Collection Of Urine Specimens Research Articles

Bimanual Examinations in Asymptomatic Well Women: Interpreting Current Practice Guidelines

Rachel Wiebe Skouta, RN, NP, and Elsie Duff, NP, PhD(c) Bimanual examinations are not an effective assessment of gynecological health problems among asymptomatic well women. Annual bimanual exams do not increase the detection of adnexal masses, whether benign or malignant, and there is limited benefit in the use of these exams as part of regular screening for ovarian cysts or fibroids. There is also limited evidence to support the sensitivity and specificity of the pelvic exam; the effects of variables such as practitioner experience, client symptoms, client body shape, and client emotional experiences during the exam have not been well researched. As a result, the bimanual exam is not supported as a reproductive cancer screening tool. The purpose of this article is to address current guidelines and recommendations for routine health screening of well women. In symptomatic cases, pelvic ultrasounds and cancer antigen 125 (CA-125) tests are effective screening tools to detect ovarian cancer. Pap tests every 3 years is a standard screening for cervical cancer. Because premenopausal women are more likely to develop benign ovarian follicular cysts, excessive screening in these women may simply increase anxiety, promote repetitive screening, and lead to unnecessary surgery for a condition that may resolve spontaneously. More effective testing methods are available for gynecological pathology screening. Advances in screening technology have made the pelvic exam irrelevant when assessing for sexually transmitted infections (STIs). With improved technologies, such as nucleic-amplification tests, urine specimen collection, and vaginal selfswabs, bimanual exams have been rendered

A prospective study of multiple protein biomarkers to predict progression in diabetic chronic kidney disease.

Diabetic nephropathy imposes a substantial cardiovascular and renal burden contributing to both morbidity and excess mortality. Progression of chronic kidney disease (CKD) in diabetes mellitus is variable, and few biomarkers are available to predict progression accurately. Identification of novel predictive biomarkers may inform clinical care and assist in the design of clinical trials. We hypothesized that urinary and plasma protein biomarkers predict CKD progression independently of the known clinical markers such as albuminuria and estimated glomerular filtration rate (eGFR) in diabetic nephropathy. We studied 67 US veterans with CKD due to type 2 diabetes mellitus and 20 age-matched controls (no CKD, hypertension or cardiovascular disease). After clinical evaluation and the collection of blood and urine specimens for 24 biomarkers, we followed subjects prospectively for the next 2-6 years. CKD progression was defined in three ways: (i) clinically by examining eGFR versus time plots for each individual (slope progression), (ii) progression to end-stage renal disease (ESRD) and (iii) a composite outcome of ESRD or death. Among 17 urinary and 7 plasma biomarkers evaluated, the relationship of the biomarkers with outcome was as follows: (i) for progression identified by eGFR plots, urinary C-terminal fibroblast growth factor (FGF)-23 emerged to have the strongest primary association (adjusted odds ratio [aOR] 2.08, P = 0.008); (ii) for ESRD, plasma vascular endothelial growth factor (VEGF) had an association (aOR: 1.44, P = 0.027) and (iii) for the composite outcome of death and ESRD, plasma C-terminal FGF-23 also had a robust direct association (aOR: 3.07, P = 0.008). The relationship of biomarkers with future progression of CKD is complex and depends in part on how CKD progression is defined. Biomarkers in the FGF-23 and VEGF-A pathways predicted patient progression independently of albuminuria levels in this patient cohort. Additional studies in other cohorts will help further validate this pilot study.

Laboratory Diagnosis of Urinary Tract Infections: Guidelines, Challenges, and Innovations

The culture-based diagnosis of urinary tract infections (UTIs) present several challenges to clinical microbiologists, physicians, and the health care system in general because the diagnosis of UTI is not always straightforward. The 8 million office visits for the assessment of UTIs each year represent a significant health care cost of approximately $1 billion annually. The resulting 1.5 million hospitalizations further impact the health care system. UTIs represent 40% of nosocomial infections, and they are usually associated with urinary catheters. Importantly, catheter-associated urinary tract infections (CAUTIs) are one of the hospital-acquired complications chosen by the Centers for Medicare and Medicaid Services for which hospitals no longer receive additional payment. Although this rule may result in an increased focus on CAUTIs, increased education for health care workers, early catheter removal, and alternatives to indwelling catheterizations, it may also result in more urine specimens being submitted for culture. An increase in urine cultures will definitely have an impact on both clinical microbiology staffing and laboratory expenditures, especially if the urine cultures are positive for significant amounts of microbial growth. Therefore, it is imperative that the clinical microbiology laboratory employ well-documented guidelines for processing and interpreting urine cultures and implement state-of-the-art methodology, when appropriate. The purpose of this review is to discuss recent guidelines and recommendations for the collection and processing of urine specimens, interpretation of culture results, current challenges, and potential options for routine urine culture.

Bioanalysis of urine samples after manipulation by oxidizing chemicals: technical considerations.

Drug testing programs are established to help achieve a drug-free work environment, promote fair competition in sport, facilitate harm minimization and rehabilitation programs, better manage patient care by clinicians and service law enforcement authorities. Urine remains the most popular and appropriate testing matrix for such purposes. However, urine is prone to adulteration, where chemicals, especially oxidizing chemicals, are purposely added to the collected urine specimens to produce a false-negative test result. This article will describe the effect of various popular oxidizing adulterants on urine drug test results, the countermeasures taken by laboratories in dealing with adulterated urine samples and the prospect of developing more robust and economical methods to combat urine adulteration in the future.

Analysis of timeliness and accuracy of collection of clinical urine specimen

Objective To investigate the timeliness and accuracy of collection of clinical urine specimen.Methods Totals of 371 collections of urine specimen were followed , the cause of not-in-time and inaccuracy was analyzed , improvement strategies were proposed , and effective collections of clinical specimen were managed .Results Totals of 330 urine specimens were collected timely and accurately , accounting for 88.95%, and 41 specimens failed, accounting for 11.05%, in which 10 were delayed because of patients＇menstruation, anuria or inspection on that day （2.70%）, and 31 were not collected timely or accurately （8.35%）.Twenty-two urine specimens were wrongly collected because of the first urine specimen of admission （91.67%）, ten were wrongly collected for leaving two or more than two urine specimens at the same time （41.67%）, and twelve were wrongly collected because of family assistance due to low education level （50.00%）.Conclusions The timeliness and accuracy should be listed as one of the quality monitoring indicators of specialist nurses .Nurses＇knowledge and quality consciousness of specimens collection should be strengthened to help patients with collection , so as to improve the timeliness and accuracy of urine specimens collection. Key words: Quality control; Urine specimen; Collection; Investigation

Allostatic load and spinal cord injury: review of existing research and preliminary data.

To introduce allostatic load (AL) as a framework for measuring stress-related outcomes after spinal cord injury (SCI) by identifying the number and nature of biomarkers investigated in existing studies and by generating preliminary data on AL in 30 persons with traumatic SCI. This systematic review and pilot study were conducted at a medical university in the southeastern United States. A review of literature published between 1993 and 2012 identified studies using 2 or more of 5 classes of AL biomarkers. We then collected data on 11 biomarkers (n = 30) from self-selected participants using physical exams and blood and urine specimen collection. These included waist to hip ratio, systolic and diastolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, dihydroepiandrosterone, glycosylated hemoglobin, C-reactive protein, interleukin-6, and cortisol, norepinephrine, and epinephrine normalized by 12-hour creatinine. We were unable to identify any studies investigating AL biomarkers from each of the 5 areas or any studies specifically proposing to investigate AL. AL scores were relatively low, with metabolic indicators being the most elevated and neuroendocrine the least elevated. AL is a promising, yet underutilized, construct that may be feasibly assessed after SCI.

Diagnostic accuracy of a point-of-care urine test for tuberculosis screening among newly-diagnosed hiv-infected adults: a prospective, clinic-based study

BackgroundA rapid diagnostic test for active tuberculosis (TB) at the clinical point-of-care could expedite case detection and accelerate TB treatment initiation. We assessed the diagnostic accuracy of a rapid urine lipoarabinomannan (LAM) test for TB screening among HIV-infected adults in a TB-endemic setting.MethodsWe prospectively enrolled newly-diagnosed HIV-infected adults (≥18 years) at 4 outpatient clinics in Durban from Oct 2011-May 2012, excluding those on TB therapy. A physician evaluated all participants and offered CD4 cell count testing. Trained study nurses collected a sputum sample for acid-fast bacilli smear microscopy (AFB) and mycobacterial culture, and performed urine LAM testing using Determine™ TB LAM in the clinic. The presence of a band regardless of intensity on the urine LAM test was considered positive. We defined as the gold standard for active pulmonary TB a positive sputum culture for Mycobacterium tuberculosis. Diagnostic accuracy of urine LAM was assessed, alone and in combination with smear microscopy, and stratified by CD4 cell count.ResultsAmong 342 newly-diagnosed HIV-infected participants, 190 (56%) were male, mean age was 35.6 years, and median CD4 was 182/mm3. Sixty participants had culture-positive pulmonary TB, resulting in an estimated prevalence of 17.5% (95% CI 13.7-22.0%). Forty-five (13.2%) participants were urine LAM positive. Mean time from urine specimen collection to LAM test result was 40 minutes (95% CI 34–46 minutes). Urine LAM test sensitivity was 28.3% (95% CI 17.5-41.4) overall, and 37.5% (95% CI 21.1-56.3) for those with CD4 count <100/mm3, while specificity was 90.1% (95% CI 86.0-93.3) overall, and 86.9% (95% CI 75.8-94.2) for those with CD4 < 100/mm3. When combined with sputum AFB (either test positive), sensitivity increased to 38.3% (95% CI 26.0-51.8), but specificity decreased to 85.8% (95% CI 81.1-89.7).ConclusionsIn this prospective, clinic-based study with trained nurses, a rapid urine LAM test had low sensitivity for TB screening among newly-diagnosed HIV-infected adults, but improved sensitivity when combined with sputum smear microscopy.

Legal issues in mandatory drug testing under Malaysia’s drug intervention programme

The Malaysian government’s drug intervention programme has been implemented to combat the nation’s drug abuse problem by eliminating drug dependency and preventing relapse (National Drug Policy, 1983). Drug testing is widely used as a criminal justice tool to coerce drug dependants into compulsory treatment at government-run drug rehabilitation centres. Over the years, a significant number of court cases have challenged the legality of detention of drug dependants at the centres due to procedural errors in mandatory drug testing. This article examines the necessary criteria to determine optimum validity of drug testing results i.e. from the collection of urine specimen, chain of custody, accuracy and reliability of urinalysis to interpretation of test results. Non-compliance with such procedures may result in unlawful detention of individuals at drug rehabilitation centres for a period of 2 years and thereafter supervision within the community for another 2 years.

Urinary Tract Infection in Children: A Review

Urinary tract infection (UTI) is one of the most common paediatric infections. By the time children are 5 years old, about 8% of girls and about 1-2% of boys have had at least one episode of UTI. UTIs are caused mainly by colonic bacteria, such as Escherichia coli, followed by Klebsiella and Proteus. However, any organism that gains access to the urinary tract system may cause infection, including fungi (Candida species) and viruses. In some instances, UTI results in recognition of an important underlying structural abnormality of the urinary tract. The febrile infant or child with clinically significant bacteriuria and no other site of infection to explain the fever, even in the absence of systemic symptoms has UTI. Signs and symptoms of UTIs vary depending on the child's age and on which part of the urinary tract is infected. The diagnosis of UTI is based on routine microscopic examination and culture of a properly collected urine specimen. Imaging studies are done in selected patients to identify anatomic abnormalities. Most cases of uncomplicated UTI respond readily to outpatient antibiotic treatment without further sequelae. All patients should have close follow-up to evaluate response to antibiotics and to prevent the development of long term complication. DOI: http://dx.doi.org/10.3329/dmcj.v1i2.15919 Delta Med Col J. Jul 2013;1(2):51-57

Comparison of 2 Techniques Used to Obtain Sterile Urine Specimens From Urethral Catheters

The objective of this study was to compare the rates of urine contamination and the frequencies of minor adverse events between the vacuum tube and injector techniques methods for the collection of sterile urine specimens. This study was a cross-sectional study. The sample population was composed of patients who underwent a urodynamics procedure. This study was performed at the urodynamics unit of a rehabilitation and care center in Turkey. Sterile urine specimens (n = 576) were collected from 144 patients using the vacuum tube technique and the injector technique; the rates of urine contamination and minor adverse events were evaluated. χ2 Statistics and Fisher exact tests were used to assess the contamination rates and frequencies of minor adverse events during the collection of sterile urine specimens. The contamination rate of urine specimens collected using an injector was 0.9% (P > .05). The rate of minor adverse events during specimen collection was lower when using the vacuum technique than when using an injector and sterile urine container (2 vs 36 events, P < .05). The vacuum tube technique of urine specimen collection was not superior to the injector technique in regard to contamination. The use of the vacuum tube technique for the collection of sterile urine specimens can prevent minor adverse events related to spillage/leakage of urine. More research from multiple settings and work environments is needed to strengthen the evidence base of vacuum tube technique of sterile urine specimen collection.

P2.063 Validation of Copan eNat, a Molecular Transport Medium, For the Collection and Preservation of Urine Specimens For the Detection of STI Infections with the Seegene Anyplex II STI-7 V1.1 Assay

Backgrounds Urine is used for screening STI infections with molecular assays. Copan developed the eNat, a molecular medium that preserves and stabilises nucleic acid (NC), for collection, and storage of clinical specimens for microbial detection by real-time PCR. Seegene uses dry container (DC) for urine collection for detection of urogenital pathogens with the Anyplex II STI-7 (STI7). Study objective was to validate the eNat for nucleic acid preservation in urines for STDs detection with the STI7 assays. Methods In this study, 80 urines, collected in DC from patients attending a Milan STD clinic. Urines were tested as per current method and after adding urine to 1ml eNat. To find the urine volume with same sensitivity as urine in DC, 1, 2, and 3ml urine in 1 ml eNAT were tested. After vortexing the eNAT samples, NC was extracted from 350ul with the Automated Purification Systems (NIMBUS IVD) and eluted in 100ul buffer. Purified NCs were tested with the with the Seegene STI7 assay. Results In the 80 urine samples tested, 43 negative and 37 positive were detected with DC, while 1 ml, 2 ml and 3 ml urine in eNAT detected 45.40.40 negative or partial negative (1, 2, 3) and 35.40.40 positive (1, 2, 3) respectively. More co-infections were detected with eNAT 3 ml. Loss of sensitivity with 1 ml eNAT and inhibition with DC versus 3 ml in eNAT was detected in 7 samples. Conclusions Good agreement was found between Copan eNat-3 ml urine and urine in DC for the detection of 7 STI with the Seegene assay. Copan eNAT, is available in leak proof tube, easy to transport-store urines, prevents bacterial overgrowth, stabilises NC at RT and is compatible with the STI7 assay.

Diagnostic technology: alternative sampling methods for collection of urine specimens in older adults

Diagnostic technology: alternative sampling methods for collection of urine specimens in older adults

Implementation of a Quality Improvement Project to Document & Decrease the Rate of Contaminated Urine Cultures in our Neonatal Population

ISSUE: Lo et al. (2008) found that urinary tract infections (UTI) are the most common hospital acquired infection. They identified that 80% of UTI’s are attributable to an indwelling urinary catheter. The two guiding documents infection preventionist reference when seeking guidance on Catheter Associated Urinary Tract Infection (CAUTI) prevention are the Healthcare Infection Control Practices Advisory Committee (2010) and the SHEA/IDSA Practice Recommendations (2008). Neither document addresses the neonatal population, nor does the National Healthcare Safety Network (NHSN) (2010) have a CAUTI benchmark for NICU’s. Furthermore, we were unable to identify expected rates of urine contamination specific for the neonatal population. The following abstract outlines our response to this literature gap. Project aim: To decrease the rate of contaminated urine cultures by 20% by the end of 2013. PROJECT: Our NICU is a Level III, 54 bed unit in an urban teaching facility. Using the Plan-Do-Study-Act methodology we analyzed all urine cultures collected from January through mid October, 2012. We conducted a literature review, created and delivered education on appropriate urine specimen collection using LippincottWilliams &Wilkins (2012) and implemented an audit process on every urine culture ordered. RESULTS: January through October, 2012 we had 26 incidences of symptomatic UTI, Criterion 3 & 4, using the NHSN (2012) surveillance definitions. In two incidences the patients involved had a foley in place. Over the same time period we collected an average of 24 urine specimens a month, 17 of which, on average, were negative. Ninety percent were collected by straight catheterization and 78% of the positive cultures were collected from male patients. Approximately 9% of positive cultures yielded mixed flora with no predominant organism, while 41.3% had colony counts 10,000 or less. Specimen collection education occurred in November, 2012. Preliminary results indicate a reduction in the number of contaminated urine cultures in NICU. Process measure results are pending. LESSON LEARNED: The Division of Health Care Quality Promotion (2009) estimated that CAUTI cost w$1000 per incidence. Costs associated with UTI treatment include antimicrobial therapy, central access required to deliver therapy, follow-up urine cultures and renal ultrasounds. Non-fiscal costs include adverse effects of antimicrobial therapy on bowel flora, increased risk of necrotizing enterocolitis, multidrug-resistant-organism development, pain and discomfort to the neonate, and emotional toll on the family members and care providers. The bottom line is, just because these infections are not benchmarked, doesn’t mean they shouldn’t be measured.

Retrospective Assessment of Transcription-Mediated Amplification-Based Screening for Trichomonas vaginalis in Male Sexually Transmitted Infection Clinic Patients

Transcription-mediated amplification (TMA) enhances detection of Neisseria gonorrhoeae and Chlamydia trachomatis from rectal and pharyngeal sources. The utility of TMA for detection of Trichomonas vaginalis has recently been described. We report on the performance of TMA for detection of sexually transmitted infection (STI) agents from extraurogenital sources, with a focus on T. vaginalis. Within a 21-month interval, 1,314 consecutive male patient encounters at an STI clinic resulted in collection of 2,408 specimens for C. trachomatis, N. gonorrhoeae, and T. vaginalis TMA screening. A total of 471 encounters were managed with a single specimen collection (94.9% urine), with 12.7% positive for at least one STI agent. This detection percentage increased to 14.4% with collection of specimens from two sources and to 20.3% with collection from three sources (P = 0.03 versus single-source sampling). A total of 44.4% of encounters were managed by collection of urine and pharyngeal specimens and 19.1% by the addition of a third (rectal) collection. While procurement of urine and rectal specimens resulted in greater detection of C. trachomatis (6.1% and 11.3% rates, respectively) than of other STI agents, 858 pharyngeal specimens yielded a 2.9% T. vaginalis detection rate compared with 2.1% for N. gonorrhoeae and 1.6% for C. trachomatis. All T. vaginalis pharyngeal detections were confirmed by TMA-based alternative target testing. A total of 38.1% of T. vaginalis-positive pharyngeal specimens were derived from symptomatic patient encounters. A total of 85.7% of males with T. vaginalis-positive pharyngeal collections indicated strictly heterosexual preference. Additional specimen source sampling is necessary to make STI screening comprehensive. Incorporation of extraurogenital sources into assessment for T. vaginalis detection may identify additional symptomatic and asymptomatic male STI carriers.

Urine Specimen Collection: How a Multidisciplinary Team Improved Patient Outcomes Using Best Practices

The Institute of Medicine challenged the health care system to ensure safe care for all patients. This article reviews one hospital's attempt to minimize contamination of urine specimens by using a multidisciplinary team to implement evidence-based best practices. The clinical nurse specialist (CNS) collaborated with microbiology and laboratory personnel to review literature, collect and analyze data, provide staff education, and facilitate change in urine collection kits and urine processing that significantly improved the quality of urine specimens in a 350-bed hospital in the Midwest.

Low level of adherence to instructions for 24-hour urine collection among hospital outpatients.

Introduction:We hypothesized that patients are poorly informed about proper procedure for 24-hour urine specimen collection and its relevance in determination of biochemical analytes, despite availability of leaflets and webpage with instruction for collection. The aim of this survey was to question outpatients how well are they informed about procedure of 24-hour urine specimen collection.Materials and methods:The survey with 10 questions was done in outpatient laboratory of University Department of Chemistry, Medical School University Hospital Sestre Milosrdnice, Zagreb, Croatia. The study included 59 patients with collected 24-hour urine sample who have consented to participate in the survey.Results:Out of 59 participants, most of them (0.97) were older than 40 years. Internet was not recognized as a source of information (1/59). Almost one third of the patients have changed their drinking habits to collect more urine volume. Although most of the patients (0.60) were aware that the bottle of water is the best choice for the container, almost half of them were collected urine samples in the plastic soft drink bottle. Laboratory staff and physicians often have given information about proper collection procedure, but that information was insufficient.Conclusions:Patients are usually not aware of importance of proper preanalytical procedure for collecting urine specimen and how improper collection could affect results of requested tests. Education of outpatients, general practitioners and laboratory staff is needed in order to improve sample quality and trueness of results.

Self-Report of Alcohol Use Increases When Specimens for Alcohol Biomarkers Are Collected in Persons With HIV in Uganda

Self-Report of Alcohol Use Increases When Specimens for Alcohol Biomarkers Are Collected in Persons With HIV in Uganda

Clinical effects of improved urine specimen collection for female infants

Objective To explore the clinical effects of improved urine specimen collection for baby girl.Methods Totals of 82 female infant were recruited and used improved method and traditional method to collect urine,Put the asepsis tampon into the the opening of the collector when collected the urine specimen in improved method group,while the collector was directly used to collected the urine specimen.Then,the average number of collector,total times of collectors polluted by ease nature,average time of specimen collection,and the assay in two groups were observed and compared.Results The average number of collectors,total times of collectors polluted by ease nature,average time of specimen collection of improved method group respectively were(2.43 ±0.18),(24.02 ±8.43)and (2.32 ±0.16) hours,and that of the traditional method group were ( 6.78 ± 0.87 ),(78.01 ± 11.32 ) and (6.69 ± 0.35 ) hours,and the differences were statistically significant ( t =44.84,34.65,103.53,respectively;P ＜ 0.01 ),while there was no difference in the lab tests such as pH,blood and epithelial cell counts and the specific gravity of urine(P ＞ 0.05),Conclusions Improved urine sample collection method for female infant can significantly improve the success rate of urine specimen collection,reduce the average number of collectors and the time and have no influence on the assay,which can be popularized in clinic. Key words: Urine specimen; Urine collector; Female infant; Assay result

Increased urinary excretion of nephrin, podocalyxin, and βig-h3 in women with preeclampsia

Emerging evidence has shown that podocyte injury and reduced specific podocyte protein expressions contribute to proteinuria in preeclampsia. We collected urine specimens from women with preeclampsia to study whether podocyte-specific protein shedding is associated with renal barrier dysfunction. Urine specimens from women with normal pregnancies and from pregnant women complicated by chronic hypertension were used for comparison. We determined soluble podocyte slit protein nephrin levels in the urine specimens. Podocalyxin, βig-h3, and VEGF concentrations were also measured. We found that nephrin and podocalyxin were barely detectable in the urine specimens from normal pregnant women and from women with chronic hypertension. In preeclampsia, urinary nephrin and podocalyxin concentrations were significantly increased and highly correlated to each other, r(2) = 0.595. Nephrin and podocalyxin were also correlated with urine protein concentrations. βig-h3 was detected in the urine specimens from women with preeclampsia, and it is highly correlated with nephrin and podocalyxin concentrations in preeclampsia. βig-h3 was undetectable in normal pregnancy and pregnancy complicated by chronic hypertension. Elevated VEGF levels were also found in women with preeclampsia compared with those of normal pregnancy and pregnancy complicated by chronic hypertension. These results provide strong evidence that podocyte protein shedding occurs in preeclampsia, and their levels are associated with proteinuria. The finding of urinary βig-h3 excretion in preeclampsia suggests that increased transforming growth factor activity might also be involved in the kidney lesion in this pregnancy disorder.

Using Bedtime (pm) and early Morning (am) urine cortisol/creatinine ratios to evaluate pituitary-adrenal function in an office practice

To evaluate the use of cortisol/creatinine ratios in urine specimens collected at bedtime (PM) and the following morning (AM) in a general endocrine practice as a means of assessing pituitary-adrenal function in normal volunteers, outpatients with symptoms but no clinical endocrine dysfunction, patients with Cushing syndrome, and patients with known hypopituitarism. Double-voided PM and AM urine samples were collected from 26 healthy control subjects and 131 outpatients who had complaints of fatigue and malaise, inability to lose weight, or nonspecific concerns about potential underlying problems with their metabolism. The findings on physical examination and laboratory studies were normal in each of these outpatients. Urine was assayed for free cortisol and creatinine and expressed as ng of cortisol/mg of creatinine. Eleven patients with documented Cushing syndrome also collected urine specimens, and data for 11 patients with known hypopituitarism were also studied. A clear diurnal pattern of low cortisol excretion at night that increased some 7-fold in the morning (P<.0001) was reproducibly identified in healthy control subjects and those outpatients with no clinical endocrine disease. In the healthy control subjects, the mean PM urine cortisol/creatinine ratio was 15.8 (95% confidence interval [CI], 12.5 to 19.0); the mean AM cortisol/creatinine was 91.5 (95% CI, 65.0 to 118.0). The mean AM/PM ratio was 6.9, and the mean difference in AM-PM was 75.7. In the outpatients, there was no significant difference in PM, AM, AM/PM, and AM-PM values in comparison with those in healthy control subjects, and no significant difference was noted in these variables among the 3 groups of outpatients (those with fatigue, weight gain, and metabolism concerns). In 11 patients with Cushing syndrome, the mean PM urine cortisol/creatinine ratio was 127.0 (95% CI, 87.0 to 166.0), and there was loss of diurnal variation with the AM/PM ratio of 1.16 (95% CI, 0.98 to 1.35). Patients with hypopituitarism had little to no increase in AM urine cortisol/creatinine in comparison with PM urine cortisol/creatinine. Determination of PM and AM urine cortisol/creatinine ratios offers a convenient method for assessing pituitary-adrenal function.