Burnout is a work-related syndrome involving emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment that has become prevalent in all levels of medical training. We ...sought to understand factors associated with burnout identified in vascular surgery trainees.
An anonymous electronic survey consisting of demographic and programmatic information as well as validated scales for burnout, depression, perceived stress, self-efficacy, and social support was given to all vascular surgery trainees in the United States. Univariate and multivariate analyses were used to compare responses. Residents were grouped into quartiles based on burnout level, and predictors of burnout were determined.
Of the 514 invitations sent, 177 (34%) respondents completed the survey. Trainees in the highest quartile of burnout were more likely to have moderate to severe depression (40% vs 4%; P < .01), higher perceived stress score (odds ratio OR, 1.3; P < .01), lower social support (OR, 0.89; P < .01), and lower self-efficacy (OR, 0.76; P < .01), and they were less likely to reconsider vascular surgery as a career if given the chance to do it over (χ2 = 20; P < .01). Trainees without a self-identified mentor were significantly more likely to report burnout (χ2 = 15; P < .01). In addition, trainees who reported more frequent 80-hour work infractions each month (3.6 vs 2.3; P < .01) and those without access to programmatic social events (χ2 = 11; P < .01) had higher levels of burnout. In contrast, trainees with the lowest quartile of burnout scores reported lower depression (OR, 0.43; P < .01), lower stress (OR, 0.63; P < .01), more social support (OR, 0.1.2; P < .01), higher self-efficacy (OR, 1.2; P < .01), and fewer work week violations each month (2.3 vs 2.9; P = .04). Lower burnout scores were associated with program mentorship (χ2 = 7.3; P < .01), program-sponsored social events (χ2 = 8.7; P < .01), and being more likely to choose vascular surgery again if given the chance (χ2 = 6.3; P < .01). Highest burnout scores did not correlate with sex (χ2 < .01; P = 1), age (32 years vs 32 years; P = .65), marital status (χ2 < .01; P = 1), proximity to family (OR, 1.2; P = .26), alcohol consumption (χ2 = 0.23; P = .63), postgraduate year (OR, 1.1; P = .47), number of prior program graduates (OR, 0.95; P = .73), use of physician extenders in the program (OR, 0.93; P = .74), or total debt (OR, 1.0; P = .63). Similarly, there were no significant associations with these variables among trainees with the lowest quartile of burnout scores. On multivariate analysis, higher depression (OR, 1.6; P < .01) and higher perceived stress (OR, 1.2; P < .01) were associated with higher burnout scores, and lower burnout scores were associated with lower perceived stress (OR, 0.67; P < .01).
Burnout in vascular surgery trainees is associated with higher levels of depression and perceived stress and lower levels of social support and self-efficacy. The addition of programmatic social events, limiting 80-hour work week violations, and addition of formal mentoring programs may decrease levels of burnout.
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Burnout affects surgical residents’ well-being.
We sought to identify factors associated with burnout among surgery residents.
An electronic/anonymous survey was sent to surgical residents at 18 ...programs, consisting of demographic/programmatic questions and validated scales for burnout, depression, perceived stress, self-efficacy, and social support. Residents were grouped into quartiles based off burnout, and predictors were assessed using univariate and multivariate analyses.
42% of residents surveyed completed it. Burnout was associated with depression, higher perceived stress/debt, fewer weekends off, less programmatic social events, and residents were less likely to reconsider surgery if given the chance. Low burnout was associated with lower depression/stress, higher social support/self-efficacy, more weekends off per month, program mentorship, lower debt, and residents being more likely to choose surgery again if given the chance. On multivariate analysis, higher depression/perceived stress were associated with burnout, and lower burnout scores were associated with lower stress/higher self-efficacy.
Burnout in surgery residents is associated with higher levels of depression and perceived stress. The addition of programmatic social events, limiting weekend work, and formal mentoring programs may decrease burnout.
•Burnout is associated with general surgery residency.•Burnout is associated with depression, higher perceived stress.•Burnout is associated with fewer weekends off and less social events.•Lower burnout is associated with lower stress and higher self-efficacy.•The addition of programmatic changes may alter burnout in residents.
AbstractAortic graft infection remains one of the most complex clinical challenges faced by vascular specialists; often associated with significant patient morbidity and mortality regardless of the ...approach used for management. The cryopreserved aortic allograft (CAA) is now a commonly used in situ aortic replacement in the management of graft infection; preferred over rifampin-soaked prosthetic grafts. In the review, we summarize the indications for CAA usage, as well as operative technique, clinical results, and alternative treatments. We propose the use of a novel term “tertiary aortic fistula”, to distinguish aortic fistulae in the setting of aortic endograft infection, a clinical entity whose natural history and best management are currently being characterized.
Papillary muscle rupture is a rare condition. Its clinical presentation, diagnosis and management can be very challenging for the clinician.
A 73-year-old woman with hypertension presented with chest ...pain, ST-segment changes, and elevated serum troponin levels. Coronary angiography was normal. Echocardiography revealed normal ventricular function, flail posterior mitral leaflet, and severe mitral regurgitation. She underwent emergent mitral valve replacement.
The diagnostic and management strategies of this uncommon presentation are discussed.
The optimal revascularization modality following complete resection of aortic graft infection (AGI) without enteric involvement remains unclear. The purpose of this investigation is to determine the ...revascularization approach associated with the lowest morbidity and mortality using real-world data in patients undergoing complete excision of AGI.
A retrospective, multi-institutional study of AGI from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and perioperative variables were recorded. The primary outcome was infection-free survival. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariable analyses were performed.
A total of 241 patients at 34 institutions from seven countries presented with AGI during the study period (median age, 68 years; 75% male). The initial aortic procedures that resulted in AGI were 172 surgical grafts (71%), 66 endografts (27%), and three unknown (2%). Of the patients, 172 (71%) underwent complete excision of infected aortic graft material followed by in situ (in-line) bypass (ISB), including antibiotic-treated prosthetic graft (35%), autogenous femoral vein (neo-aortoiliac surgery) (24%), and cryopreserved allograft (41%). Sixty-nine patients (29%) underwent extra-anatomic bypass (EAB). Overall median Kaplan-Meier estimated survival was 5.8 years. Perioperative mortality was 16%. When stratified by ISB vs EAB, there was a significant difference in Kaplan-Meier estimated infection-free survival (2910 days; interquartile range, 391-3771 days vs 180 days; interquartile range, 27-3750 days; P < .001). There were otherwise no significant differences in presentation, comorbidities, or perioperative variables. Multivariable Cox regression showed lower infection-free survival among patients with EAB (hazard ratio HR, 2.4; 95% confidence interval CI, 1.6-3.6; P < .001), polymicrobial infection (HR, 2.2; 95% CI, 1.4-3.5; P = .001), methicillin-resistant Staphylococcus aureus infection (HR, 1.7; 95% CI, 1.1-2.7; P = .02), as well as the protective effect of omental/muscle flap coverage (HR, 0.59; 95% CI, 0.37-0.92; P = .02).
After complete resection of AGI, perioperative mortality is 16% and median overall survival is 5.8 years. EAB is associated with nearly a two and one-half-fold higher reinfection/mortality compared with ISB. Omental and/or muscle flap coverage of the repair appear protective.
Endovascular stent graft placement has been used to facilitate resection of tumors invading the thoracic aorta. Here we describe the first use of an aortic endograft for preoperative protection of ...the thoracic descending aorta before left pneumonectomy for a primary lung cancer invading the thoracic spine and thoracic descending aorta.
Clinical practice guidelines recommend protamine sulfate for reversal of enoxaparin associated bleeds dependent on the time from last administration and dose of enoxaparin. We present a case of a ...hemodynamically unstable patient with an enoxaparin induced abdominal wall hematoma/hemorrhage and the previous enoxaparin administration 21.5 h prior to presentation with a therapeutic anti-Xa assay (0.8 IU/mL) upon assessment in the emergency department. Along with resuscitative efforts, an interdisciplinary team collaborated to administer protamine sulfate 50 mg intravenous once (0.5 mg per 1 mg of enoxaparin) to reverse the therapeutic anticoagulation. Our case demonstrates the importance of monitoring renal function and the potential for accumulation of enoxaparin in patients with renal dysfunction leading to prolonged therapeutic anti-Xa assays. With the availability of anti-Xa assays, future reversal recommendations of enoxaparin associated bleeds using protamine sulfate should include the initial anti-Xa assay as a guide for the dosing regimen.
Abstract Objective Asymptomatic internal carotid artery occlusion (CO) presents a clinical dilemma, and presently, the natural history, stroke risk, and optimal management remain ill defined. This ...study compared outcomes, including neurovascular events (NVEs) and health care costs, between patients with CO and patients with asymptomatic carotid artery stenosis (CS). Methods A prospectively maintained database was queried to identify patients with CO and CS with at least >50% carotid stenosis by duplex. We identified and reviewed 622 consecutive patients with asymptomatic carotid artery disease at one academic medical center between 2011 and 2013. Patients with CO (n = 97) were identified and propensity matched by age and gender in a 1:2 ratio with CS patients (n = 194) for further analyses. Univariate and multivariate models were used to analyze baseline characteristics, clinical variables, and 1-year follow-up data from the date of diagnosis. Multivariate analysis was performed by multiple linear regression modeling. Institutional Review Board approval was obtained. Results Follow-up data were available for 99% of matched patients. CO patients were younger (72 vs 75 years; P < .01) and more likely male (67% vs 53%; P = .01) compared with CS patients. After propensity matching, baseline characteristics were similar between groups, with a trend toward higher use of statin therapy among patients with CO. Antiplatelet therapy was used in 79% of patients with CS and in 74% of patients with CO ( P = .45). The rate of NVE among CO patients was higher than among CS patients at 1 year of follow-up (14% vs 7%; P = .03). Among those with NVE, neither antiplatelet therapy (64% vs 77%; P = .49) nor statin therapy (86% vs 77%; P = .58) appeared to have a significant effect. Health care costs ($14,361 vs $12,142; P = .44) and hospital admission rate (63% vs 71%; P = .18) were similar between groups. Not surprisingly, the rate of vascular procedures was higher in the CS group (55% vs 27%; P = .04). Conclusions Patients with asymptomatic CO experience more NVEs compared with similar patients with moderately severe CS. Further study of preventative strategies, including intensity of medical therapy, is warranted.
ABSTRACT
Cardiac surgeons have variable exposure to thoracic aortic EndoVascular repair (TEVAR) as the primary surgeon. As paradigms evolve and EndoVascular structural heart interventions expand, ...TEVAR utilization by cardiac surgeons is of particular interest. In order to definitively manage thoracic aortic pathologies in the modern era, cardiac surgeons must incorporate TEVAR into their armamentarium during surgical training or risk a prolonged learning curve.
Key Points
Stent‐grafts, also known as endografts, must provide an adequate seal against the target vessel(s) at both proximal and distal areas of apposition, known as “landing zones.”
TEVAR may be utilized for aneurysmal or occlusive (i.e., dissection) vascular disease.
It is essential to be familiar with each step of the stent‐graft procedures to decrease the likelihood of potentially lethal complications.
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