[The "right" patient for implant surgery in urology : Why patient selection, informed consent, and communication are so important for patient satisfaction]. / Der "richtige" Patient für die Implantatchirurgie in der Urologie : Warum Patientenselektion, Aufklärung und Patientenkommunikation so wichtig für die Patientenzufriedenheit sind.

In implant surgery for erectile dysfunction and urinary incontinence, adequate patient selection is essential for postoperative therapy success. Several scientific studies report patient satisfaction rates for penile implants and artificial urinary sphincter implantation of over 90%. Nevertheless, studies also report, that between 5 and 30% of the patients are not satisfied with the result of their operation. Sufficient patient information and consent prior surgical procedure in urological prosthetics are a key determinant for later patient satisfaction and therapy success. Diligent assessment of realistic expectations, possible complications, and risks must be made. Unrealistic and exaggerated expectations need to be met and discussed with the patient. Therefore adequate physician-patient communication is essential. Especially in the case of surgical revision or for patients with risk factors, the probability of complications is higher and may significantly increase later dissatisfaction. Also, the involvement of the partner plays a major role in later patient satisfaction in urological implant surgery. Finally, there is a group of patients for which the risk of later dissatisfaction is particularly high. These are patients with compulsive/obsessive behavior, unrealistic expectations, patients after revision surgery, self-entitled patients, as well as those patients who deny the extent of their illness, visit multiple surgeons (surgeon hopping) or have psychiatric illnesses. These patients are referred to with the acronym "CURSED" patients.

Mixed reality for teaching catheter placement to medical students: a randomized single-blinded, prospective trial.

BACKGROUND: Cost-effective methods to facilitate practical medical education are in high demand and the "mixed-reality" (MR) technology seems suitable to provide students with instructions when learning a new practical task. To evaluate a step-by-step mixed reality (MR) guidance system for instructing a practical medical procedure, we conducted a randomized, single-blinded prospective trial on medical students learning bladder catheter placement. METHODS: We enrolled 164 medical students. Students were randomized into 2 groups and received instructions on how to perform bladder catheter placement on a male catheterization training model. One group (107 students) were given their instructions by an instructor, while the other group (57 students) were instructed via an MR guidance system using a Microsoft HoloLens. Both groups did hands on training. A standardized questionnaire covering previous knowledge, interest in modern technologies and a self-evaluation was filled out. In addition, students were asked to evaluate the system's usability. We assessed both groups's learning outcome via a standardized OSCE (objective structured clinical examination). RESULTS: Our evaluation of the learning outcome revealed an average point value of 19.96 ± 2,42 for the control group and 21.49 ± 2.27 for the MR group - the MR group's result was significantly better (p = 0.00). The self-evaluations revealed no difference between groups, however, the control group gave higher ratings when evaluating the quality of instructions. The MR system's assessment showed less usability, with a cumulative SUS (system usability scale) score of 56.6 (lower half) as well as a cumulative score of 24.2 ± 7.3 (n = 52) out of 100 in the NASA task load index. CONCLUSIONS: MR is a promising tool for instructing practical skills, and has the potential to enable superior learning outcomes. Advances in MR technology are necessary to improve the usability of current systems. TRIAL REGISTRATION: German Clinical Trial Register ID: DRKS00013186.

[Treatment mapping of lower urinary tract symptoms due to benign prostatic hyperplasia-an analysis of the Governing Body of German Prostate Centers]. / Versorgungsabbild des benignen Prostatasyndroms ­ eine Analyse des Dachverbandes der Prostatazentren Deutschlands (DVPZ) e. V.

BACKGROUND: Due to the high incidence and demographic development, there is an urgent need for healthcare research data on lower urinary tract symptoms due to benign prostatic hyperplasia (LTUS/BPH). Since 2005 the Governing Body of German Prostate Centers (DVPZ) has been collecting data from 22 prostate centers in order to determine the quality and type of cross-sectoral care in particular for LUTS/BPH patients. OBJECTIVES: Presentation of the DVPZ database in general, as well as an investigation of treatment patterns for medical and instrumental therapies. MATERIALS AND METHODS: The analysis is based on UroCloud data sets from 30 November 2017. In the UroCloud data on diagnostics, therapy and course of disease are recorded in a web-based manner. RESULTS: A total of 29,555 therapies were documented for 18,299 patients (1.6/patient), divided into 48.5% instrumental, 29.2% medical treatment, and 18.0% "wait and see" (in 4.3% no assignment was possible). Patients treated with an instrumental therapy were oldest (median: 72 years, interquartile range: 66-77), had the largest prostate volumes (50 ml, 35-75 ml), and were mostly bothered by symptoms (International Prostate Symptom Score = 19/4). The majority of patients under medical treatment received alphablockers (56%); phytotherapeutics were used least frequently (3%). Instrumental therapies are dominated by transurethral resection (TUR) of the prostate (60.0%), open prostatectomy (9.4%) and laser therapy (5.0%), with laser therapy having the shortest hospital stay (5 days) and the lowest transfusion and re-intervention rates (1.0% and 4.6%, respectively). CONCLUSIONS: The DVPZ certificate covers the complete spectrum of cross-sectoral care for LUTS/BPH patients and documents the use of the various therapies as well as their application and effectiveness in the daily routine setting.

[Barriers to guideline adherence : Identification of barriers to guideline adherence using a survey on the AWMF S3 guideline epidemiology, diagnosis, treatment, and management of uncomplicated bacterial, community-acquired urinary tract infections in adult patients]. / Barrieren der Leitlinienadhärenz : Identifizierung von Barrieren der Leitlinienadhärenz am Beispiel einer Umfrage zur AWMF-S3-Leitlinie Epidemiologie, Diagnostik, Therapie und Management unkomplizierter bakterieller ambulant erworbener Harnwegsinfektionen bei erwachsenen Patienten.

BACKGROUND: Several studies have shown that nonadherence to guidelines is pretty common in the treatment of urinary tract infections (UTI). However, no urological study has raised the question, what are barriers or reasons for this nonadherence, yet. OBJECTIVES: Consequently, we performed a survey among German urologists with the primary endpoint identification of barriers for nonadherence to German guidelines on UTI. MATERIALS AND METHODS: A 19-item questionnaire was developed and transferred to the online portal "Survey Monkey®" (Private Equity, San Mateo, CA, USA) and tested for usability by our study group. The link for the survey was sent twice to the members of the German Society of Urology (DGU). RESULTS: Overall, 307 questionnaires were completed. The mean age of the study population was 46.7 years (standard deviation 11.5). The majority (34.9%) followed guidelines in 80% of the cases. Main reasons for nonadherence on the physicians' side were 23.4% personal experience and lacking practicality of UTI guidelines on the individual complex patient. On the open questions urologists mostly stated (11.7%) that the main reason on the physician side for nonadherence is ignorance. Therefore they, in open questions, suggest to promote guidelines more in meetings and more designed practically with shortcuts and simple layout. Patient-associated factors mentioned were mostly in 26.7%. Furthermore, German urologists stated that guidelines should also have a patient section, where the main recommendations are explained in plain language. CONCLUSION: We performed the first survey on identifying barriers for nonadherence to guidelines in urology. Despite some limitations, our results are very important for the further design of guidelines. This has the potential to improve guideline adherence.

[Nationwide survey among institutes of microbiology in academic medicine : Is the interdisciplinary approach the right way to treat patients with urogenital infections?] / Infektiologisch interessierte Urologen werden gebraucht : Nationale Umfrage universitärer Mikrobiologien zur interdisziplinären Zusammenarbeit von Urologie und Mikrobiologie.

BACKGROUND: Increasing antibiotic resistance is a current and severe problem in medicine, especially in urology. Multidisciplinary antibiotic stewardship programmes are an important approach to counteract increasing resistance rates. This approach includes collaboration between urologists and microbiologists. OBJECTIVES: The primary endpoint was to describe the current setting of interdisciplinary work of urologists and microbiologists in university hospitals in Germany. The secondary endpoints were the identification of problems of this interdisciplinary approach in daily routine and implications for the future in patient treatment. MATERIALS AND METHODS: A newly developed, 24-item questionnaire was sent to 34 German microbiology departments at medical universities between June and October 2016; the departments were contacted up to four times. Only complete questionnaires were included in our analysis. RESULTS: The response rate was 50.0%. In the majority of the urological cases a microbiologist was only contacted sporadically and asked for advice, but on the other hand most of the microbiologists think that this contact and discussion about the patient is reasonable and preferable. Of the respondents, 82.4% think that with a consequent interdisciplinary approach there might be lower antibiotic resistance rates in the future. One essential problem of ideal microbial diagnostics and therapeutic advice is that the microbiologist does not receive all relevant information upon request. This might be the case in up to 76.5%. Other problems are of economic nature or shortage of manpower. CONCLUSION: Interdisciplinary patient care between urologists and microbiologists is reasonable and preferable. This approach has the potential of decreasing antibiotic resistance rates in the future.

The treatment of chronic depression, part 3: psychosocial functioning before and after treatment with sertraline or imipramine.

BACKGROUND: Previous research has suggested that depressed patients, and particularly chronically depressed patients, have significant impairments in many areas of their lives. While previous studies suggested that these "psychosocial" impairments improve following pharmacologic treatment, no large scale definitive study using multiple measures of psychosocial functioning has been reported. METHOD: We assessed multiple domains of psychosocial functioning using interviewer-rated and self-report measures within the context of a 12-week acute treatment trial of sertraline and imipramine for patients with chronic depression (double depression and chronic major depression). We also compared the psychosocial functioning data of this sample before and after treatment with normative data available from published community samples. RESULTS: Chronically depressed patients manifested severe impairments in psychosocial functioning at baseline. After treatment with sertraline or imipramine, psychosocial functioning improved significantly. Significant improvements appeared relatively early in treatment (week 4). Despite these highly significant improvements in functioning during acute treatment, the study sample as a whole did not achieve levels of psychosocial functioning comparable to a comparator nondepressed community sample. However, patients who reached full symptomatic response (remission) during acute treatment did have levels of psychosocial functioning in most areas at endpoint that approached or equaled those of community samples. CONCLUSION: These results indicate that successful antidepressant treatment with sertraline or imipramine can alleviate the severe psychosocial impairments found in chronic depression.

Ultrasound detection of foreign bodies and procedure guidance.

As emergency physicians become familiar with the use of ultrasonography, this safe procedure will likely become a standard technique having multiple uses in the emergency department. Ultrasonography assists in foreign body localization and retrieval and is potentially important in applications, such as reliable endotracheal tube placement, visualization of ingested medication, vascular access, and drainage of collected fluids.

Safety of imaging exploding bullets with ultrasound.

STUDY OBJECTIVE: To evaluate the safety of using ultrasound to image exploding bullets that have not detonated. METHODS: We evaluated various types of exploding bullets using ultrasonography at various depths with various transducers and using standard radiography. RESULTS: None of the unexploded bullets subjected to ultrasonography or standard radiography exploded. CONCLUSION: Our results suggest that evaluation of exploding bullets with ultrasonography is safe.

Validation of red cell sodium-lithium countertransport measurement--influence of different loading conditions.

Increased sodium-lithium countertransport in erythrocytes from patients with long-standing type I (insulin-dependent) diabetes mellitus has been considered as an early marker of nephropathy. Since the activity and kinetics of the sodium-lithium countertransport may critically depend on loading conditions, this study was aimed at determining sodium-lithium countertransport activity, Michaelis constant Km and maximum velocity Vmax in erythrocytes loaded in two different Li+ solutions. Sodium-lithium countertransport activity was determined in erythrocytes in 8 healthy control subjects after loading with 150 mmol/l LiCl compared with those loaded with 150 mmol/l LiHCO3. Sodium-lithium countertransport activity was similar for both loading procedures, although the erythrocyte lithium content did significantly differ (mean +/- SEM, 7.0 +/- 0.5 for LiCl and 8.9 +/- 0.5 mmol/l of cells for 150 mmol/l LiHCO3). There were no significant changes in the Km and Vmax. Increase of osmolality in efflux media containing 200 and 250 mmol/l NaCl resulted in a negligible shrinking of the red blood cells, not exceeding 2.2%. The main advantage is the short loading time of 15 min for LiHCO3 compared with 3 hours for LiCl. Under these conditions saturating intracellular Li+ concentrations can be obtained much more rapidly than with LiCl loading, thereby minimising alterations of the cell membranes. LiHCO3 loading shortens the experimental time considerably and enables a greater number of samples to be screened from larger population cohorts.

Nuts and bolts issues to consider when selling your practice.

Ten issues are provided that will help physicians and administrators through the process of selling a practice. Those issues include determining the buyers reasons for buying, determine your reason for selling, finding the right people, how the buyer is valuing your practice, how you value your practice, preparing the selling package, employment agreements and compensation packages, negotiating the operating contract, tax consequences and knowing when to walk away from the deal.

Evolutionary perspectives on paranoid disorder.

Certain subtypes of DD may represent abnormal forms of previously well-characterized, content-specific behaviors that represent evolved adaptations to challenges of social interaction and mating. Such rare delusional states may be manifestations of an adaptive hypersensitivity to important environmental threats or opportunities, or may be a byproduct of behavioral misfiring triggered by unfamiliar environmental cues or perceptions.

Winter depression and functional impairment among ambulatory primary care patients.

This study of primary care patients sought to estimate the prevalence of and functional impairment associated with winter-seasonal depression. Three hundred three patients visiting a primary care clinic in January or February were assessed for seasonal patterns of health change, current DSM-III-R major depressive disorder (MDD), and current functional status. Approximately 9% of patients met criteria for MDD with winter-seasonal pattern, and an additional 29% reported seasonal mood changes without meeting criteria for current MDD. Multivariate analysis revealed that the functional impairment associated with such winter seasonality exceeded that associated with any of the common chronic medical conditions measured, and that such dysfunction was evident even in the absence of a diagnosable depressive disorder (MDD). Winter-seasonal pain was reported by one quarter of the overall sample and by half of those with current MDD, supporting preliminary reports that pain may be a common presenting symptom in seasonal affective disorder. The findings suggest that efforts at detection and treatment of such syndromes in primary care settings would be justified.

Gender differences in presentation of chronic major depression.

The authors examine gender differences in presentation of illness in 96 males and 198 females with DSM-III-R chronic major depression (i.e., major depression of at least 2 years' duration). Women were found to have increased severity of illness as measured by Hamilton Rating Scale for Depression (HAM-D), Beck Depression Inventory (BDI), and Clinical Global impressions (CGI) scores. Symptom comparisons revealed that women experience more psychomotor retardation than men. Women reported increased functional impairment on the Social Adjustment Scale-Self-Report (SAS-SR), particularly in the areas of marital and family adjustment. Men were more likely to have a history of alcohol and substance abuse/dependence. These findings represent the first systematic study of gender differences in a chronic depressive population.

Early-morning administration of short-acting beta blockers for treatment of winter depression.

Propranolol, 60 mg or less, was administered daily between 5:30 and 6:00 a.m. to 33 patients with winter depression. After open treatment with a mean dose of 33 mg/day, 24 patients (73%) met the remission criteria; 23 completed double-blind continuation or placebo substitution. Subjects who continued to receive propranolol had a mean increase in Hamilton depression score of 3.5, whereas patients switched to placebo had an increase of 11.2; the difference was statistically significant. These findings are consistent with the hypothesis that duration of nocturnal melatonin secretion is the critical seasonal time cue in humans.

A prospective study of ultrasonography in the ED by emergency physicians.

The objective of this study was to examine the use of limited, goal-directed, two-dimensional ultrasound studies performed by emergency physicians and to assess the frequency, variety, and accuracy of their readings. A 1-year prospective study was performed by using an emergency department (ED) ultrasound machine with a 3.5-mHz mechanical oscillating sector transducer and a 5.0-mHz vaginal transducer. In a series of proctoring sessions, radiologists trained emergency physicians to do limited, goal-directed ultrasonography. Laser print ultrasonograms were collected from all ED ultrasound examinations performed during a 1-year period and were compared with either formal ultrasonograms performed in the radiology department, the patient's hospital record, or both. Sensitivity, specificity, and positive predictive value (PPV), as well as negative predictive values (NPV), were calculated. The setting was a 104-bed community hospital with an ED volume of 25,000 patients annually, and patients whom the emergency physician believed needed ultrasound studies in the ED were entered. ED ultrasonography was performed in 167 patients by 14 physicians during a 1-year period. For 132 patients who completed formal follow-up, the overall diagnostic accuracy of interpretations of ED ultrasonograms yielded a sensitivity of .95, specificity of .98, PPV of .99, and NPV of .89. Eleven categories of ultrasound use were reported. The three studies most commonly performed were for gallbladder disease (53%), intrauterine pregnancy (28%), and abdominal aortic aneurysms (7%). Accuracy of ED gallbladder ultrasonograms for 65 patients showed a sensitivity of .86, specificity of .97, PPV of .97, and NPV of .85.(ABSTRACT TRUNCATED AT 250 WORDS)

Seasonal variations of current symptoms in a healthy population.

Among a large workplace population interviewed over a year, current symptoms were assessed using the Hopkins Symptom Checklist (HSCL). Variation in symptoms by date of assessment was observed among the 314 women but not the 1556 men. Among women, symptoms were greatest during late autumn and winter, and significant inverse correlations were found between available daylight at the time of assessment and standard symptom dimensions of anxiety and somatisation, as well as an expanded mood scale more inclusive of depressive symptoms within the check-list. The amplitude of the seasonal effect was such that the prevalence of female 'cases', as defined by HSCL criteria, was twice as high during winter than during the rest of the year. The data are consistent with a role for light-dark exposure in eliciting or synchronizing annual mood rhythms. The sex-by-season interactions may contribute to the sex differences in overall prevalence of depression.

Detection of major depressive disorder in primary care patients.

BACKGROUND: The aim of this study was to assess the utility of a two-phase case detection strategy for major depressive disorder and a quantitative self-rating instrument for dysphoria. METHODS: A convenience sample of 302 ambulatory patients received three self-administered depression rating instruments: a modified version of the Dartmouth Cooperative (COOP) Functional Health Assessment Chart on emotional condition, a three-question screening test for depression taken from the Diagnostic Interview Schedule (DIS), and the Inventory to Diagnose Depression (IDD). All patients' medical charts were reviewed after the administration of these instruments, and those charts of patients found to be depressed were reviewed again 6 months later. A family practice ambulatory patient center in a university hospital was the setting for the study. RESULTS: The IDD detected current major depressive disorder in 41 persons (13.6 percent of sample). Twenty-five of the 41 IDD-positive patients had not previously had a major depressive disorder diagnosed according to chart notes. Six months later, 16 of the 25 patients with newly diagnosed major depressive disorders had not returned to the clinic since the index visit. A single question (DIS question 073b), when compared with the IDD diagnosis of major depressive disorder, had a sensitivity of 95.1 percent, specificity of 78.9 percent, positive predictive value of 41.5 percent, and negative predictive value of 99 percent. Dysphoria, as measured by the modified COOP chart on emotional condition, was significantly worse among those with current major depression (IDD positive) than for those without (IDD negative). CONCLUSIONS: A two-phase case detection strategy for major depressive disorder consisting of a single screening question followed by a self-administered diagnostic instrument can efficiently pick out virtually all ambulatory primary care patients with a major depressive disorder. A brief functional assessment chart can quantify the extent of dysphoria.

Ultrasound for the detection of foreign bodies.

STUDY OBJECTIVE: To determine the ability of an emergency physician to detect a variety of foreign bodies in an experimental model using a portable ultrasound device. DESIGN: Ten pieces of beef were sliced into cubes approximately 6 cm on each side. Six different groups of foreign bodies were examined: gravel, cactus spine, glass, metal, wood, and plastic. An independent observer placed the objects in a random fashion into the beef cubes. One hundred twenty observations were made using sets of ten beef cubes at a time. Five foreign bodies were placed into each set of ten beef cubes. INTERVENTIONS: A blinded emergency physician used a portable ultrasound with a 7.5-MHz transducer to determine the presence or absence of a foreign body in each cube. MEASUREMENTS AND MAIN RESULTS: Ultrasound detected 59 of 60 foreign bodies, including all cubes of meat embedded with gravel, cactus spine, plastic, metal, and wood. Glass was detected nine of ten times. Of the 60 cubes of meat with no foreign bodies, one false-positive was recorded. This yielded sensitivity, specificity, positive predictive value, and negative predictive value of 98%. Positive determinations by ultrasound were significantly greater in the meat cubes with foreign bodies compared with the control group with no foreign bodies (P less than .001 by chi 2). Although the subset of glass foreign bodies had one false-positive and one false-negative, it was not significantly different in comparison with the other groups (P greater than .05 by chi 2). CONCLUSION: Ultrasound has promise as a diagnostic tool for the detection of a variety of foreign bodies. Further clinical studies using ultrasound for the detection of foreign bodies are warranted.

Efficacy of brief, intense light exposure for treatment of winter depression.

A high-intensity fluorescent lighting system, tilted downward toward the head, and emitting negligible levels of ultraviolet radiation, was tested under two random crossover protocols in winter-depressed patients: 30-minute sessions at (a) 3,000 lux vs. 10,000 lux in early morning, and (b) morning vs. evening sessions at 10,000 lux. Judgment of clinical remission was based jointly on relative and absolute score improvements on a Structured Interview Guide for the Hamilton Depression Scale--Seasonal Affective Disorder Version (SIGH-SAD) and a set of supplementary atypical-vegetative items. Data are presented for 24 subjects who showed relapse upon withdrawal. An overall remission rate of 75 percent was found for morning light at 10,000 lux. The rates for evening light (25%) and 3,000 lux morning light (19%) were significantly lower. The remission rate for morning light treatment of 10,000 lux for 30 minutes approximately equalled 2,500 lux treatment for 2 hours (data from our earlier studies), suggesting a reciprocity between dosing dimensions of intensity and duration. No pathological changes were revealed by ophthalmological examinations given after 2 to 6 weeks of daily treatment.