Second specimen testing in diabetes mellitus

Since hospitals practices vary in respect to the time for obtaining urine specimens to be tested for glycosuria, this study was done to determine if results differ in relation to voiding times. Based on the assumption that glucose spilled above the renal threshold collects and mixes in the bladder over a period of time causing a change in readings of glucose and acetone, the times for urine testing were set up to include routine collection times with a second specimen tested 30 minutes later (7:00 a.m., 11:00 a.m., 11:30 a.m., 5:00 p.m., 5:30 p.m., 9:00 p.m., and 9:30 p.m.). The sample consisted of 72 patients all receiving insulin injections at 7:30 a.m. each day with no food intake from 10:00 p.m. the preceding night until insulin injections were given the next morning. The five drop Clinitest method was used by six trained examiners to determine the glucose and acetone content of each voided specimen. Urinary volume was measured with each testing as an indirect index to voiding frequency. The results of an analysis of variance indicated significant differences between voiding times of both acetone and glucose concentrations. A Duncan Multiple Range of Means Test indicated the first voiding of the day to be significantly different than subsequent voiding in sugar and acetone. These results tended to support the theory of cumulation of spilled glucose and acetone in the bladder requiring emptying prior to urine collection for glycosuria and acetonuria.

SECOND SPECIMEN TESTING IN DIABETES MELLITUS by Leslie Lorraine Feinauer A thesis submitted to the faculty of the University of Utah in partial fulfillment of the requirements for the degree of Master of Science Department of Nursing University of Utah June, 1969 This Thesis for the Master of Science Degree by Leslie Lorraine Feinauer has been approved May, 1969 Chairman, Supervii'ory Committee Supervisory Head, 'Major Departmen Sean, Grad ate School y tJ ACKNOWLEDGMENTS The author wishes to acknowledge the assistance of Dr. Royal M. Murdock, Dr. Maxine Cope and the personnel of the Latter-day Saints Hospital in the completion and presentation of this thesis. iii TABLE OF CONTENTS Page iii ACKNOWLEDGMENTS. LIST OF TABLES v LIST OF FIGURE vi vii ABSTRACT CHAPTER I. II. III. IV. INTRODUCTION 1 METHOD • • 7 RESULTS. 9 • • • • DISCUSSION • • 15 REFERENCES 18 APPENDIXES 19 APPENDIX A. FIVE DROP CLI!-JlrrSST PROCEDURE 20 APPENDIX B. ACETEST PROCEDURE 21 VITA . 22 • • iv LIST OF TABLES Page TABLE I. II. III. IV. SUMMARY OF ANALYSIS OF VARIANCE OF GLUCOSE CONCENTRATIONS . . . 10 SUMMARY OF ANALYSIS OF VARIANCE OF ACETONE CONCENTRATIONS . . . . 11 SUMMARY OF DUNCAN MULTIPLE RANGE TEST OF MEANS FOR GLUCOSE CONCENTRATIONS. . . . . . . . . . 12 SUMMARY OF DUNCAN MULTIPLE RANGE TEST OF MEANS FOR ACETONE CONCENTRATIONS . . . . . . . . . . 13 v LIST OF FIGURES Page FIGURE 1. SEQUENCE OF EVENTS PRODUCING GLYCOSURIA. . . . . . • . • . vi 5 ABSTRACT Since hospitals practices vary in respect to the time for obtaining urine specimens to be tested for glycosuria, this study was done to determine if results differ in relation to voiding times. Based on the assumption that glucose spilled above the renal threshold collects and mixes in the bladder over a period of time causing a change in readings of glucose and acetone, the times for urine testing were set up to include routine collection times with a second specimen tested 30 minutes later (7:00 a.m., 7:30 a.m., 11:00 a.m., 11:30 a.m., 5:00 p.m., 5:30 p.m., 9:00 p.m., and 9:30 p.m.). The sample consisted of 72 adult patients all receiving insulin injections at 7:30 a.m. each day with no food intake from 10:00 p.m. the preceding night until insulin injections were given the next morning. The five drop Clinitest method was used by six trained examiners to determine the glucose and acetone content of each voided specimen. Urinary volume was measured with each test- ing as an indirect index to voiding frequency. The results of an analysis of variance indicated significant differences between voiding times of both acetone and vii glucose concentrations. A Duncan Multiple Range of Means Test indicated the first voiding of the day to be significantly different than subsequent voidings in sugar and acetone. These results tended to support the theory of cumulation of spilled glucose and acetone in the bladder requiring emptying prior to urine collection for glycosuria and acetonuria. viii CHAPTER I INTRODUCTION Nursing procedures often seem to be handed down from century to century and are carried out without question or empirical study. In some hospitals it is routine procedure to collect and discard one urine specimen prior to collecting the sample to be tested 30 minutes later. In Salt Lake City, Utah, the Latter-day Saints Hospital followed this process. In other hospitals in the same area only one sample was obtained and tested unless the two step procedure was specifically requested by the attending physician. Since urine testing by ward personnel using some type indicator was the method by which insulin dosages were calculated and administered according to a sliding scale based on the test results, the measurements needed to be as reliable as possible. The purpose of this study was to determine the reliability of differences between the tests over time. Diabetes mellitus is an endocrine or pancreatic disorder found when cells within the Islets of Langerhans are unable to produce sufficient amounts of insulin to meet body needs. Normally, the insulin produced causes activation of glucokinase, a hepatic enzyme which stimulates glycogen deposition 2 in the liver (Bard, 1967; Best, 1966; Ellenberg, 1962; Moore, 1966). Insulin also has an inhibi effect on glucose-6- phosphatase, the hepatic enzyme responsible for the augmentation of glucose across the cell membrane for cellular use after it is broken down and secreted by the liver (Guyton, 1966, Chapter 75; Moore, 1966, Chapter 33; Best and Taylor, 1966, Chapter 67). vJhen there is an insufficient supply of insulin, the glucokinase is inhibited so that glucose is not deposited in the liver and glucose-6-phosphate is over activated causing an abnormally high amount of glucose to be excreted from the liver (Bard, 1967; Best and Taylor, 1966, Chapter 67; Ellenberg and fkin, 1962; Guyton, 1966, Chapter 75; Moore, 1966, Chapter 67). Due to the limited ability of glucose to cross the cell membranes without the aid utilization. insulin, there is a decrease in The oxidation of glucose is decreased. In order for the glucose to enter the cells, the concentration of glucose in the extracellular fluid must be elevated. Normally blood glucose levels range from 70-120 mg. percent. vJhen the degree of hyperglycemia reaches a level of 120-180 mg. percent, the amount of glucose filtered at the renal glomerulus exceeds the maximum capacity of the tubules for glucose reabsorption and glycosuria results. Glycosuria occurs when the blood glucose is elevated because of the relative insulin de ciency. The blood glucose level at any 3 given time is determined by the balance between the incoming amount and the utilized or leaving amount of glucose from the bloodstream (Guyton, 1966, Chapter 75; Moore, 1966, Chapter 33) . The excessive filtered amount of glucose acts as a diuretic by osmosis and thus there is an increased volume of urine produced. Large amounts of sodium and chloride ions are also lost due to this increased urine flow (Bard, 1967; Best and Taylor, 1966, Chapter 67; Ellenberq and Rifkin, 1962; Guyton, 1966, Chapter 75; Malins, 1968, Chapter 2; Marble, 1962, pp. 60-100; Moore, 1966, Chapter 33). The inhibition of carbohydrate metabolism as discussed may well have bearing on the resultant decrease in lipogenesis rates seen in diabetes mellitus. The by-products of carbohy- drate metabolism are necessary for the lipogenesis to take place. This decrease is about five percent of normal. It is also postulated by Moore (1966), that enzymatic inhibition is the cause of decreased carbohydrate end products. Because of the inhibition of the carbohydrate utilization, most of the energy source for the body must come from the adipose tissue fat. In this state, Ilpolysis is increased to such an extent that acetylcoenzyme A is produced in excess of the amount which can be handled by the citric acid cycle and can be oxidized by the extra hepatic tissue. This excess is channeled at an increasing rate to ketone bodies 4 (beta-hydroxybutric acid and acetone) production. When this rate of production exceeds the capacity of extrahepatic cells to oxidize them, ketonemia and ketouria result (Bard, 1967; Best and Taylor, 1966, Chapter 67; Ellenberg and Rifkin, 1962; Guyton, 1966, Chapter 75; Malins, 1968, Chapter 3; Marble, 1962, p. 100; Moore, 1966, Chapter 33). The sequence of events in diabetes taken from Marble (1962, p. 68) are shown in Figure 1. Smith and Gips (1967) have stated that the bladder must be emptied one-half hour prior to collection men for sugar and acetone testing. urine speci- This procedure is based upon the theory that collection of urine over a period of time in the bladder will cause a different indication of glucose spilled than does a "fresh" sample due to mixing and/or dilution of the urine. In other literature consulted, there was no mention of emptying of the bladder prior to specimen collection (Blake, 1963; Fuerst, 1964; Krug, 1966; Matheney, 1964; Shafer, 1967). No studies of this problem have been found in Index Medicus, 1960 through May, 1969, Index to Diabetic Literature 1950 through May,1969, International Index to Nursing 1956 through May, 1969, and Nursing Studies Index 1956 through May, 1969. It would appear that empirical research has not been published on second voiding specimens in diabetic patients. 5 Decreased Concentration of Effective ~-=__==~~~~~Insul L Decreased glucose entry into adipose tissue Release of amino acids from peripheral depots Increased cJncentration of free fatty acids in adipose tissue HYPERGLYCEMIA of free Increased amino acids acids in serum 1 GLYCOSURIA Increased utilization of free fatty acids by tissues including the liver l Increased utilization of amino acids by the liver "'-= ~ Increased gluconeogenesis ~ Figure 1 Sequence of Events Producing Glycosuria (Marble, 1962) 6 If there were no significant difference in sugar and acetone between the first voided specimen and the second and subsequent specimens, the added procedure should be discarded. The purpose of this study was to determine if there were reliable differences in the glycosuria and acetonuria found between the first and subsequent collections of urine in testing diabetic patients receiving insulin. CHAPTER II METHOD All patients admitted to one of two 30 bed medical units at the Latter-day Saints Hospital in Salt Lake City, Utah, with a diagnosis of diabetes mellitus were used as subjects for this study. Each patient was given insulin injections at 7:30 a.m. following urine testing. From 10:00 p.m. the pre- ceding evening until they received insulin injections in the morning, the patients were not given food substance of any kind. An average of five to six admissions per week met the criteria for inclusion within the study. Although 107 patients constituted the original sample, 35 were dropped due to inability of the patient to void spontaneously at the testing intervals; need for catheterization; difficulty with time of morning insulin injection; or intake of food stuffs after 10:00 p.m. the preceding evening. Seventy-two patients allover 16 years of age constituted the final sample. A team of three registered nurses and three practical nurses were trained to conduct the urine tests using the five drop Clinitest method for glucose and acetest for acetone. The exact steps of these testing procedures are outlined in the Appendixes A and B. The urinary test results were re- corded using the routine scoring procedure. The clinical 8 scores on Clinitest were converted to numerical values. A negative score was given a value of 0; trace a value of 1; 1+ a value of 2; and so on until 4+ was given a value of 5. The acetest was scored similarly giving negative a value of 0; trace a value of 1; small a value of 2; moderate a value of 3 and large a value of 4. In order to check reliability of the testing personnel, the six team merrlbers involved in the study were each given two urine specimens of unknown concentrations obtained from two patients selected at random. Both specimens were the same for each individual in the group. They reported their findings individually with 100 percent agreement among group members and examiner. Laboratory analysis also resulted in complete agreement with the tester's and examiner's findings. During the investigation each patient's urine specimens were collected and tested at 7:00 a.m., 7:30 a.m., 11:00 a.m., 11:30 a.m., 5:00 p.m., 5:30 p.m., 9:00 p.m. and 9:30 p.m .. In addition to acetone and glucose, the urinary volume was measured as an indirect indication or measure of voiding frequency. The urine specimens were collected using a clean receptacle for each voiding--paper cups were used or cleaned urinals and bedpans when necessary. CHAPTER III RESULTS In order to ascertain the differences between voidings as to glucose and acetone concentrations, two 7 x 71 analyses of variance containing Time and Ss were used. Table I represents the glucose concentrations found in each specimen as it relates to the voiding times. As is shown there was significant source of variance in the glucose over time. Similar information is recorded in Table II with acetone rather than glucose concentrations shown. cant variance Again a signifi- acetone is seen over time. In order to determine more precisely the areas of difference in glucose results, a Duncan Multiple Range Test, shown in Table III was calculated. The mean glucose concen- tration at 7:00 a.m. was significantly different from all other concentrations except the sample taken at 11:00 a.m .. The concentration at 7:30 a.m. was significantly different from the samples obtained at 5:00 p.m., 9:00 p.m. and 9:30 p.m .. The 11:00 a.m. and 11:30 a.m. samples were signifi- cantly different from the 9:00 p.m. and 9:30 p.m. samples. The 5:00 p.m. sample was different than the 9:30 p.m. sample to a significant degree. Table IV summarizes the results of a Duncan Multiple 10 TABLE I SUMMARY OF ANALYSIS OF VARIANCE OF GLUCOSE CONCENTRATIONS Source Degrees of Freedom Sum Squares Within 7 Time (T) 7 39.36 568 1313.29 71 941.36 S8 x T 497 371.93 Total 575 1352.98 Between S8 *p< .001 Mean Square F 5.67 7.58* 13.26 .748 11 TABLE II SUMMARY OF ANALYSIS OF VARIANCE OF ACETONE CONCENTRATIONS Source Degrees of Freedom Sum Squares Mean Square .417 Within 7 Time (T) 7 2.92 568 336.39 71 249.96 3.520 Ss x T 497 86.43 .174 Total 575 339.31 Between Ss *p<.05 F 2.40* 12 TABLE III SUMMARY OF DUNCAN MULTIPLE RANGE TEST OF MEANS FOR GLUCOSE CONCENTRATIONS Time 7:00 (1) 11:00 (3) Means 1.31 1.07 (1) (3) (2) (4 ) (5 ) (6) (7) (8 ) *p<.05 .24 7:30 (2 ) 11:30 (4) 5:00 (5) 5:30 (6) 9:00 (7) 9:30 (8 ) .91 .90 .80 .74 .55 .42 .40* .41* .51* .57* .76* . 89 * .16 .17 .27 .33* .52* .56* .01 .11 .17 .36* .49* .10 .16 .35* .48* .06 .25 .38* .19 .32 .13 13 TABLE IV SUMMARY OF DUNCAN MULTIPLE RANGE TEST OF MEANS FOR ACETONE CONCENTRATIONS Time 7:00 (1) 7:30 (2 ) 11:00 (3 ) 5:00 (5) 11:30 (4 ) 5:30 (6 ) 9:00 (7 ) Means .333 .306 .264 .208 .167 .153 .153 .033 .069 .125 .166* .180* .180* .194* .042 .098 .139 .153 .153 .167* .056 .097 .111 .111 .125 .041 .055 .055 .069 .014 .014 .028 .000 .014 (1) (2 ) (3) (5 ) (4 ) (6) (7 ) (8 ) *p<.05 9:30 (8 ) .139 .014 14 Range Test to determine areas of acetone significance. The mean acetone concentration at 7:00 a.m. was significantly different from concentrations at 11:30 a.m., 5:30 p.m., 9:00 p.m. and 9:30 p.m .. The 7:30 a.m. concentration was significant from the 9:30 p.m. sample. A correlation between the amount of urine voided and the concentration of glucose using the Pearson Product Moment Correlation was .28 which was significant at the .02 level. CHAPTER IV DISCUSSION The purpose of the present study was to determine, in a general hospital using routine methods and experienced personnel, if there were differences in concentrations of sugar and acetone at the first voiding of the day and one 30 minutes later and subsequent voidings. This study was based on the assumption that the renal threshold selectively discards glucose and acetone when the concentration of these are beyond the serum capacity. Thus, unless emptied shortly before testing its contents, the bladder acts as a store for all glucose and acetone spilled from time of last voiding. As has been shown, the significant difference between the first and second specimen in glucose testing controlling the other variables which could interfere (insulin, food, etc.) indicated variance in voiding results. This tended to indicate the unreliability of specimens voided after a period of urine retention. On the basis of tubular physiology, it also tended to support the second specimen theory as a more reliable index of serum glucose. The specimens collected after 7:30 a.m. were uncontrolled as to frequency of voiding, eating and insulin injections. 16 These constitute too many variables to indicate further specific evidence to support the second specimen theory; however, it is interesting to note that there was a significant variance in glucose among voiding periods for all times. Acetone means using a Duncan Multiple range were found to be significant among various voidings but not in relation to first and second voided specimens. This may have been due to the decreased frequency of positive test results. The correlation between concentration of glucose and urine volume indicated definite evidence of diuresis due to increased concentration of glucose in urine. In conclusion, the present study indicated variability of test results in sugar and acetone according to time of voiding. The most meaningful implication being the necessity of emptying the bladder prior to testing urine for glucose and acetone after storage in the bladder over a period of time. Recommendations reached as a result of this study are listed below: 1. Further studies should be done using serum glucose examinations concomitantly with voided specimens to determine the glucose level of the blood at voiding times. 2. Hospitals should evaluate their urine testing pro- cedure. Since the simple procedure for sugar and acetone testing is used as an index for therapy, it is hoped that this 17 study has stimulated some thought as to the mode for more accurately determining these measurements. REFERENCES Bard, P. Medical physiology. St. Louis: C. V. Mosby, 1967. Best, C. H. and Taylor, N. B. The physiological basis of medical practice. Baltimore: Williams and Wilkins, 1966. Blake, Florence G. and Wright, F. H. Pediatric nursing. Philadelphia: J. B. Lippincott, 1963. Ellenberg, M. and Rifkin, A. (Eds.) Clinical diabetes mellitus. New York: McGraw-Hill, 1962. Fuerst, Elinor V. and Wolff, LaVerne. Fundamentals of nursing. Philadelphia: J. B. Lippincott, 1964. Guyton, A. C. Textbook of medical physiology. Saunders, 1966. Krug, Elsie. Pharmacology in nursing. Mosby, 1966. Malins, J. Clinical diabe~es mellitus. Spottiswoods, 1968. Philadelphia: St. Louis: C. V. London: Eyre and Marble, A. and Cahill, G. F. The chemistry and chemotherapy of diabetes mellitus. Springfield, Ill.: Charles Thomas, 1962. Matheney, Ruth V. Fundamentals of patient centered nursing. St. Louis: C. V. Mosby, 1964. Moore, W. W. Endocrine. In E. E. Selkurt (Ed.) Physiology. Boston: Little, Brown, 1966. Shafer, Kathleen. Medical-surgical nursing. V. Mosby, 1967. St. Louis: C. Smith, Dorothy W. and Gips, Claudia D. Care of the adult patient. Philadelphia: J. B. Lippincott, 1963. APPENDIXES APPENDIX A FIVE DROP CLINITEST PROCEDURE The clinitest tablet contains anhydrous copper sulphate, anhydrous sodium hydroxide, citric acid and sodium bicarbonate. When this tablet is added to a mixture of five drops of urine and ten drops of water, in a test tube, the solution boils due to the heat generated from the chemical reaction. Fifteen seconds after boiling has ceased, the tube is shaken and compared with the color scale provided by the manufacturers to determine the glucose content. (Malins, 1968, p. 399). APPENDIX B ACETEST PROCEDURE One drop of urine is placed upon one acetest tablet. After five seconds the color of the tablet is compared with the color scale provided by the manufacturers to determine the acetone content of the urine. (Malins, 1968, p. 399).