Palliative care training and associations with burnout in oncology fellows.

BACKGROUND: Burnout among physicians can lead to decreased career satisfaction, physical and emotional exhaustion, and increased medical errors. In oncologists, high exposure to fatal illness is associated with burnout. METHODS: The Maslach Burnout Inventory, measuring Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA), was administered to second-year US oncology fellows. Bivariate and multivariate analyses explored associations between burnout and fellow demographics, attitudes, and educational experiences. RESULTS: A total of 254 fellows out of 402 eligible US fellows responded (63.2%) and 24.2% reported high EE, 30.0% reported high DP, and 26.8% reported low PA. Over half of the fellows reported burnout in at least one domain. Lower EE scores were associated with the fellows' perceptions of having received better teaching, explicit teaching about certain end-of-life topics, and receipt of direct observation of goals-of-care discussions. Fellows who reported better overall teaching quality and more frequent observation of their skills had less depersonalization. Fellows who felt a responsibility to help patients at the end of life to prepare for death had higher PA. LIMITATIONS: This survey relies on the fellows' self-reported perceptions without an objective measure for validation. Factors associated with burnout may not be causal. The number of analyses performed raises the concern for Type I errors; therefore, a stringent P value (0.01) was used. CONCLUSIONS: Burnout is prevalent during oncology training. Higher-quality teaching is associated with less burnout among fellows. Fellowship programs should recognize the prevalence of burnout among oncology fellows as well as components of training that may protect against burnout.

Intraoperative use of recombinant activated factor VII during complex aortic surgery.

OBJECTIVE: Postoperative bleeding is a major cause of morbidity and mortality after complex aortic surgery. Intraoperative coagulopathy is a well-known culprit in this process. Recombinant activated factor VII is increasingly used for the postoperative management of such bleeding. We report our experience with the intraoperative use of this agent. METHODS: We performed a propensity-matched analysis on 376 retrospectively identified patients who underwent aortic root, arch, or ascending aortic replacement surgeries from 1999 to 2010. We matched a total of 58 patients: recombinant activated factor VII-treated group (n = 29) and nonrecombinant activated factor VII-treated group (n = 29). We compared the matched patients on re-exploration, mortality, bleeding-related events, use of blood and blood products, length of intensive care unit stay, duration of hospitalization, and thrombotic complications. RESULTS: Propensity-matched patients had similar preoperative and intraoperative characteristics. The mean dose of recombinant activated factor VII group was 23 ± 12 µg/kg. We found significantly lower rates of surgical re-exploration (P = .004), fewer prolonged intubations (P = .004), less total chest tube output (P = .01), and fewer units of packed red blood cells (P = .01) and fresh-frozen plasma (P = .04) transfused postoperatively in the recombinant activated factor VII group. There was no significant difference in mortality (P = 1), duration of intensive care unit stay (P = .44) or hospital stay (P = .32), or thrombotic complications between the groups (P = .5). CONCLUSIONS: We recommend the intraoperative administration of low-dose recombinant activated factor VII but limited to the management of persistent, nonsurgical, mediastinal bleeding in aortic surgery. Further prospective randomized studies and larger cohorts are needed to verify these findings.

Bovine thrombin induces an acquired coagulopathy in sensitized patients undergoing revision spinal surgery: a report of two cases.

STUDY DESIGN: A report of two cases is presented. OBJECTIVE: To raise awareness of bovine thrombin-induced factor V deficiency. SUMMARY OF BACKGROUND DATA: Bovine thrombin is a frequently used hemostatic agent in spinal surgery. Current preparations contain clotting factors in addition to thrombin, particularly factor V, which are immunogenic. Re-exposure of sensitized patients to bovine thrombin products during subsequent surgery may lead to the formation of antibodies that cross-react with human clotting factors, most commonly against factor V. Hemorrhagic complications have been reported in nonspinal patients due to a bovine thrombin-induced factor V deficiency. METHODS: Two spinal cases are reported, and the literature is reviewed. RESULTS: In the cases outlined, both patients underwent revision spinal surgery, with re-exposure to bovine thrombin. Both patients developed abnormal coagulation profiles, with an acquired factor V deficiency. No hemorrhagic complications occurred; however, second-stage surgery was delayed in one patient and not undertaken in the other. In both patients, the coagulopathy resolved spontaneously. CONCLUSIONS: Bovine thrombin-induced coagulopathy is well recognized in cardiac surgery but has not been reported in spinal surgical patients. Data available from cardiac surgical patients suggests that those who are sensitized to two or more bovine clotting factors are at greatest risk of hemorrhagic complications. The cases we present demonstrate that this phenomenon occurs in spinal surgical patients and serve to raise awareness of the potential danger of bovine thrombin in sensitized patients.