Uncertainty abounds in the clinical environment. Medical students, however, are not explicitly prepared for situations of uncertainty in clinical practice, which can cause anxiety and impact well-being. To address this gap, we sought to capture how students felt in various clinical scenarios and identify programs they found helpful as they worked through uncertainty in their clerkships to better inform curriculum that prepares them to acknowledge and navigate this uncertainty. This is an observational cross-sectional study of third-year medical students surveyed at the end of core clerkships. The survey consisted of the General Self-Efficacy (GSE) Scale and Intolerance of Uncertainty Scale (IUS). Items asked students to rate preparedness, confidence, and comfort with uncertainty in clinical practice. Items on curricular programs asked students to identify training that prepared them for uncertainty in clerkships, and examined correlations with specific clinical practice uncertainty domains (CPUDs). Spearman’s rank-order correlation, Chi-Square, and ANOVA were used to analyze quantitative data. Open responses were analyzed using Braun and Clarke’s Framework. Response rate was 98.9% (287/290). GSE was inversely correlated with IUS (p < 0.001). GSE was positively correlated with all CPUDs (p < 0.005). IUS had an inverse correlation with all CPUDs (p < 0.005). Pedagogies with statistically-significant relationships with preparing students for uncertainty, communicating and building relationships with patients during times of uncertainty, and overall well-being included: team debriefs, role plays, case- and team-based learning, story slams, and sharing narratives with peers and faculty (p < 0.05). Qualitatively, students appreciated storytelling, role-modeling of communication strategies, debriefing, and simulations. Strategically immersing specific educational formats into formal curriculum may help cultivate skills needed to prepare students for uncertainty. Clinical debriefs, interprofessional role plays, simulations, communications skills training, instructor emotional vulnerability, storytelling, and peer-to-peer conversations may have the most impact. Further study is required to evaluate their longitudinal impact.
Introduction Priapism remains a challenging consult for urologists. Proper understanding of the risk of priapism after intracavernosal injections (ICI) and management trends for patients with priapism may help urologists facing this issue. Objective To describe rates of priapism and patient demographics after ICI and management trends after a diagnosis of priapism using a global database. Methods TriNetX is a collaborative research enterprise which collects real-time data from almost 89 million patients located in 58 healthcare organizations across the globe and analyzes patient data from 20 years back to present (2002-2022). We queried TriNetX for all adult patients receiving ICI or presenting for priapism, using Common Procedural Terminology (CPT) and International Classification of Diseases-10 (ICD-10) codes. The index event was defined as usage of ICI or incidence of priapism. We performed descriptive statistics to describe rates of priapism after ICI within 3 days and between 4 and 90 days after injection and described demographic differences between patients presenting with priapism after ICI and those who did not. We evaluated treatment options for priapism at 1 week, 90 days, 1 year, and 5 years after the initial event. We also described rates of additional priapism episodes within 1 year and 5 years after index priapism encounter. Analyses were run on June 28th, 2022. Results There were 26104 usages of ICI and 17545 recorded instances of priapism. Of patients receiving ICI, 4% and 1.6% had priapism at 3 days and between 4 and 90 days, thus most patients presented with priapism near-immediately. Patients presenting with priapism after ICI tended to be younger (46.4 years vs 57.4 years, p<0.01) and had a disproportionate prevalence of mood disorders (20% vs 14%, p<0.01), pain disorders (16% vs 12%, p<0.01) and sickle cell disease (6% vs <1%, p<0.01). They were less likely to have comorbidities such as diabetes (14% vs 22%, p<0.01), hypertension (33% vs 40%, p<0.01) or a history of prostate cancer (13% vs 25%, p<0.01) and less likely to have taken phosphodiesterase 5 inhibitors such as sildenafil (30% vs 35%, p<0.01) or tadalafil (29% vs 38%, p<0.01) in the past. The most common treatment for priapism was irrigation and/or injection of medications (11.3% same day, Table 1). The prevalence of implants for patients experiencing priapism steadily increased throughout the various timepoints, but overall remained low. Conclusions Priapism remains an infrequent problem that is difficult to study given the relative rarity of presentation. By utilizing a global data set, we are to describe rates of priapism after ICI and treatments for priapism. For patients prescribed ICI, proper counseling of the risks of priapism is important to reduce damaging long term consequences if the condition does occur. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific, Coloplast.
Introduction Urologists are not immune from the opioid epidemic. While narcotics still have a role to play in postoperative pain management, examining individual surgeries, such as inflatable penile prosthesis placement (IPP), to identify opportunities to limit opioid use should be a priority. Objective By querying a large, global research network, we sought to evaluate the impact of a narcotic prescription on short term patient outcomes and long-term opioid use following IPP placement. Methods TriNetX is a collaborative research enterprise which collects real-time data from almost 89 million patients located in 58 healthcare organizations across the globe and analyzes patient data from 20 years back to present (2002-2022). We queried TriNetX for all adult patients undergoing IPP. The index event was surgery. Cohorts included patients prescribed oxycodone within 2 days of surgery, tramadol within 2 days of surgery, or one of many frequently prescribed oral opioids (oxycodone, hydrocodone, hydromorphone, oxymorphone or tramadol) within 2 days of surgery. The control cohorts were patients not prescribed a narcotic in the same timeframe. TrinetX identifies prescriptions using RxNorm Concept Unique Identifier, part of the Unified Medical Language System. We also compared patients taking opioids within 6 months to 1 day prior to surgery against “opioid naive” patients. Our short-term outcome was the rate of return visits to the Emergency Department (ED) within 90 days of the index event. Our long-term outcomes were a diagnosis of opioid abuse (ICD-10 F11.1) or dependence (ICD-10 F11.2) disorder 6 months or later after surgery, and we also evaluated persistent opioid use 9 to 15 months after surgery, consistent with previous literature. Propensity score matching (PSM) was performed on potential cofounders: age, race, mental and behavioral disorders, pain disorders, and prior opioid use. The analyses were performed on June 28th, 2022. Results There were 9702 patients who received an IPP (Table 1). Patients considered opioid- or oxycodone naive were less likely to have a diagnosis of opioid dependence or abuse (Relative Risk (RR)=0.51 and RR=0.42) at 6 months. Patients prescribed an opioid postoperatively, or oxycodone or tramadol specifically, were more likely have persistent opioid, oxycodone, or tramadol use (all p<0.05) at 9 to 15 months, except for patients prescribed postoperative tramadol for the outcome of any oral opioid prescription (p=0.75). Patients prescribed any opioid or oxycodone specifically were more likely to have an ED visit (RR=1.5 and 1.3) while patients prescribed tramadol postoperatively showed no difference in ED visits (RR=1.2). There was no significant difference in ED visits based on opioid naivety, while all patients taking preoperative opioids were more likely to continue taking an opioid at 9 to 15 months (all p<0.01). Conclusions The prescription of opioids after IPP has risks of long-term opioid use and prescribing opioids in general may increase healthcare utilization in the short term. Prescribing a partial agonist, such as tramadol, may reduce persistent opioid use while being non-inferior in need to return to the emergency department when compared to oxycodone; however, a non-opioid regimen is preferred to maximally reduce risk. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific, Coloplast
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