L. Sibert

Acute bacterial prostatitis: heterogeneity in diagnostic criteria and management. Retrospective multicentric analysis of 371 patients diagnosed with acute prostatitis.

BackgroundThere is currently a lack of consensus for the diagnosis, investigations and treatments of acute bacterial prostatitis (AP).MethodsThe symptoms, investigations and treatments of 371 inpatients diagnosed with AP were analyzed through a retrospective study conducted in four departments – Urology (U), Infectious Diseases (ID), Internal Medicine (IM), Geriatrics (G) – of two French university hospitals.ResultsThe cause of admission, symptoms, investigations and treatments depended markedly on the department of admission but not on the hospital. In U, patients commonly presented with a bladder outlet obstruction, they had a large imaging and functional check-up, and received alpha-blockers and anti-inflammatory drugs. In ID, patients were febrile and received longer and more appropriate antibiotic treatments. In G, patients presented with cognitive disorders and commonly had post-void urine volume measurements. In IM, patients presented with a wide range of symptoms, and had very diverse investigations and antibiotic regimen.Overall, a 3:1 ratio of community-acquired AP (CA-AP) to nosocomial AP (N-AP) was observed. Urine culture isolated mainly E. coli (58% of AP, 68% of CA-AP), with venereal agents constituting less than 1%. The probabilistic antibiotic treatments were similar for N-AP and CA-AP (58% bi-therapy; 63% fluoroquinolone-based regimen). For N-AP, these treatments were more likely to be inadequate (42% vs. 8%, p < 0.001) and had a higher rate of bacteriological failure (48% vs. 19%, p < 0.001).Clinical failure at follow-up was more common than bacteriological failure (75% versus 24%, p < 0.001). Patients older than 49 had more underlying urinary tract disorders and a higher rate of clinical failure (30% versus 10%, p < 0.0001).ConclusionThis study highlights the difficulties encountered on a daily basis by the physicians regarding the diagnosis and management of acute prostatitis.

Stability of clinical reasoning assessment results with the Script Concordance test across two different linguistic, cultural and learning environments.

The Script Concordance (SC) test is designed to measure the organization of knowledge that allows interpretation of data in clinical reasoning. An originality of the test is that answer keys use an aggregate scoring method based on answers given by a panel of experts. Previous studies have shown that the SC test has good construct validity. This study, done in urology, explores (1) the stability of the construct validity of the test across two different linguistic and learning environments and (2) the effect of the use of experts who belong to different environments. An 80-item SC test was administered to participants from a French and a Canadian university. Two levels of experience were tested: 25 residents in urology (11 from the French university and 14 from the Canadian university) and 23 students (15 from the French faculty, eight from the Canadian faculty). Reliability analysis was studied with Cronbachs alpha coefficient. Scores between groups were compared by analysis of variance. Reliability coefficient of the 80 items test was 0.794 for the French participants and 0.795 for the Canadian participants. Scores increased with clinical experience in urology in the two sites. Candidates obtained higher scores when correction was done using the answer key provided by the experts from the same country. These data support the stability of the construct validity of the tool across different learning environments.

Assessment of Clinical Reasoning Competence in Urology with the Script Concordance Test: an Exploratory Study Across Two Sites from Different Countries

OBJECTIVES The script concordance (SC) test is designed to measure the organisation of knowledge that allows interpretation of data in clinical reasoning. This study explores the use of this new written examination tool in urology. MATERIALS AND METHODS An 80 items SC test was administered to participants from a French and a Canadian university. Three levels of experience were tested: urologists (n = 22), residents in urology (n = 25) and students (n = 23). Scores between groups were compared by analysis of variance. Reliability analysis was studied with Cronbach alpha coefficient. RESULTS Mean global scores were 51.45 +/- 5.29 for students, 58.19 +/- 3.81 for residents and 62.27 +/- 5.46 for urologists. The difference between the three groups was statistically significant (P < 0.00001). Interaction between levels of expertise and sites was apparently not significant (P = 0.326). Cronbach alpha was 0.79 for the test. CONCLUSIONS This study shows that the SC test is able to discriminate among participants according to their levels of clinical experience in urology. The results are similar in two different learning environments. The SC test appears as a simple and direct approach to testing organisation and use of knowledge in urology.

Online clinical reasoning assessment with the Script Concordance test: a feasibility study

BackgroundThe script concordance (SC) test is an assessment tool that measures capacity to solve ill-defined problems, that is, reasoning in context of uncertainty. This tool has been used up to now mainly in medicine. The purpose of this pilot study is to assess the feasibility of the test delivered on the Web to French urologists.MethodsThe principle of SC test construction and the development of the Web site are described. A secure Web site was created with two sequential modules: (a) The first one for the reference panel (n = 26) with two sub-tasks: to validate the content of the test and to elaborate the scoring system; (b) The second for candidates with different levels of experience in Urology: Board certified urologists, residents, medical students (5 or 6th year). Minimum expected number of participants is 150 for urologists, 100 for residents and 50 for medical students. Each candidate is provided with an individual access code to this Web site. He/she may complete the Script Concordance test several times during his/her curriculum.ResultsThe Web site has been operational since April 2004. The reference panel validated the test in June of the same year during the annual seminar of the French Society of Urology. The Web site is available for the candidates since September 2004. In six months, 80% of the target figure for the urologists, 68% of the target figure for the residents and 20% of the target figure for the student passed the test online. During these six months, no technical problem was encountered.ConclusionThe feasibility of the web-based SC test is successful as two-thirds of the expected number of participants was included within six months. Psychometric properties (validity, reliability) of the test will be evaluated on a large scale (N = 300). If positive, educational impact of this assessment tool will be useful to help urologists during their curriculum for the acquisition of clinical reasoning skills, which is crucial for professional competence.

Approche symptomatique des douleurs sexuelles chroniques

OBJECTIVE To colligate the clinical and ethiopathogenical elements to take into account in the assessment of sexual activity-related chronic pelvic and perineal pain, in the male as well as in the female subject. SUBJECTS AND METHODS Review of articles and consensus conferences published on this subject in the Medline (Pubmed) database, selected according to their scientific relevance. RESULTS In the female subject, only dyspareunia has benefitted from a consensual definition. Deep dyspareunia must start investigations in search of pelvic organs disorders, endometriosis, painful bladder syndrome adhesions. Superficial dyspareunia can be a part of provoked vestibulodynia. Vaginismus can be linked to a local disorder, but can also be caused by an excess of nociception. In the male subject, painful ejaculation must start investigation in search of a local urological disorder. It can also be of iatrogenous origin, or be included in a chronic pelvic pain syndrome. Although less documented, other pelvic and perineal pain syndrome, coitus-related or not, exist in the male subject. CONCLUSION Assessment of these sexual dysfunctions is primarily based on history taking and clinical examination. In the absence of systematically researched organic disorder, these pains can be part of functional disorders, in which case a global assessment must be undergone, by taking into account all aspects of the pain, including emotional aspects.

Effects of Vitamin A on In Vitro Maturation of Pre-Pubertal Mouse Spermatogonial Stem Cells

Testicular tissue cryopreservation is the only potential option for fertility preservation in pre-pubertal boys exposed to gonadotoxic treatment. Completion of spermatogenesis after in vitro maturation is one of the future uses of harvested testicular tissue. The purpose of the current study was to evaluate the effects of vitamin A on in vitro maturation of fresh and frozen-thawed mouse pre-pubertal spermatogonial stem cells in an organ culture system. Pre-pubertal CD1 mouse fresh testes were cultured for 7 (D7), 9 (D9) and 11 (D11) days using an organ culture system. Basal medium was supplemented with different concentrations of retinol (Re) or retinoic acid (RA) alone or in combination. Seminiferous tubule morphology (tubule diameter, intra-tubular cell type), intra-tubular cell death and proliferation (PCNA antibody) and testosterone level were assessed at D7, D9 and D11. Pre-pubertal mouse testicular tissue were frozen after a soaking temperature performed at -7°C, -8°C or -9°C and after thawing, were cultured for 9 days, using the culture medium preserving the best fresh tissue functionality. Retinoic acid at 10-6M and retinol at 3.3.10-7M, as well as retinol 10-6M are favourable for seminiferous tubule growth, maintenance of intra-tubular cell proliferation and germ cell differentiation of fresh pre-pubertal mouse spermatogonia. Structural and functional integrity of frozen-thawed testicular tissue appeared to be well-preserved after soaking temperature at -8°C, after 9 days of organotypic culture using 10-6M retinol. RA and Re can control in vitro germ cell proliferation and differentiation. Re at a concentration of 10-6M maintains intra-tubular cell proliferation and the ability of spermatogonia to initiate spermatogenesis in fresh and frozen pre-pubertal mouse testicular tissue using a soaking temperature at -8°C. Our data suggested a possible human application for in vitro maturation of cryopreserved pre-pubertal testicular tissue.

Communication between Consultants and Referring Physicians: A Qualitative Study to Define Learning and Assessment Objectives in a Specialty Residency Program

Background: Outpatient consultation constitutes a major part of medical practice. However, little is known about the skills which should be taught to residents in order for them to improve their consultant-referring physician relationships. Purposes: To specify the consultant skills which are required to ensure an effective communication between specialists and referring physicians. Methods: A qualitative study based on (a) a literature search and (b) focus group interviews. Results: Skills thus identified and described are classified in two groups: observable skills and principles/attitudes. Conclusions: The consensual specification of these abilities permits a greater efficacy in the teaching of consultant skills.

Introducing the objective structured clinical examination to a general practice residency programme: results of a French pilot study

OSCE for evaluating clinical competence still remains limited in France. This study presents the results of the first experimental use of an OSCE as a formative assessment of French general practice trainees. Fifty trainees rotated through a circuit of 15 standardized patient-based OSCE cases. Differences in scores were determined by analysis of variance. Reliability was calculated with the coefficient alpha. Pearson correlations were used to determine the relationship between station scores and overall OSCE score. Written questionnaires based on Likert-type scales were used to measure OSCE feasibility. No difference was found between total session scores. Significant item-total score correlations were found for 12 of the 15 clinical problems. The reliability of the examination was 0.58. Most participants agreed that the clinical situations were realistic, simulated patients were believable and sampling of cases was representative of general practice. These data confirm the feasibility of OSCE in assessing performance of general practice trainees. Optimal training of observers should improve examination reliability. This study warrants further development to confirm its usefulness as a summative assessment tool.

Approche globale des douleurs pelvipérinéales chroniques : du concept de douleur d’organe à celui de dysfonctionnement des systèmes de régulation de la douleur viscérale

OBJECTIVE Analysis of complex pelvic and perineal pain. MATERIAL AND METHODS Review of the literature concerning the various types of functional pelvic pain. RESULTS Various forms of pelvic pain are frequently associated: painful bladder syndrome (interstitial cystitis), irritable bowel syndrome, endometriosis pain, vulvodynia, chronic pelvic pain syndrome (chronic prostatitis). Pelvic pain is often associated with fibromyalgia or complex regional pain syndrome (reflex sympathetic dystrophy). The pathophysiological mechanisms involved in these syndromes are all very similar, suggesting a triggering element, neurogenic inflammation, reflex muscular and autonomic responses, central hypersensitization, emotional reactions and biopsychosocial consequences. DISCUSSION The concept of visceral pain is evolving and, in practice, complex pelvic pain can comprise neuropathic components, complex regional pain syndrome components, hypersensitization components, and emotional components closely resembling posttraumatic stress syndrome. CONCLUSIONS When pain cannot be explained by an organ disease, the pain must be considered to be expressed via this organ. Chronic pelvic and perineal pain can become self-perpetuating and identification of its various mechanisms can allow the proposal of individually tailored treatments.

Les infiltrations des nerfs somatiques dans la prise en charge thérapeutique des douleurs pelvipérinéales chroniques

INTRODUCTION Chronic pelvic and perineal pain can be related to a nerve lesion caused by direct or indirect trauma or by an entrapment syndrome, which must then be demonstrated by a test block. The purpose of this article is to review the techniques and modalities of somatic nerve block in the management of chronic pelvic and perineal pain. MATERIAL AND METHODS A review of the literature was performed by searching PubMed for articles on somatic nerve infiltrations in the management of chronic pelvic and perineal pain. RESULTS Nerves involved in pelvic and perineal pain are: thoracolumbar nerves (obturator, ilioinguinal, iliohypogastric and genitofemoral) and sacral nerves (pudendal and inferior cluneal branches of the posterior cutaneous nerve of the thigh). Infiltration has a dual objective: to confirm the diagnostic hypothesis by anaesthetic block and to try to relieve pain. Evaluation of the severity and site of the pain before and immediately after the test block is essential for interpretation of the block. The various infiltration techniques for each nerve are described together with their respective advantages, disadvantages and risk of complications. CONCLUSION Somatic nerve blocks are an integral part of the management of chronic pelvic and perineal pain and are predominantly performed under CT guidance in order to be as selective as possible. Once the diagnosis and the level of the nerve lesion have been defined, more specific therapeutic procedures can then be proposed.