosis are less likely to test smear positive than are men. Submission of poor-quality sputum specimens by women might be one reason for the difference between the sexes. We did a pragmatic randomised controlled trial to assess the effect of sputum-submission instructions on female patients. 1494 women and 1561 men with suspected tuberculosis attending the Federal Tuberculosis Centre in Rawalpindi, Pakistan, were randomly assigned between May and July, 2005 either to receive sputum-submission guidance before specimen submission or to submit specimens without specific guidance, according to prevailing practice. Of enrolled patients, 133 (4%) declined to participate. The primary outcome measure was the proportion of instructed and non-instructed women testing smear positive. Intention-to-treat analysis was undertaken on the basis of treatment allocation. This study is registered with the International Standard Randomised Controlled Trial number 34123170. Instructed women were more likely to test smear positive than were controls (Risk ratio 1.63 [95% CI 1.19-2.22]). Instructions were associated with a higher rate of smear-positive case detection (58 [8%] in controls vs 95 [13%] in the intervention group; p=0.002), a decrease in spot-saliva submission (p=0.003), and an increase in the number of women returning with an early-morning specimen (p=0.02). In men, instructions did not have a significant effect on the proportion testing smear positive or specimen quality. In the Federal Tuberculosis Centre in Rawalpindi, lower smear positivity in women than in men was mainly a function of poor-quality specimen submission. Smear positivity in women was increased substantially by provision of brief instructions. Sputum-submission guidance might be a highly cost-effective intervention to improve smear-positive case detection and reduce the disparity between the sexes in tuberculosis control in low-income countries.

Prevalence of Pulmonary Tuberculosis in Kanchanpur District of Far Western Nepal

Keeping in view of high prevalence of tuberculosis in far western development region in different reports, adoor to door survey of 125 household was carried out randomly in Mahendra Nagar municipality ward no13 of Kanchanpur district to pick up symptomatics suggestive of pulmonary tuberculosis and find the prevalence in the target population. A total of 200 sputum specimens from 70 symptomatics within the age rangeof 10-80 years were collected and subjected to smear microscopy by Ziehl - Neelsen's method. Out of 10positive cases (14.28%), infection in males and females was 80% and 20% respectively. The infection wasfound in the productive age group 20-69. The highest prevalence was obtained in 20-29 age group (25%)followed by 40-49 (11%), 30-39 (9%), 50-59 (8%) and 60-69 (8%). The diagnostic yield of single sputumspecimen examined was insufficient in field condition, especially where the sputum positivity was low. Of thethree sputum smears examined, the early morning specimen had the best result.Key Words: Pulmonary tuberculosis, prevalence, sputum smears.

Night-time Polyuria and Urine Hypo-osmolality in Enuretics Identified by Nocturnal Sequential Urine Sampling: Do they Represent a Subset of Relative ADH-deficient Subjects?

Early morning urine osmolality was tested in two urinary specimens, one taken immediately upon awakening and the other approximately 30 min thereafter, in 52 enuretic and 15 non-enuretic children. In a follow-up study, using the same study population, urine osmolality and volume were measured sequentially at 3-h intervals at 19.00, 22.00, 01.00, 04.00 and 07.00 h. Thereafter, all enuretics were treated by intranasal DDAVP for a 6-month period. There were no differences in urinary osmolality between enuretic and non-enuretic children when comparing the two early morning specimens. Nor were there any differences between groups in urine osmolalities at 19.00, 01.00 and 07.00 h. In contrast, at 04.00 h, urine osmolality was significantly lower in 17 of 52 enuretics [designated as ADH-negative (ADH-)] compared to the remaining enuretics [designated as ADH-positive (ADH+)] and non-enuretic children (610 +/- 251 vs 995 +/- 195 and 1089 +/- 195 mosmol/kg H2O, respectively, p < 0.05). This decreased osmolality was paralleled by an increase in urine production during the time period 01.00-04.00 (83 +/- 24 vs 52 +/- 18 and 45 +/- 22 ml, respectively, p < 0.05). At the end of the 6-month period of DDAVP treatment, the percentage response was similar between the ADH- and ADH+ enuretics (79% vs 75%). However, the time taken to achieve a response was quicker in the ADH- subjects. These data suggest the existence of a subgroup of enuretics whose underlying pathophysiology is the development of nocturnal polyuria probably due to a relative night-time ADH deficiency. Nocturnal sequential monitoring of urinary osmolality, as described above, allows identification of this subgroup.

Serum sialic acid and the long-term complications of insulin-dependent diabetes mellitus.

Elevated serum sialic acid (SSA) predicts cardiovascular disease in the non-diabetic population and is also associated with the presence of microalbuminuria and clinical proteinuria in patients with insulin-dependent diabetes (IDDM). We have studied 121 patients with IDDM of long duration (mean duration 25.2 years) to investigate the relationship of SSA concentrations to the presence of retinopathy, nephropathy, and neuropathy. SSA levels were elevated in patients with retinopathy (0.578 +/- 0.161 gl-1, n = 98) when compared with those without retinopathy (0.468 +/- 0.145 gl-1, n = 23, p = 0.002). Patients with nephropathy (urinary albumin:creatinine ratio of > 3 mg mmol-1 in all of three early morning specimens of urine) also had raised SSA levels (0.625 +/- 0.169 gl-1, n = 30) compared with those without nephropathy (0.533 +/- 0.160 gl-1, n = 91, p = 0.006). There was a significant correlation of SSA with urinary albumin:creatinine ratio (correlation coefficient 0.33, p < 0.001). SSA levels were not related to the presence or absence of neuropathy (0.567 +/- 0.181 gl-1, n = 28, vs 0.533 +/- 0.160 gl-1, n = 93, p = 0.92, respectively). In conclusion, retinopathy and nephropathy but not neuropathy are associated with increased SSA levels in patients with IDDM. The significance of this is not yet clear but it is possible that sialic acid is involved in the pathophysiology of microvascular disease in IDDM.

Biological variation in urinary excretion of pyridinium crosslinks: recommendations for the optimum specimen.

We assessed the analytical and biological variation of pyridinium crosslinks in early morning, 2 h fasting, and 24 h urine specimens from 14 healthy adults over a 1 month period. The results were expressed both in terms of pyridinoline concentration and pyridinoline/creatinine ratio. The data obtained were used to select the optimum specimen for clinical purposes. We found that: (a) early morning specimens are preferred; (b) results should be expressed as pyridinoline/creatinine ratio; (c) reference intervals should be stratified according to gender; (d) the necessary analytical imprecision (CV < or = 9%), derived from biological variation, is not easily achieved by current methods; (e) the difference between serial results from an individual must be > 50% to be statistically significant; and (f) assessment of risk for osteoporotic fracture by means of the pyridinium crosslink assay would, in a significant number of patients, require analysis of multiple urine specimens.

Microalbuminuria as a predictor of preeclampsia.

Urinary albumin concentration (UA) and albumin/creatinine ratio (UA/UC) in early morning specimens were assayed in 225 consecutive pregnant women at 20, 26, 28 and 30 weeks of gestation. 193 did not develop preeclampsia (control group), 14 developed preeclampsia later (preeclamptic group), 9 were excluded and 9 dropped out. Reference intervals of UA and UA/UC of healthy pregnant women (wk 20-30) was obtained. A statistically significant increase in urinary albumin excretion was observed with increasing gestational age as a normal phenomenon. There was no significant difference in the values of UA and UA/UC in the preeclamptic group when compared with the control group at the same stage of gestation. This indicates that microalbuminuria cannot be used as a predictor of preeclampsia.

Urinary luteinizing hormone testing and prediction of ovulation in spontaneous, clomiphene citrate and human menopausal gonadotropin-stimulated cycles. A clinical evaluation

A urinary luteinizing hormone test was utilized to predict ovulation in 99 spontaneous, 122 clomiphene citrate, and 82 human menopausal gonadotropin stimulated cycles. Tests were performed in early morning and evening specimens and follicular development was monitored by daily ultrasonography. A positive detection rate of 98, 97, and 94%, respectively, was obtained. Evidence of luteinized unruptured follicles was seen more frequently in stimulated cycles, concurring with negative test results. In 2 spontaneous, 1 clomiphene citrate and 5 hMG induced cycles two distinct LH surges were detected concomitant with a pattern of follicular atresia and subsequent new follicular development. Most ovulations occurred between 16 and 28 h after LH detection, significantly earlier in spontaneous than in clomiphene citrate stimulated cycles (p less than 0.02), whereas pre-ovulatory follicles were larger in the clomiphene citrate group (p less than 0.001). The mean duration of the follicular and luteal phases, as calculated from the LH peak, was substantially shorter in the hMG cycles than in the other two groups (p less than 0.001).

The Optimum Urine Collections for the Detection and Monitoring of Bence Jones Proteinuria

Twenty patients with malignant disease and Bence Jones (BJ) proteins were studied to determine the optimum urine collections for the detection and monitoring of light chain proteinuria. A 24-hour urine protein collection was followed by individual collections of each sequentially voided specimen over the same time interval. Samples were analyzed quantitatively for protein, and protein electrophoresis was performed on each specimen. Only one patient had BJ protein nondetectable by protein electrophoresis in the early morning specimen. Six patients had one or more random specimens (excluding the early morning specimens) absent for BJ protein on protein electrophoresis. Three patients had nondetectable protein on electrophoresis of the 24-hour specimen despite having some random specimens positive. All random specimens with protein values exceeding 0.20 g/L had BJ protein visibly detectable on electrophoresis. Thirteen specimens with protein less than 0.05 g/L still had BJ protein detected by electrophoresis. There was a linear relationship between the early morning protein concentration and the total 24-hour urinary protein production. The authors conclude that early morning specimens or 24-hour urine collections are preferable for the detection and monitoring of light chain proteinuria. These collection methods are not mutually exclusive because there are individual patients who will be negative in one collection but positive in the other.

Protein Creatinine Index and Albustix in Assessment of Proteinuria

The protein creatinine index in early morning and random urine specimens was compared with the 24 hour urinary excretion of protein in normal subjects and outpatients with abnormal proteinuria. A protein creatinine index (defined as (mg protein/1 divided by creatinine mmol/1) times 10) below 125 in a random specimen excluded abnormal proteinuria, whereas an index of more than 136 indicated the presence of pathological proteinuria. The index for random specimens provided a useful semiquantitative assessment of the 24 hour excretion of protein (mg protein/24 hours), but the index for early morning specimens was less reliable. Errors with Albustix were partly due to intra and inter observer variations in the interpretation of the colour formed when compared with the chart provided. It is proposed that the protein creatinine index on random urine samples should be used to supplement dipsticks in screening for proteinuria in cases where misclassification would be serious.