Influencing medical student choice of primary care worldwide: international application of the four pillars for primary care physician workforce

Primary care is a crucial part of a functional health care system, though in many parts of the world there are current or projected gaps in the primary care physician workforce. The academic family medicine organizations in the United States (US) developed the “Four Pillars for Primary Care Physician Workforce,” a model built on decades of research, highlighting four main areas of emphasis for increasing primary care physician output: 1) pipeline; 2) process of medical education; 3) practice transformation; and 4) payment reform. This commentary proposes that this model, although developed in the US context, is applicable in other medical education settings, including Israel, based on the recently reported findings of Weissman and colleagues in this journal.     

Molecular Motion in Viscous DGEBA with Nanoparticles as Seen by Quasi‐Elastic Neutron Scattering

Pure and filled epoxies are widely used in industry. Nanocomposites especially are affected by interphase regions where properties deviate from bulk. The study of molecular mobility in epoxy monomers is a first step to understanding the molecular dynamics in nanocomposites and their effect on crosslinking in epoxy networks. Here, quasi‐elastic neutron scattering is used to disentangle the molecular motions of monomeric diglycidylether of Bisphenol A (DGEBA) and a suspension of zeolite nanoparticles in DGEBA on a timescale from 2 ps to 5.5 ns. Regarding molecular transport of DGEBA inside the suspension, the particles have no impact on the faster rotational motions. A combination of neutron time‐of‐flight and backscattering spectroscopy reveals a pronounced hindrance of DGEBA molecular dynamics on/in the zeolite particles along with a new type of molecular motion occurring on intermediate timescales. That localized motion is attributed to jump diffusion motions, emanating from interphase effects at the zeolite particles.     

Clonal identity of Candida albicans in the oral cavity and the gastrointestinal tract of pre‐school children

The clonal relationship between oral and fecal Candida albicans isolated from children of pre‐school age was examined using RAPD analysis. Significantly higher levels of C. albicans were found in saliva, dental plaque, carious specimens and stools of 56 patients with severe caries as compared to 52 healthy control subjects. The highest prevalence was found in carious specimens and a strong correlation was observed between its presence in saliva, dental plaque, carious specimen and feces. RAPD analysis of isolates from 23 patients with simultaneous oral and fecal C. albicans revealed clonal counterparts present in both oral and stool samples in 15 cases; five patients harbored closely related strains; and three patients harbored unrelated strains. Our results demonstrate a strong correlation between oral and gastrointestinal C. albicans colonization. We assume that carious teeth may constitute an ecologic niche for C. albicans potentially responsible for recurrent oral and non‐oral candidiasis.     

Endothelin 1 activates and sensitizes human C-nociceptors

Microneurography was used to record action potentials from afferent C-fibers in cutaneous fascicles of the peroneal nerve in healthy volunteers. Afferent fibers were classified according to their mechanical responsiveness to von Frey stimulation (75g) into mechano-responsive and mechano-insensitive nociceptors. Various concentrations of Endothelin1 (ET1) and Histamine were injected into the receptive fields of C-fibers. Activation and heat sensitization were monitored. Axon reflex flare and psychophysical ratings were assessed after injection of ET1 and codeine into the forearms after pre-treatment with an H1 blocker or sodium chloride. 65% of mechanosensitive nociceptors were activated by ET1. One-third showed long lasting responses (>15min). In contrast, none of thirteen mechano-insensitive fibers were activated. Sensitization to heat was observed in 62% of mechanosensitive and in 46% of mechano-insensitive fibers. Injection of ET1 produced a widespread axon reflex flare, which was suppressed by pre-treatment with an H1 receptor blocker. In addition, pain sensations were induced more often than itching by ET1 in contrast to codeine. No wheal was observed after injection of ET1. Both itching and pain were decreased after H1 blocker treatment. In summary: (1) In humans ET1 activates mechanosensitive, but not mechano-insensitive, nociceptors. (2) Histamine released from mast cells is not responsible for all effects of ET1 on C-nociceptors. (3) ET1 could have a differential role in pain compared to other chemical algogens which activate additionally or even predominantly mechano-insensitive fibers.     

Biopsie der Prostata und Punktion der Niere und Blase

Background

Biopsies of the kidney, prostate and urinary bladder are amongst the most frequent interventions in urology. A correct indication, preparation and performance are important to achieve good results and low complication rates.

Objectives

In this review complication management in biopsies of the kidney, prostate and urinary bladder are discussed.

Materials and methods

A selective search of the literature, with emphasis on systematic reviews and larger cohort studies was performed.

Results

Complication rates are generally low. However, certain factors such as coagulation disorders, anatomical malformations, accompanying morbidities or antibiotic resistance may play a significant role and increase rates of complications. Especially complications such as hematuria and injury of contiguous organs are described in the literature.

Discussion

Biopsies of the kidney, prostate and urinary bladder can be performed with low complication rates if general and specific factors in the planning of the intervention and prevention of complications are considered.     

Gonokokken- und Chlamydieninfektionen der Harnröhre

The German STI guidelines for gonococcal and chlamydial infections were recently updated. Representing the German Society of Urology (DGU) in these guidelines consensus processes, the authors summarize the recommendations regarding screening, appropriate laboratory diagnostics and dose-increased dual antimicrobial therapy of urethritis caused by Neisseria gonorrhoeae and Chlamydia trachomatis. Urologists need to be informed about an approaching era of untreatable gonorrhea. Although of limited use, whenever possible Neisseria gonorrhoeae cultures are required to monitor developing resistance to current treatment regimes. Recommendations for the use of nucleic acid amplification tests (NAATs) for detection of chlamydia and gonorrhea as the standard laboratory test remain. Because the majority of persons infected by Chlamydia trachomatis are not aware of the infection, untreated infection can lead to serious complications later on with the burden of disease and infertility sequelae considered to be a predominantly female problem. Principally, both partners should be treated simultaneously in order to prevent re-infection. Furthermore, therapy control is recommended for every gonorrhea.     

Validation of the German version of the ‘Hypogonadism Related Symptom Scale’ (HRS) in andrological patients with infertility,HIV infection and metabolic syndrome

As commonly used self‐reported screening instruments for male hypogonadism demonstrated lack of specificity, a Hypogonadism Related Symptom Scale (HRS) was developed in 2009 as a novel self‐rating screening tool. As the questionnaire has not been validated, the purpose of our study was to perform a validation in patients presenting with different disorders (e.g. infertility, HIV infection or metabolic syndrome) and disease‐related risk to develop hypogonadism. Two hundred and eighteen patients aged 19–71 years (40.1 ± 9.5) who completed the HRS and other common questionnaires [International Index Of Erectile Function (IIEF), National Institutes of Health Chronic Prostatitis Symptom Index (NIH‐CPSI), Hospital Anxiety and Depression Scale (HADS), short form (SF)‐12] were included. In all patients, blood levels of total testosterone, luteinizing hormone, follicle‐stimulating hormone, oestradiol and sex hormone‐binding globulin were determined and free testosterone was calculated. Cronbach's α for the scale was 0.896, split‐half 0.871 for the 1st half and 0.807 for the 2nd half. Spearman–Brown coefficient was 0.767, and Guttman split‐half coefficient was 0.759. Consistent correlations were found between HRS and IIEF5 (ρ = 0.57, P < 0.001), and HADS (ρ = ?0.6, P < 0.001). In addition, HRS was significantly correlated with total testosterone (ρ = 0.135, P < 0.05), free testosterone (ρ = 0.148, P < 0.05) and oestradiol (ρ = ?0.134, P < 0.05). Our validation study confirms the data from the initial development of the HRS questionnaire. Clinicians might have an additional advantage from the HRS when investigating males with suspected hypogonadism.     

The Integral Theory System Questionnaire: an anatomically directed questionnaire to determine pelvic floor dysfunctions in women

Purpose

Anatomical damage to pelvic floor structures may cause multiple symptoms. The Integral Theory System Questionnaire (ITSQ) is a holistic questionnaire that uses symptoms to help locate damage in specific connective tissue structures as a guide to reconstructive surgery. It is based on the integral theory, which states that pelvic floor symptoms and prolapse are both caused by lax suspensory ligaments. The aim of the present study was to psychometrically validate the ITSQ.

Materials and methods

Established psychometric properties including validity, reliability, and responsiveness were considered for evaluation. Criterion validity was assessed in a cohort of 110 women with pelvic floor dysfunctions by analyzing the correlation of questionnaire responses with objective clinical data. Test–retest was performed with questionnaires from 47 patients. Cronbach’s alpha and “split-half” reliability coefficients were calculated for inner consistency analysis.

Results

Psychometric properties of ITSQ were comparable to the ones of previously validated Pelvic Floor Questionnaires. Face validity and content validity were approved by an expert group of the International Collaboration of Pelvic Floor surgeons. Convergent validity assessed using Bayesian method was at least as accurate as the expert assessment of anatomical defects. Objective data measurement in patients demonstrated significant correlations with ITSQ domains fulfilling criterion validity. Internal consistency values ranked from 0.85 to 0.89 in different scenarios.

Conclusions

The ITSQ proofed accurate and is able to serve as a holistic Pelvic Floor Questionnaire directing symptoms to site-specific pelvic floor reconstructive surgery.