[Educational film on the geriatric basic assessment in primary care-Methods of cinematic authenticity]. / Lehrfilm über das geriatrische Basisassessment in der hausärztlichen Versorgung ­ Methoden filmischer Authentizität.

BACKGROUND: The relevance of care of older persons in general practice requires the conveyance of procedural and conditional knowledge of the geriatric basic assessment (GBA) even during medical studies. There is a need for action with respect to student knowledge on specific problems of older patients. This paper describes how the primary care situation can be made tangible for students based on a film project at the Hannover Medical School (MHH). METHOD: During film production, strategies for creating authenticity were applied using cinematic means. The film is used in the teaching module of family medicine at MHH. Student evaluation investigated whether the educational film provided an emotional experience and whether the presentation mode of the GBA was perceived as authentic. RESULTS: The majority of students were emotionally touched by the film. The educational film was successful in conveying the complexity of care of older people and in presenting the special role of family physicians in geriatric care. DISCUSSION: The students recognized the necessity of the GBA and found the representation predominantly realistic; however, individual cinematic reception and previous experiences also influence the perception of the cinematic form with respect to the representation of reality. This method might improve the conveyance of authenticity in educational videos in medicine.

Generalist palliative care for non-cancer patients : A review article.

BACKGROUND: Most patients in the last phase of life can be treated in the context of generalist palliative care, especially by general practitioners. In contrast to specialized palliative care, non-cancer patients predominate in this setting. OBJECTIVE: The aim of this article is to review the literature and elaborate current topics for non-cancer patients at the end-of-life in primary palliative care. MATERIALS AND METHODS: A literature search was carried out in the databases PubMed and Scopus from 2008 to 2013 followed by a qualitative content analysis according to the PRISMA statement. RESULTS: A total of 127 articles could be included in the qualitative content analysis and the final review whereby four core topics were identified: (1) specific target groups (e. g. elderly patients, patients with advanced heart failure and pain), (2) collaboration of general practitioners with other physicians and health professionals, (3) qualifications in palliative care and (4) provision of primary palliative care. Most articles found were related to the fourth topic and the subtopic of barriers and facilitators of palliative care. Insufficient coordination of the persons involved was a barrier often discussed. Advanced care planning including concrete palliative care aspects at an early stage can be beneficial for both patients and professionals. CONCLUSION: The current literature search highlights the importance of optimizing the processes and structures in providing palliative care and the discussion of end-of-life issues at an early stage in general practice. Therefore, a structured identification of palliative care needs identified by appropriate assessment instruments is crucial.

[Generalist palliative care for non-cancer patients: A review article]. / Hausärztliche Palliativversorgung bei nichtonkologischen Patienten: Eine Übersichtsarbeit.

BACKGROUND: Most patients in the last phase of life can be treated in the context of generalist palliative care, especially by general practitioners. In contrast to specialized palliative care, non-cancer patients predominate in this setting. OBJECTIVE: The aim of this article is to review the literature and elaborate current topics for non-cancer patients at the end of life in primary palliative care. MATERIAL AND METHODS: A literature search was carried out in the databases PubMed and Scopus from 2008 to 2013 followed by a qualitative content analysis according to the PRISMA statement. RESULTS: A total of 127 articles could be included in the qualitative content analysis and the final review whereby four core topics were identified: (1) specific target groups (e.g. elderly patients, patients with advanced heart failure and pain), (2) collaboration of general practitioners with other physicians and health professions, (3) qualifications in palliative care and (4) provision of primary palliative care. Most articles found were related to the fourth topic and the subtopic of barriers and facilitators of palliative care. Insufficient coordination of the persons involved was a barrier often discussed. Advanced care planning including concrete aspects of palliative care at an early stage can be beneficial for both patients and professionals. CONCLUSION: The current literature search elucidates the importance of optimizing the processes and structures in providing palliative care and the discussion of end of life issues at an early stage in general practice. Therefore, a structured identification of palliative care needs identified by appropriate assessment instruments is crucial.

Cranberry juice for the prevention of pediatric urinary tract infection: a randomized controlled trial.

PURPOSE: Proanthocyanidins found in cranberry have been reported to have in vitro and in vivo antibacterial activity. We determined the effectiveness of cranberry juice for the prevention of urinary tract infections in children. MATERIALS AND METHODS: A total of 40 children were randomized to receive daily cranberry juice with high concentrations of proanthocyanidin vs cranberry juice with no proanthocyanidin for a 1-year period. The study was powered to detect a 30% decrease in the rate of symptomatic urinary tract infection with type I and II errors of 0.05 and 0.2, respectively. Toilet trained children up to age 18 years were eligible if they had at least 2 culture documented nonfebrile urinary tract infections in the calendar year before enrollment. Patients with anatomical abnormalities (except for primary vesicoureteral reflux) were excluded from study. Subjects were followed for 12 months. The participants, clinicians, outcome assessor and statistician were all blinded to treatment allocation. RESULTS: Of the children 39 girls and 1 boy were recruited. Mean and median patient age was 9.5 and 7 years, respectively (range 5 to 18). There were 20 patients with comparable baseline characteristics randomized to each group. After 12 months of followup the average incidence of urinary tract infection in the treatment group was 0.4 per patient per year and 1.15 in the placebo group (p = 0.045), representing a 65% reduction in the risk of urinary tract infection. CONCLUSIONS: Cranberry juice with high concentrations of proanthocyanidin appears to be effective in the prevention of pediatric nonfebrile urinary tract infections. Further studies are required to determine the cost-effectiveness of this approach.

Publications by the American Academy of Pediatrics Section on Urology: the quality of research design and statistical methodology.

PURPOSE: We provide a systematic assessment of the quality of research methodology, statistical analysis and reporting in 2 recent pediatric supplements of The Journal of Urology. MATERIALS AND METHODS: All original clinical publications in 2 Pediatric Supplements of The Journal of Urology (2005 and 2007) were identified for formal review. We collected data on variables indicating the quality of methodology and statistical analysis. Two independent reviewers with formal training in clinical epidemiology reviewed each article. RESULTS: Of the 103 published articles 92 met study inclusion criteria. Common study designs included a retrospective cohort in 68% of articles and a prospective cohort in 17%. Demographic statistics were incomplete in many articles, that is in 24% no measure of central tendency and in 18% no measures of dispersion were provided. In 40% of articles the statistical methods were not clearly described. Of all studies eligible for univariate or multivariate analysis only 52% and 23%, respectively, provided the appropriate analysis. Deficiencies in reporting and interpreting p values, ORs/RRs and CIs were noted in 53%, 83% and 78% of studies, respectively. Limitations of studies, such as biases and confounders, were only acknowledged in a third of articles. Comparison of articles published in 2005 vs 2007 revealed a significant improvement in reporting the results of multivariate analysis (p = 0.0297). CONCLUSIONS: Methodological and statistical shortcomings were common in our sampling of the pediatric urology literature. This may result in misleading conclusions. Pediatric urologists are encouraged to involve colleagues with formal training in research design from the outset of their studies.

Health related quality of life in patients with spina bifida: a prospective assessment before and after lower urinary tract reconstruction.

PURPOSE: In a previous retrospective cohort study we challenged the assumption that lower urinary tract reconstruction improves health related quality of life in spina bifida cases. We readdressed this issue prospectively in a new series of patients. MATERIALS AND METHODS: A total of 31 consecutive incontinent patients with spina bifida undergoing reconstruction with a continent stoma with or without augmentation, with or without bladder neck reconstruction and with or without cecostomy were assessed preoperatively and 6 months postoperatively with the Parkin disease specific health related quality of life score. The instrument stratifies patients by ages 12 years or younger and 13 years or older. An additional 4-item questionnaire was used to score bladder and bowel continence. RESULTS: There was no significant change in health related quality of life following surgery in either age group. The median score changed from 167 to 174 in patients 12 years old or younger (p = 0.74) and from 199 to 193 in patients 13 years old or older (p = 0.42) despite a significant improvement in scores on all continence questions (p <0.05). In patients 12 years old or younger there was significant improvement in 3 items in the domains of independence and emotional expression (p <0.05). In adolescents 4 items changed significantly, and all were related to the independence and emotional domains (p <0.05). CONCLUSIONS: Despite improvement in some question items we did not note an improvement in overall quality of life following reconstruction. Correcting only 1 system in a profound multisystem disability may be insufficient to improve health related quality of life or perhaps only caregiver quality of life is improved. The impact of lower urinary tract reconstruction on quality of life in patients with spina bifida requires further assessment before improvements are assumed.

Sarcoidosis: a rare cause of Kleine-Levine-Critchley syndrome.

Hypothalamic sarcoidosis is a rare entity that can alter the hypothalamic-pituitary axis and induce various combinations of endocrine changes. We present a case of neurosarcoidosis with uncommon features of hypersomnolense and hyperphagia. Current strategies to increase awareness and prevention of the harmful effects of obesity require clinicians to be cognizant of potential disorders that produce these features The mechanism, differential diagnosis and therapeutic options of this organic etiology are reviewed.

Strengths and pitfalls of meta-analysis reports in vesicoureteral reflux.

There are many ongoing controversies surrounding vesicoureteral reflux (VUR). These include variable aspects of this common congenital anomaly. Lack of evidence-based recommendations has prolonged the debate. Systematic reviews (SRs) and meta-analysis (MA) are considered high-level evidence. The purpose of this review article is to summarize and critically appraise the available SR/MA pertaining to VUR. We also discuss the strength and pitfalls of SR/MA in general. A thorough literature search identified 9 SRs/MAs relevant to VUR. Both authors critically reviewed these articles for contents and methodological issues. There are many concerns about the quality of the studies included in these SRs. Clinical heterogeneity stemming from different patient selection criteria, interventions, and outcome definitions is a major issue. In spite of major advances in understanding different aspects of VUR in the last few decades, there is a paucity of randomized controlled trials in this field.

Spinal cord magnetic resonance imaging for investigation of nonneurogenic lower urinary tract dysfunction--can the yield be improved?

PURPOSE: Magnetic resonance imaging has been used to detect occult neuropathy in patients with nonneurogenic lower urinary tract dysfunction. There is substantial controversy surrounding the role of this test for lower urinary tract dysfunction. We identified factors associated with positive magnetic resonance imaging to improve patient selection. MATERIALS AND METHODS: A case-control study was done in all pediatric patients referred to our radiology department for spinal magnetic resonance imaging primarily because of lower urinary tract symptoms between 1995 and 2004. Patients with known neurological disorders or anomalies associated with neurogenic bladder (overt spinal dysraphism, imperforate anus, etc) were excluded. A total of 80 patients with a median age of 6.5 years (range 4 to 17) were identified, of whom 47 (59%) were female. Bivariate analysis was used to evaluate the association of certain variables with positive magnetic resonance imaging findings, including patient age, gender, type of urinary symptoms, fecal soiling, abnormal neuro-orthopedic examination, lumbar cutaneous findings, resistance to medical management and urodynamic findings. RESULTS: Magnetic resonance imaging revealed spinal abnormalities in 6 cases (7.5%), including intradural arachnoid cyst in 1, sacral dysgenesis in 3, syrinx/hydromyelia in 1 and tethered cord in 1. An abnormal lumbar cutaneous finding was the only variable associated with positive magnetic resonance imaging (Fisher's exact test p = 0.002). CONCLUSIONS: Spinal magnetic resonance imaging has a low impact in the management of lower urinary tract dysfunction. With proper patient selection the pretest probability of positive magnetic resonance imaging may be increased and, therefore, many unnecessary studies may be avoided. Abnormal cutaneous findings are associated with abnormal magnetic resonance imaging.

Screening asymptomatic siblings for vesicoureteral reflux: sound science or religious rhetoric?

INTRODUCTION: Many urologists endorse the concept of screening asymptomatic siblings of children known to have vesicoureteral reflux. Others oppose screening until there is better evidence to justify the cost and potential morbidity of adopting a widespread screening program. METHODS: A literature review of the following topics was carried out: 1) screening programs in general; 2) reflux in general; 3) familial reflux; and 4) screening for familial reflux. RESULTS: The evidence supporting our traditional surgical and medical management strategies for reflux is weak. The evidence supporting screening is lacking. Public Health organizations do not address the issue of screening for this condition. Despite this, there is a significant body of peer reviewed literature and compelling expert opinion, in support of screening. Possible reasons for this are explored. CONCLUSIONS: A randomized controlled trial to definitively assess the utility of screening would be larger and more challenging to perform than any ever done in the history of this condition. Until such time that high quality evidence exists, screening of asymptomatic siblings will continue to be based upon our individual clinical experience and teachings, the morbidity of the index case, and socioeconomic factors. We must continue to re-evaluate our management strategies for this condition in light of new information as it accrues.

Should the presence of congenital para-ureteral diverticulum affect the management of vesicoureteral reflux?

PURPOSE: The presence of congenital para-ureteral diverticulum (PUD) has been presumed to lower the resolution rate of vesicoureteral reflux (VUR). PUD is considered an important cause of distortion of the vesicoureteral junction and persistence of VUR. Early surgery has been recommended based on this assumption. However, the scientific evidence supporting this approach is weak. We have been managing this group of patients more conservatively in the last 7 to 8 years on the premise that the presence of PUD is not per se an indication for surgery. To test this hypothesis, we performed a retrospective cohort study to compare the outcome of VUR in children with and without PUD. MATERIALS AND METHODS: We identified 141 consecutive patients with VUR associated with PUD between 1990 and 2004. Of the patients 57 with duplication, ureterocele, neurogenic bladder or outlet obstruction were excluded from study. Median age of the remaining 84 patients at diagnosis was 2.9 years and 56 (69%) were males. Reflux was bilateral in 4 patients, and low (I to II), intermediate (III) and high (IV to V) grade in 39%, 35% and 26%, respectively. Followup was 3 to 168 months (median 47). The outcome was compared to a control group of 95 patients (150 units) with primary VUR and no PUD. The baseline parameters and followup were comparable in both groups. RESULTS: Overall, VUR resolved in 43%, persisted in 27% and was surgically corrected in 30% of the units with PUD. In the 25 patients (26 units) who underwent surgical intervention breakthrough urinary tract infection or new renal scars were the indication in only 5. The remainder were operated on because of persistent VUR and the presence of PUD, mainly before 1997. The incidence of breakthrough urinary tract infection or new renal scar was similar in the controls (6% in PUD group vs 10% in controls, p = 0.7). The resolution rate was 60% for low grade, 39% for intermediate grade and 22% for high grade VUR. These figures were not significantly different from those of the control group in which the resolution rates were 52%, 28% and 33% for comparable grades (p = 0.9). Kaplan-Meier analysis and log rank test did not show any difference in resolution of VUR in the 2 groups (p = 0.84). Multivariate analysis identified grade as the only variable affecting resolution (p = 0.028). The size of PUD did not affect the likelihood of resolution. CONCLUSIONS: The outcome of VUR is similar in children with or without PUD. Therefore, treatment of these patients should not differ. Surgery should be reserved for patients with breakthrough infection or renal scar progression.

fumble encodes a pantothenate kinase homolog required for proper mitosis and meiosis in Drosophila melanogaster.

A number of fundamental processes comprise the cell division cycle, including spindle formation, chromosome segregation, and cytokinesis. Our current understanding of these processes has benefited from the isolation and analysis of mutants, with the meiotic divisions in the male germline of Drosophila being particularly well suited to the identification of the required genes. We show here that the fumble (fbl) gene is required for cell division in Drosophila. We find that dividing cells in fbl-deficient testes exhibit abnormalities in bipolar spindle organization, chromosome segregation, and contractile ring formation. Cytological analysis of larval neuroblasts from null mutants reveals a reduced mitotic index and the presence of polyploid cells. Molecular analysis demonstrates that fbl encodes three protein isoforms, all of which contain a domain with high similarity to the pantothenate kinases of A. nidulans and mouse. The largest Fumble isoform is dispersed in the cytoplasm during interphase, concentrates around the spindle at metaphase, and localizes to the spindle midbody at telophase. During early embryonic development, the protein localizes to areas of membrane deposition and/or rearrangement, such as the metaphase and cellularization furrows. Given the role of pantothenate kinase in production of Coenzyme A and in phospholipid biosynthesis, this pattern of localization is suggestive of a role for fbl in membrane synthesis. We propose that abnormalities in synthesis and redistribution of membranous structures during the cell division cycle underlie the cell division defects in fbl mutant cells.

Functional analysis of the Drosophila diaphanous FH protein in early embryonic development.

The Drosophila Formin Homology (FH) protein Diaphanous has an essential role during cytokinesis. To gain insight into the function of Diaphanous during cytokinesis and explore its role in other processes, we generated embryos deficient for Diaphanous and analyzed three cell-cycle-regulated actin-mediated events during embryogenesis: formation of the metaphase furrow, cellularization and formation of the pole cells. In dia embryos, all three processes are defective. Actin filaments do not organize properly to the metaphase and cellularization furrows and the actin ring is absent from the base of the presumptive pole cells. Furthermore, plasma membrane invaginations that initiate formation of the metaphase furrow and pole cells are missing. Immunolocalization studies of wild-type embryos reveal that Diaphanous localizes to the site where the metaphase furrow is anticipated to form, to the growing tip of cellularization furrows, and to contractile rings. In addition, the dia mutant phenotype reveals a role for Diaphanous in recruitment of myosin II, anillin and Peanut to the cortical region between actin caps. Our findings thus indicate that Diaphanous has a role in actin cytoskeleton organization and is essential for many, if not all, actin-mediated events involving membrane invagination. Based on known biochemical functions of FH proteins, we propose that Diaphanous serves as a mediator between signaling molecules and actin organizers at specific phases of the cell cycle.

Identification of the chromosome localization domain of the Drosophila nod kinesin-like protein.

The nod kinesin-like protein is localized along the arms of meiotic chromosomes and is required to maintain the position of achiasmate chromosomes on the developing meiotic spindle. Here we show that the localization of ectopically expressed nod protein on mitotic chromosomes precisely parallels that observed for wild-type nod protein on meiotic chromosomes. Moreover, the carboxyl-terminal half of the nod protein also binds to chromosomes when overexpressed in mitotic cells, whereas the overexpressed amino-terminal motor domain binds only to microtubules. Chromosome localization of the carboxyl-terminal domain of nod depends upon an 82-amino acid region comprised of three copies of a sequence homologous to the DNA-binding domain of HMG 14/17 proteins. These data map the two primary functional domains of the nod protein in vivo and provide a molecular explanation for the directing of the nod protein to a specific subcellular component, the chromosome.

DNA binding and meiotic chromosomal localization of the Drosophila nod kinesin-like protein.

The Drosophila no distributive disjunction (nod) gene encodes a kinesin-like protein that has been proposed to push chromosomes toward the metaphase plate during female meiosis. We report that the nonmotor domain of the nod protein can mediate direct binding to DNA. Using an antiserum prepared against bacterially expressed nod protein, we show that during prometaphase nod protein is localized on oocyte chromosomes and is not restricted to either specific chromosomal regions or to the kinetochore. Thus, motor-based chromosome-microtubule interactions are not limited to the centromere, but extend along the chromosome arms, providing a molecular explanation for the polar ejection force.