An Ontological, Anthropological, and Psychoanalytic Perspective on Physician Burnout.

Post-industrialization, societies have evolved with profound changes in ways of life. However, it was not until just recently that the overall impact of its deleterious and pernicious effects has been widely recognized, studied, and accepted. In the last few years, increased rates of stress and burnout (BO) not only affect clinicians, personally, but health care systems across the nation. The understanding of BO in the realm of current nosological limitations lacks context and is often unrecognized given the stigma associated with mental illness. However, the emerging data regarding this syndrome is highly concerning. Its impact on professionals and leaders across various disciplines is puzzling and underscores the nature and extent of the problem. A search of PubMed, PsycINFO, Cochrane Library, and Google Scholar was conducted from the date of inception until June 2022 using the keywords Burnout", "Mental Health"," Physicians", "Addiction", "Health Care Workers", "Anthropology", "Psychopathology", Philosophy", "Wellness". The search resulted in the identification of 135 articles; 56 articles met the inclusion criteria for the review. Post-pandemic BO has reached distressing levels. BO remains poorly understood highly complex and has multifactorial etiology which is now included in the 11th Revision of the International Classification of Diseases (ICD-11) as an occupational phenomenon. Besides being linked with known factors such as long work hours, administrative burdens, and a lack of control over one's work environment there are many confounders. It is a serious issue that can have negative consequences for both the physician and the patient, and therefore mitigation strategies are needed. The awareness of these unmanifested conflicts, mindfulness training, limiting addictive habits, and efforts toward wellness may provide some alternative solutions. Lastly, developing a coherent philosophy may be useful for distress tolerance, dealing with ambiguity related to the profession, and paving the way to a more meaningful life.

Implementation of enhanced recovery in cardiac surgery: An experimental study with the control group.

INTRODUCTION: The Enhanced Recovery After Cardiac Surgery protocol is the most recent addition to cardiac treatment. In this paper, we aimed to test the safety and viability of this protocol in our hospital to improve our standard of care. METHODS: This study was conducted as an experimental study with a historical control at the Maritime Heart Center, Halifax, Nova Scotia, Canada. In order to quantify the success of this protocol, we measured the postoperative Length of Hospital Stay and three intensive care unit variables: time to extubation, time to ambulation, and opioid consumption. In the study, 100 patients were in the Enhanced Recovery After Cardiac Surgery group, and 103 patients were used as historic controls-selected by strenuous chart review and selection criteria. RESULTS: The primary outcome (Length of Hospital Stay) was reduced from a mean of 8.88 ± 3.50 days in the control group to a mean of 5.13 ± 1.34 days in the Enhanced Recovery After Cardiac Surgery group (p < 0.001). Likewise, we observed a significant reduction in intensive care unit variables: time to extubation was reduced from 10.54 ± 7.83 h in the control group to 6.69 ± 1.63 in the Enhanced Recovery After Cardiac Surgery group (p < 0.01), and time to ambulation was reduced from 36.27 ± 35.21 h in the control group to 9.78 ± 2.03 in the Enhanced Recovery After Cardiac Surgery group (p < 0.01) and opioid consumption was reduced from 50.58 ± 11.93 milligram morphine equivalent in the control group to 11.58 ± 4.43 milligram morphine equivalent in the Enhanced Recovery After Cardiac Surgery group (p < 0.01). CONCLUSION: Enhanced Recovery After Cardiac Surgery protocols were seamlessly integrated into selected cardiac surgical patients, contingent on a high level of interprofessional communication and collaboration.

Cardiovascular Outcomes in Nova Scotia During the Early Phase of the COVID-19 Pandemic.

BACKGROUND: This study sought to determine the impact of the COVID-19 pandemic response to healthcare delivery on outcomes in patients with cardiovascular disease. METHODS: This is a population-based cohort study performed in the province of Nova Scotia, Canada (population 979,499), between the pre-COVID (March 1, 2017-March 16, 2020) and in-COVID (March 17, 2020-December 31, 2020) periods. Adult patients (age ≥ 18 years) with new-onset or existing cardiovascular disease were included for comparison between periods. The main outcome measures included the following: cardiovascular emergency department visits or hospitalizations, mortality, and out-of-hospital cardiac arrest. RESULTS: In the first month of the in-COVID period, emergency department visits (n = 51,750) for cardiac symptoms decreased by 20.8% (95% confidence interval [CI] 14.0%-27.0%, P < 0.001). Cardiovascular hospitalizations (n = 20,609) declined by 48.1% (95% CI 40.4% to 54.9%, P < 0.001). The in-hospital mortality rate increased in patients with cardiovascular admissions in secondary care institutions by 55.1% (95% CI 10.1%-118%, P = 0.013). A decline of 20.4%-44.0% occurred in cardiovascular surgical/interventional procedures. The number of out-of-hospital cardiac arrests (n = 5528) increased from a monthly mean of 115 ± 15 to 136 ± 14, beginning in May 2020. Mortality for ambulatory patients awaiting cardiac intervention (n = 14,083) increased from 0.16% (n = 12,501) to 2.49% (n = 361) in the in-COVID period (P < 0.0001). CONCLUSIONS: This study demonstrates increased cardiovascular morbidity and mortality during restrictions maintained during the COVID-19 period, in an area with a low burden of COVID-19. As the healthcare system recovers or enters subsequent waves of COVID-19, these findings should inform communication to the public regarding cardiovascular symptoms, and policy for delivery of cardiovascular care.

CONTEXTE: Cette étude visait à déterminer les répercussions de la réponse à la pandémie de COVID-19 sur la prestation des soins de santé et son incidence sur les résultats obtenus par les patients atteints d'une maladie cardiovasculaire. MÉTHODOLOGIE: Il s'agit d'une étude de cohorte représentative de la population réalisée dans la province de la Nouvelle-Écosse, au Canada (population de 979 499 habitants), entre la période précédant le début de la pandémie de COVID-19 (du 1er mars 2017 au 16 mars 2020) et la période de pandémie (du 17 mars 2020 au 31 décembre 2020). Des patients adultes (âge ≥ 18 ans) atteints d'une maladie cardiovasculaire préexistante ou d'apparition récente ont été inclus pour la comparaison entre les périodes. Les principaux paramètres d'évaluation comprenaient les visites ou hospitalisations dans un service d'urgences cardiovasculaires, la mortalité et l'arrêt cardiaque en milieu extrahospitalier. RÉSULTATS: Au cours du premier mois de la période de pandémie, les visites aux services des urgences (n = 51 750) pour des symptômes cardiaques ont diminué de 20,8 % (intervalle de confiance [IC] à 95 % : 14,0 % ­ 27,0 %, p < 0,001). Les hospitalisations en raison d'un événement cardiovasculaire (n = 20 609) ont décliné de 48,1 % (IC à 95 % : 40,4 % ­ 54,9 %, p < 0,001). Le taux de mortalité hospitalière parmi les patients admis dans des établissements de soins secondaires a augmenté de 55,1 % (IC à 95 % : 10,1 % ­ 118 %, p = 0,013). Une baisse de 20,4 à 44,0 % du nombre d'interventions chirurgicales ou interventionnelles visant à prendre en charge un événement cardiovasculaire a également été enregistrée. Le nombre d'arrêts cardiaques survenus en milieu extrahospitalier (n = 5 528) est passé d'une moyenne mensuelle de 115 ± 15 à 136 ± 14, à compter de mai 2020. La mortalité des patients ambulatoires en attente d'une intervention cardiaque (n = 14 083) a augmenté, passant de 0,16 % (n = 12 501) à 2,49 % (n = 361) pendant la période de pandémie (p < 0,0001). CONCLUSIONS: Cette étude révèle une augmentation de la morbidité et de la mortalité cardiovasculaires durant le maintien des restrictions liées à la COVID-19 dans une région où le fardeau associé à cette maladie est faible. À mesure que le système de santé se rétablit ou affronte les vagues subséquentes de COVID-19, ces résultats devraient éclairer les communications au public concernant les symptômes cardiovasculaires et orienter la politique de prestation de soins cardiovasculaires.

Patient-prosthesis mismatch and surgical aortic valve replacement outcomes: Retrospective analysis of single-center surgical data.

BACKGROUND: Patient-prosthesis mismatch (PPM) has been identified as a risk factor for mortality and reoperation in patients undergoing surgical aortic valve replacement (SAVR). We present a retrospective analysis of risk factors for PPM and the effects of PPM on early postoperative outcomes after SAVR. METHODS: Chart review was conducted for patients (N = 3003) undergoing SAVR. PPM was calculated from valve reference orifice areas and patient body surface area. Logistic regression was used to analyze risk factors for PPM and develop a risk score from these results. Regression was also conducted to identify associations between projected PPM status and postoperative outcomes. RESULTS: Risk factors for PPM included female sex, higher body mass index (BMI), and use of the St. Jude Epic valve. Patients receiving St. Jude trifecta valves or mechanical valves were less likely to have predicted PPM. We developed a risk score using BMI, sex, and valve type, and retrospectively predicted PPM in our cohort. Mild PPM (odds ratio [OR] = 2.267), severe PPM (OR = 2.869), male sex (OR = 2.091), and younger age (OR = 0.940) were all predictors of SAVR reoperation, while aortic root replacement was associated with reduced reoperation rates (OR = 0.122). Severe PPM carried a risk of in-hospital mortality (OR = 3.599), and moderate PPM carried a smaller but significant risk (OR = 1.920). Other factors increasing postoperative morbidity and mortality included older age, renal failure, and diabetes. CONCLUSION: PPM could be retrospectively predicted in our cohort using a risk calculation from sex, BMI and valve type. We conclude that all degrees of PPM carry risk for mortality and reoperation.

Mitral valve myxoma presenting with transient ischemic attack: a case report and review of the literature.

BACKGROUND: Myxomas account for approximately half of all primary cardiac neoplasms. Most occur in the left atrium and only rarely are attached to the mitral valve, with just over 30 such cases reported in the literature. These neoplasms can manifest with a combination of obstruction of blood flow, systemic embolization, and constitutional symptoms. CASE DESCRIPTION: We present a case of a 32-year-old African American man presenting at an emergency department with symptoms of a transient ischemic attack. Transesophageal echocardiography identified a mass originating from the posterior leaflet of the mitral valve. The mass was surgically resected and histologically classified as a myxoma. He remained asymptomatic during the course of 5-year surveillance. CONCLUSIONS: Few similar cases have been described in the literature. Here we present a review of the diagnosis and surgical management of this rare presentation for mitral valve myxoma.

A rare presentation of myxofibrosarcoma as a Pancoast tumor: a case report.

BACKGROUND: Myxofibrosarcoma is an aggressive soft tissue neoplasm, classified as a variant of malignant fibrous histiocytoma. Most often, it occurs in middle to late adult life peaking in the seventh decade and involving the lower extremities (77%), trunk (12%), and retroperitoneum or mediastinum (8%). We report the first case of thoracic myxofibrosarcoma presenting as a Pancoast tumor. CASE PRESENTATION: A 48-year-old non-tobacco smoking African-American man presented with a slow-growing mass in his neck along with 11 kg weight loss over 9 months. A review of his systems was positive for hoarseness and lowgrade intermittent fever without any shortness of breath or cough. A physical examination revealed a mass on the left side of his neck superior to his sternoclavicular joint measuring 3 × 3 × 1 cm. He had ptosis and miosis of his left eye. His breath sounds were decreased and coarse at the left apex. A neurological examination revealed 3/5 strength in his left upper arm. The remainder of the physical examination was unremarkable. Ultrasound of his neck showed an ill-defined heterogeneous mass lateral to his left thyroid lobe. A computed tomography scan of his chest showed a large multiloculated pleural-based mass in his left lung surrounding the adjacent neurovascular structures. A percutaneous biopsy was non-diagnostic. Subsequently, he underwent a left thoracotomy with biopsy. The mass extended from his anterior mediastinum medially at the level of the pulmonary trunk, superiorly into the superior sulcus and posteriorly into his chest wall. Surgical pathology confirmed the diagnosis of myxofibrosarcoma. CONCLUSIONS: Here we present a case of Pancoast tumor with myxofibrosarcoma as the underlying etiology. Pancoast syndrome generally entails an infiltrating lesion in the superior sulcus presenting with upper extremity pain, atrophy of the hand muscles, and Horner's syndrome. The differential diagnosis of Pancoast syndrome includes inflammatory and infectious etiologies, as well as neoplasms of benign and malignant nature. Of the neoplasms implicated, the most common are non-small cell lung carcinomas; myxofibrosarcoma presenting as a Pancoast tumor has not been reported in the literature.

Reevaluation of the utilization of arterial blood gas analysis in the Intensive Care Unit: effects on patient safety and patient outcome.

PURPOSE: Arterial blood gas (ABG) analysis is a useful tool to evaluate hypercapnia in the context of conditions and diseases affecting the lungs. Oftentimes, indications for ABG analysis are broad and nonspecific and lead to frequent testing without test results influencing patient management. MATERIALS AND METHODS: Electronic charts of 300 intensive care unit (ICU) patients at a single institution were reviewed retrospectively. Reassessment of indications for ABGs led to a decrease of the number of ABGs in the ICU between March and November 2012. Data relating to ventilator days, length of stay, number of reintubations, mortality, complications after arterial puncture, demographics, and medications in 159 ICU patients between December 2011 and February 2012 (group 1) were compared with 141 ICU patients between December 2012 and February 2013 (group 2). Subgroup analysis in ventilated patients was performed. RESULTS: A decrease of number of ABGs per patient (6.12 ± 5.9, group 1 vs 2.03 ± 1.66, group 2 in ventilated patients; P = .007) was found along with a decrease in the number of ventilator days per patient (P = .004) and a shorter length of stay for ventilated patients in group 2 compared with group 1 (P = .04). CONCLUSION: A significant decrease of ABGs obtained in the ICU does not negatively impact patient outcome and safety. A decrease in the number of ABGs per patient allows cost-efficient patient care with a lower risk for complications.

Coronary artery bypass graft surgery: the past, present, and future of myocardial revascularisation.

The development of the heart-lung machine ushered in the era of modern cardiac surgery. Coronary artery bypass graft surgery (CABG) remains the most common operation performed by cardiac surgeons today. From its infancy in the 1950s till today, CABG has undergone many developments both technically and clinically. Improvements in intraoperative technique and perioperative care have led to CABG being offered to a more broad patient profile with less complications and adverse events. Our review outlines the rich history and promising future of myocardial revascularization.

Diabetes and coronary heart disease: a risk factor for the global epidemic.

Cardiovascular disease remains a leading cause of death in the United States and the world. In this we will paper focus on type 2 diabetes mellitus as a risk factor for coronary heart disease, review the mechanisms of atherogenesis in diabetics, the impact of hypertension and the treatment goals in diabetics, the guidelines for screening, and review the epidemiologic consequences of diabetes and heart disease on a global scale. The underlying premise to consider diabetes a cardiovascular disease equivalent will be explored as well as the recommendations for screening and cardiac testing for asymptomatic diabetic patients.

Use of recombinant factor VII in cardiac surgery.

The off-label use of recombinant human coagulation factor VIIa has been increasing to a number of different treatment areas since its original approval in 1999. Several US patents describe claims for FVIIa utilization in nonhemophilia patients, treatment of bleeding due to trauma, as a means to reverse major bleeding, including intracranial bleeding, induced from fibrinolytic therapy as well as a patent for using FVIIa in the treatment of bleeding for patients with bleeding disorders not caused by hemophilia, but rather bleeding disorders due to thrombocytopenia, platelet disorders, and von Willebrand's disease. Bleeding after cardiac surgery remains a serious complication that can increase both morbidity and mortality. We review the off-label usage of recombinant factor VIIa as a hemostatic agent that may help control bleeding following cardiac surgery.

Current outcomes of simultaneous carotid endarterectomy and coronary artery bypass graft surgery in North America.

OBJECTIVE: Management of patients with concomitant carotid and coronary artery disease has been controversial. Divergent strategies have been employed, including simultaneous carotid endarterectomy and coronary bypass (SCC) versus various staged procedures. Although no strict comparison group is available, this study defines current outcomes of SCC, compared qualitatively to two reference categories. METHODS: Utilizing the STS database from 2003 to 2007, patients who had SCC were compared with patients with cerebrovascular disease who had coronary bypass (CABG) with prior carotid endarterectomy (CEA), and those with carotid Doppler stenosis >75% and no carotid intervention. Logistic regression analysis adjusted for differences in baseline characteristics and operative mortality (OM), and a composite of neurological complications (NC) was assessed. RESULTS: Of 745,769 patients who underwent isolated CABG with/without CEA, 108,212 (14%) had cerebrovascular disease. Of this group, 5,732 (5%) underwent SCC. The SCC group had more males and lower preoperative risk factors. After statistical adjustment for all baseline differences, SCC had clinically and statistically higher OM and NC compared with any of the reference groups, with 20-40% higher event risk. CONCLUSIONS: Although no quantitative control group exists for comparison, SCC as recently performed in North America has a high risk compared with any of the reference groups. Suboptimal results associated with the SCC strategy suggest a need for quality improvement and research on the optimal management of patients with simultaneous carotid and coronary disease.

Current and future therapy for pulmonary hypertension in patients with right and left heart failure.

Pulmonary hypertension (PH) is a devastating condition that without proper management can deteriorate progressively. Elevated pulmonary artery pressure without an identifiable etiology is called IPAH. PH resulting from a specific disease is referred to as secondary PH; left-sided cardiac disease can lead to an increase in pulmonary artery pressure resulting in increased vascular resistance and subsequent structural remodeling. If left-sided failure progresses to right-sided failure with high pulmonary artery pressure, the outcome is ominous. It has been clearly proven that early diagnosis and effective medical therapy can markedly decrease morbidity and mortality. In this review, we discuss the current treatment modalities and their limitations for PH secondary to heart failure. Conventional therapy in patients with pulmonary arterial hypertension as well as recent advances in the medical management of PH in general, are also described. Last, the surgical management of these patients and other promising interventional modalities are reviewed.

Bivalirudin: alternative anticoagulation during cardiopulmonary bypass in patients with heparin-induced thrombocytopenia.

An estimated 1-3% of patients who receive therapeutic anticoagulation with unfractionated heparin (UFH) develop antibodies to heparin with concomitant development of thrombocytopenia, defined as HIT or Heparin-Induced Thrombocytopenia. HIT complicates the management of patients presenting for cardiac surgery, particularly those who need cardiopulmonary bypass (CPB) which requires a large dose of UFH. A portion of these patients will have significant thrombotic complications referred to as HITT (Heparin-induced thrombocytopenia with thrombosis). In patients with established or suspected HIT, all heparin must be withheld and an alternative form of anticoagulation utilized for CPB. Various approaches and pharmacological alternatives have been described but no regimen has replaced the routine use of UFH anticoagulation with protamine reversal after CPB. We review the use of bivalirudin as a reliable and safe alternative anticoagulation strategy during cardiopulmonary bypass with specific emphasis on patients with HIT and outlining some recent patents.

Weathering the storm: how can thoracic surgery training programs meet the new challenges in the era of less-invasive technologies?

OBJECTIVE: The introduction of new technologies has shifted some resident index procedures to nonsurgical specialists. We examined the operative case volume of thoracic surgery residents during the last 6 years to objectively identify changes and trends. METHODS: Program and resident data from 2002 to 2007 were entered into a database and analyzed. Program match information was obtained from the National Resident Matching Program. Resident operative experience and board examination results were obtained from the American Board of Thoracic Surgery. RESULTS: A total of 795 residents qualified for the written American Board of Thoracic Surgery examination; 627 residents graduated from 2-year programs, and 168 residents graduated from 3-year programs. The total number of resident cases was higher in 3-year programs compared with 2-year programs in all 10 index categories studied (P < .01). The total volume of cases has not significantly increased in 2-year programs. The volume of coronary artery bypass graft surgeries decreased in every resident program model studied. The volume of general thoracic cases increased in all program models. Two-year, 2-resident programs had the lowest volume in 5 of the 10 categories, reaching significance in 3 categories. The written board pass rate was lower among 2-year programs than among 3-year programs (86% vs 95%, respectively, P = .003). CONCLUSION: Training programs have so far weathered the storm by maintaining index volume with a new case mix, but significant trends in revascularization procedures are concerning. This study indicates a significant advantage in case volume and board pass rates among 3-year programs. Thoracic residency programs should be reorganized so that the number of residents does not exceed the capacity of the program to provide a meaningful experience.

A perspective on the surgical management of congestive heart failure.

Surgical treatment of patients with congestive heart failure (CHF) has steadily advanced from rescue procedures such as aneurysmectomy, rupture repair, ventricular assist devices (VADs), and transplantation to procedures that can prevent or delay the progression of cardiac dysfunction and failure. The latter include operations such as coronary artery bypass grafting (CABG) and mitral valve repair for patients with ischemic cardiomyopathy (ICMP) and mitral annular dilatation, ventricular restoration and remodeling, and cardiac resynchronization therapy. As the number of heart transplants reported worldwide continues to decline over the past decade (by over 30%), newer surgical therapies have emerged. A need arises for clinical registries such as the NIH-sponsored LVAD registry and registries for biventricular pacing and AICD implantation, for total artificial heart implants, and for mitral valve repair in patients with ICMP. Prospective trials comparing sole ventricular restoration therapy (SVR) to SVR with concomitant CABG/MVR, coronary sinus versus epicardial LV pacing for ventricular resynchronization therapy, trials comparing LVAD as destination therapy to AICD implants, mitral valve repair versus chordal-sparing valve replacement for ischemic and valvular cardiomyopathy, and off-pump versus on-pump CABG for patients with ICMP are urgently needed. Future research should also be directed toward drugs targeting "B-cell mediated" humeral vascular rejection--the Achilles heel of cardiac transplantation, xenotransplantation, permanently implantable VADs, gene therapy, and myocardial cell regeneration therapy.

Endovascular treatment of aortic aneurysms: techniques and clinical update.

Open repair of abdominal and thoracic aortic aneurysms continues to be associated with considerable morbidity and mortality. Endovascular repair of abdominal and thoracic aortic aneurysms has evolved over the past few years and has significantly reduced the morbidity of aortic aneurysm repair compared with the standard open surgical procedures. Several devices have been approved for clinical use for this purpose. This has allowed the treatment of patients who are otherwise at high risk for open repair. This review paper aims to (1) describe the general principles of use for endovascular devices and review the radiographic features and clinical trials for the devices in current use, (2) present the results of the clinical trials that led to the approval and marketing of the current devices, and (3) review new techniques and approaches for the treatment of aortic aneurysms.