Veno-arterial ECMO ventricular assistance as a direct bridge to heart transplant: A single center experience in a low-middle income country.

INTRODUCTION: The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a direct bridge to heart transplantation (BTT) is not common in adults worldwide. BTT with ECMO is associated with increased early/mid-term mortality compared with other interventions. In low- and middle-income countries (LMIC), where no other type of short-term mechanical circulatory support is available, its use is widespread and increasingly used as rescue therapy in patients with cardiogenic shock (CS) as a direct bridge to heart transplantation (HT). OBJECTIVE: To assess the outcomes of adult patients using VA-ECMO as a direct BTT in an LMIC and compare them with international registries. METHODS: We conducted a single-center study analyzing consecutive adult patients requiring VA-ECMO as BTT due to refractory CS or cardiac arrest (CA) in a cardiovascular center in Argentina between January 2014 and December 2022. Survival and adverse clinical events after VA-ECMO implantation were evaluated. RESULTS: Of 86 VA-ECMO, 22 (25.5%) were implanted as initial BTT strategy, and 52.1% of them underwent HT. Mean age was 46 years (SD 12); 59% were male. ECMO was indicated in 81% for CS, and the most common underlying condition was coronary artery disease (31.8%). Overall, in-hospital mortality for VA-ECMO as BTT was 50%. Survival to discharge was 83% in those who underwent HT and 10% in those who did not, p < .001. In those who did not undergo HT, the main cause of death was hemorrhagic complications (44%), followed by thrombotic complications (33%). The median duration of VA-ECMO was 6 days (IQR 3-16). There were no differences in the number of days on ECMO between those who received a transplant and those who did not. In the Spanish registry, in-hospital survival after HT was 66.7%; the United Network of Organ Sharing registry estimated post-transplant survival at 73.1% ± 4.4%, and in the French national registry 1-year posttransplant survival was 70% in the VA-ECMO group. CONCLUSIONS: In adult patients with cardiogenic shock, VA-ECMO as a direct BTT allowed successful HT in half of the patients. HT provided a survival benefit in listed patients on VA-ECMO. We present a single center experience with results comparable to those of international registries.

Clinical predictors of coronary artery bypass graft surgery in patients hospitalized for Non-ST acute coronary syndrome - Buenos Aires I and ReSCAR22 registries.

Objectives: To identify predictors of coronary artery bypass graft surgery (CABG) requirement as a revascularization method in in real-world non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients. Materials and methods: . An individual pre-specified analysis of patients with NSTE-ACS was performed from two prospective Argentine registries between 2017 and 2022. We analyzed the difference in baseline characteristics between patients who required CABG and those who did not require this intervention. Then, a logistic regression analysis was performed to determine independent predictors in patients who received CABG as a method of revascularization. Results: A total of 1848 patients with a median age of 54.8 (interquartile range [IQR]: 53.7-56) years and an ejection fraction of 42.1% (IQR: 41.2-43.1) were included. A total of 233 patients required CABG (12.6%). Baseline characteristics between the two groups were similar, except in patients requiring CABG, who were younger (51.5 vs. 55.7 years; p=0.010), more frequently diabetic (38.2% vs. 25.7%; p=0.001) and male (90.1% vs. 73.7%; p=0.001). In addition, they had, to a lesser extent, previous cardiac surgery (2.1% vs. 11.2%; p=0.011). After multivariable analysis, the following were independently associated with CABG: age (Odds Ratio [OR]: 0.99, 95% confidence interval [CI]: 0.98-0.99; p=0.008), male sex (OR: 3.08, 95% CI: 1.87-5.1; p=0.001), history of previous CABG (OR: 0.14, 95% CI: 0.05-0.30; p=0.001) and diabetes (OR: 1.84, 95% CI: 1.31- 2.57; p=0.001). Conclusions: In this analysis of two NSTEACS registries, younger age, male sex, a diagnosis of diabetes and the absence of previous surgery were independent predictors of the requirement for inpatient CABG.

Ten Years of a Trans-Pacific Medical Education Partnership-Training Globally to Serve Locally.

Background: In 2009, Ochsner Health in New Orleans, Louisiana, and The University of Queensland (UQ) in Brisbane, Queensland, Australia, formed a medical school partnership. The rationale for UQ to enter this partnership was to strengthen its already strong international multicultural environment and enrich the domestic Australian student experience. The rationale for Ochsner Health was to raise its academic stature and to train high-quality physicians. This partnership is unique among US international partnerships because the intent is for graduates to practice in the United States. Methods: A new 10-year agreement began in January 2020 with further enhancements to the program. This article describes the educational philosophy informing the partnership, the programmatic design, challenges faced and overcome, and outcomes from the first 10 graduating cohorts of this medical program. Results: The UQ-Ochsner Clinical School partnership posed many challenges. UQ faced a major cultural shift to implement United States Medical Licensing Examination step preparation. Student recruitment challenges and state-specific accreditation concerns had to be solved. The coronavirus disease 2019 pandemic presented unique challenges with the strict prohibition on travel into Australia. Challenges were addressed, and the tenth graduating class completed training in December 2021. More than 850 medical students have graduated from the program, with 30% staying in Louisiana for postgraduate training. The overall first-attempt match rate of 95% exceeds the US allopathic average. Although graduates have faced stigma from their designation as international medical graduates, they have successfully matched in every specialty and in almost every US state. Conclusion: The UQ-Ochsner Clinical School partnership has been successful for the institutions involved and the students who have graduated. The overarching aim of the partnership, "train globally to serve locally," has endured. Through their training in this partnership, UQ-Ochsner Clinical School graduates bring a unique global outlook to their roles while helping to fill the increasing need for physicians in the United States.

A protocol for an international, multicentre pharmacokinetic study for Screening Antifungal Exposure in Intensive Care Units: The SAFE-ICU study.

Objective: To describe whether contemporary dosing of antifungal drugs achieves therapeutic exposures in critically ill patients that are associated with optimal outcomes. Adequate antifungal therapy is a key determinant of survival of critically ill patients with fungal infections. Critical illness can alter an antifungal agents' pharmacokinetics, increasing the risk of inappropriate antifungal exposure that may lead to treatment failure and/or toxicity. Design setting and participants: This international, multicentre, observational pharmacokinetic study will comprise adult critically ill patients prescribed antifungal agents including fluconazole, voriconazole, posaconazole, isavuconazole, caspofungin, micafungin, anidulafungin, and amphotericin B for the treatment or prophylaxis of invasive fungal disease. A minimum of 12 patients are targeted for enrolment for each antifungal agent, across 12 countries and 30 intensive care units to perform descriptive pharmacokinetics. Pharmacokinetic sampling will occur during two dosing intervals (occasions): firstly, between days 1 and 3, and secondly, between days 4 and 7 of the antifungal course, collecting three samples per occasion. Patients' demographic and clinical data will be collected. Main outcome measures: The primary endpoint of the study is attainment of pharmacokinetic/pharmacodynamic target exposures that are associated with optimal efficacy. Thirty-day mortality will also be measured. Results and conclusions: This study will describe whether contemporary antifungal drug dosing achieves drug exposures associated with optimal outcomes. Data will also be used for the development of antifungal dosing algorithms for critically ill patients. Optimised drug dosing should be considered a priority for improving clinical outcomes for critically ill patients with fungal infections.

Multiparameters associated to successful weaning from VA ECMO in adult patients with cardiogenic shock or cardiac arrest: Systematic review and meta-analysis.

Venoarterial extracorporeal membrane oxygenation (VA ECMO) is a form of temporary mechanical circulatory support and simultaneous extracorporeal gas exchange for acute cardiorespiratory failure, including refractory cardiogenic shock (CS) and cardiac arrest (CA). Few studies have assessed predictors of successful weaning (SW) from VA ECMO. This systematic review and meta-analysis aimed to identify a multiparameter strategy associated with SW from VA ECMO. PubMed and the Cochrane Library and the International Clinical Trials Registry Platform were searched. Studies reporting adult patients with CS or CA treated with VA ECMO published from the year 2000 onwards were included. Primary outcomes were hemodynamic, laboratory, and echocardiography parameters associated with a VA ECMO SW. A total of 11 studies (n=653) were included in this review. Pooled VA ECMO SW was 45% (95%CI: 39-50%, I2 7%) and in-hospital mortality rate was 46.6% (95%CI: 33-60%; I2 36%). In the SW group, pulse pressure [MD 12.7 (95%CI: 7.3-18) I2 = 0%] and mean blood pressure [MD 20.15 (95%CI: 13.8-26.4 I2 = 0) were higher. They also had lower values of creatinine [MD -0.59 (95%CI: -0.9 to -0.2) I2 = 7%], lactate [MD -3.1 (95%CI: -5.4 to -0.7) I2 = 89%], and creatine kinase [-2779.5 (95%CI: -5387 to -171) I2 = 38%]. And higher left and right ventricular ejection fraction, MD 17.9% (95%CI: -0.2-36.2) I2 = 91%, and MD 15.9% (95%CI 11.9-20) I2 = 0%, respectively. Different hemodynamic, laboratory, and echocardiographic parameters were associated with successful device removal. This systematic review demonstrated the relationship of multiparametric assessment on VA ECMO SW.

[Impact of a multidisciplinary team "ECMO Team" on the prognosis of patients undergoing veno-arterial extracorporeal membrane oxygenation for refractory cardiogenic shock and cardiac arrest]. / Impacto del equipo multidisciplinario "ECMO Team" en el pronóstico de pacientes sometidos a membrana de oxigenación extracorpórea venoarterial por choque cardiogénico o paro cardiorrespiratorio refractario.

Objectives: Veno-arterial Extracorporeal membrane oxygenation (VA ECMO) is a salvage intervention in patients with cardiogenic shock (CS), and cardiac arrest (CA) refractory to standard therapies. The design of ECMO Teams has achieved the standardization of processes, although its impact on survival and prognosis is unknown. Objective: We aimed to analyze whether the creation of an ECMO Team has modified the prognosis of patients undergoing VA ECMO for refractory CS or CA. Materials and methods: . We conducted a single-center retrospective cohort study. Patients with refractory CS or CA who underwent VA ECMO were divided in two consecutive periods: from 2014 to April 2019 (pre-ECMO T) and from May 2019 to December 2022 (Post ECMO T). The main outcomes were survival on ECMO, in-hospital survival, complications, and annual ECMO volume. Results: Eighty-three patients were included (36 pre-ECMO T and 47 post-ECMO T). The mean age was 53 +/-13 years. The most common reason for device indication was different: postcardiotomy shock (47.2%) pre-ECMO T and refractory cardiogenic shock (29.7%) post-ECMO T. The rate of extracorporeal cardiopulmonary resuscitation was 14.5%. The median duration of VA ECMO was longer after ECMO team implementation: 8 days (IQR 5-12.5) vs. five days (IQR 2-9, p=0.04). Global in-hospital survival was 45.8% (38.9% pre-ECMO T vs. 51.1% post-ECMO T; p=0.37), and the survival rate from VA ECMO was 60.2% (55.6% pre-ECMO T vs 63.8% post-ECMO T; p= 0.50). The volume of VA ECMO implantation was significantly higher in the post-ECMO team period (13.2 +/3.5 per year vs. 6.5 +/-3.5 per year, p: 0.02). The rate of complications was similar in both groups. Conclusions: After the implementation of an ECMO team, there was no statistical difference in the survival rate of patients treated with VA ECMO. However, a significant increase in the number of patients supported per year was observed after the implementation of this multidisciplinary team. Post-ECMO T, the most common reason for device indication was cardiogenic shock, with longer run times and a higher rate of extracorporeal cardiopulmonary resuscitation.

Bilateral internal thoracic artery grafting in elderly patients: Any benefit in survival?

OBJECTIVE: The purpose of the present study was to compare survival outcomes in propensity score-matched patients aged 70 years or greater receiving a bilateral internal thoracic artery graft with patients receiving a single internal thoracic artery graft. METHODS: Among 4083 consecutive patients with isolated coronary artery bypass grafting who underwent operation between January 2001 and December 2018, we identified 1300 patients aged 70 years or greater; of these, 968 received a bilateral internal thoracic artery (bilateral internal thoracic artery group) and 332 received a single internal thoracic artery (single internal thoracic artery group). Propensity score matching was used to reduce the preoperative patient differences. The 10-year survival and postoperative complications were compared between the 2 groups. RESULTS: A Kaplan-Meier curve at 10 years of follow-up showed that crude survival was significantly superior in patients with bilateral internal thoracic artery grafts than in patients with single internal thoracic artery grafts (67.0% ± 2.5% vs 56.0% ± 3.4%, respectively; P < .016). In the actuarial survival, estimates for propensity score-matched patients with a bilateral internal thoracic artery showed a significantly higher rates of survival than patients with a single internal thoracic artery by the end of follow-up (66.0% ± 5.3% vs 53.0% ± 3.9%, respectively; hazard ratio, 0.64; 95% confidence interval, 0.44-0.94; P = .022, univariable Cox Model and multivariable analysis hazard ratio, 0.66; 95% confidence interval, 0.45-0.97; P = .036 Cox model). Postoperative complications were all similar between the single internal thoracic artery and bilateral internal thoracic artery groups. CONCLUSIONS: The use of bilateral internal thoracic artery grafting in older patients improves 10-year survival, with similar postoperative morbidity. This surgical technique might have beneficial effects in survival in patients aged more than 70 years. Its use could be considered more frequently.

Prevalence, Distribution and IgG Antibody Levels Associated with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Among Health-System and Community-Based Employees and Patients.

BACKGROUND: Following the high morbidity and mortality due to Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infections in New Orleans, Louisiana, we sought to assess progress toward herd immunity. METHODS: Ochsner Health employees and patients who volunteered for Abbott SARS-CoV-2 immunoglobulin G (IgG) antibody test between March 1 and May 1, 2020 were included. We estimated IgG prevalence and used logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI) for variables associated with IgG test status. RESULTS: Of the 13,343 participants with IgG test results, 78.6% were women, 70.6% were non-Hispanic White, 21.1% non-Hispanic Black, 2.9% Hispanic Americans and 5.4% belonged to other races. Overall, 7.99% (95% CI: 7.53-8.45%) of the participants tested IgG positive. In age-, sex- and body mass index (BMI)-adjusted analyses, non-Hispanic Blacks were 2.7-times more likely to test positive than non-Hispanic Whites (OR=2.72; 95% CI: 2.33-3.19). Corresponding ORs (95% CIs) were 1.29 (0.84-1.99) for Hispanic Americans and 1.22 (0.85-1.75) for Other race/ethnicities. Compared to participants in administrative occupations, physician assistants (OR=7.14; 95% CI: 1.72-29.6) and therapists (OR=4.74; 95% CI: 1.49-15.03) were significantly more likely to have IgG antibodies while the association among nurses was not significant (OR=2.35; 95% CI: 0.96-5.77). Relative to 1.40, the test threshold for positivity, our measurements indicate a strong immune response (5.38±1.69), especially among those with a higher BMI. CONCLUSIONS: SARS-COV-2 IgG antibodies were prevalent only in 8% of the participants. IgG prevalence was highest among non-Hispanic Blacks and participants with higher BMI but was lower among older participants.

Community versus individual risk of SARS-CoV-2 infection in two municipalities of Louisiana, USA: An assessment of Area Deprivation Index (ADI) paired with seroprevalence data over time.

OBJECTIVE: Determine whether an individual is at greater risk of severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) infection because of their community or their individual risk factors. STUDY DESIGN AND SETTING: 4,752 records from two large prevalence studies in New Orleans and Baton Rouge, Louisiana were used to assess whether zip code tabulation areas (ZCTA)-level area deprivation index (ADI) or individual factors accounted for risk of infection. Logistic regression models assessed associations of individual-level demographic and socioeconomic factors and the zip code-level ADI with SARS-CoV-2 infection. RESULTS: In the unadjusted model, there were increased odds of infection among participants residing in high versus low ADI (both cities) and high versus mid-level ADI (Baton Rouge only) zip codes. When individual-level covariates were included, the odds of infection remained higher only among Baton Rouge participants who resided in high versus mid-level ADI ZCTAs. Several individual factors contributed to infection risk. After adjustment for ADI, race and age (Baton Rouge) and race, marital status, household size, and comorbidities (New Orleans) were significant. CONCLUSIONS: While higher ADI was associated with higher risk of SARS-CoV-2 infection, individual-level participant characteristics accounted for a significant proportion of this association. Additionally, stage of the pandemic may affect individual risk factors for infection.

New combined risk score to predict atrial fibrillation after cardiac surgery: COM-AF.

Background and Aims: Atrial fibrillation frequently occurs in the postoperative period of cardiac surgery, associated with an increase in morbidity and mortality. The scores POAF, CHA2DS2-VASc and HATCH demonstrated a validated ability to predict atrial fibrillation after cardiac surgery (AFCS). The objective is to develop and validate a risk score to predict AFCS from the combination of the variables with highest predictive value of POAF, CHA2DS2-VASc and HATCH models. Methods: We conducted a single-center cohort study, performing a retrospective analysis of prospectively collected data. The study included consecutive patients undergoing cardiac surgery in 2010-2016. The primary outcome was the development of new-onset AFCS. The variables of the POAF, CHA2DS2-VASc and HATCH scores were evaluated in a multivariate regression model to determine the predictive impact. Those variables that were independently associated with AFCS were included in the final model. Results: A total of 3113 patients underwent cardiac surgery, of which 21% presented AFCS. The variables included in the new score COM-AF were: age (≥75: 2 points, 65-74: 1 point), heart failure (2 points), female sex (1 point), hypertension (1 point), diabetes (1 point), previous stroke (2 points). For the prediction of AFCS, COM-AF presented an AUC of 0.78 (95% CI 0.76-0.80), the rest of the scores presented lower discrimination ability (P < 0.001): CHA2DS2-VASc AUC 0.76 (95% CI 0.74-0.78), POAF 0.71 (95% CI 0.69-0.73) and HATCH 0.70 (95% CI: 0, 67-0.72). Multivariable analysis demonstrated that COM-AF score was an independent predictor of AFCS: OR 1,91 (IC 95% 1,63-2,23). Conclusion: From the combination of variables with higher predictive value included in the POAF, CHA2DS2-VASc, and HATCH scores, a new risk model system called COM-AF was created to predict AFCS, presenting a greater predictive ability than the original ones. Being necessary future prospective validations.

Utilización de oxigenación por membrana extracorpórea venoarterial en el shock cardiogénico y paro cardiorrespiratorio refractarios: experiencia inicial de 7 años en un centro de cardiología de adultos / Venoarterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock and Cardiac Arrest: An Initial 7-Year Experience in an Adult Cardiology Center

RESUMEN Introducción: La oxigenación por membrana extracorpórea venoarterial (ECMO VA) es una intervención de rescate en pacientes con shock cardiogénico (SC), y paro cardiorrespiratorio (PCR) refractarios a las terapias convencionales. Objetivo: Describir las características, y resumir nuestra experiencia inicial de 7 años de pacientes que requirieron ECMO VA por SC o PCR. Material y métodos: Se realizó un estudio de cohorte unicéntrico. Se analizaron retrospectivamente los pacientes adultos consecutivos que fueron asistidos con ECMO VA por SC o PCR refractarios entre 2014 y 2020 en el ICBA Instituto Cardiovascular. Resultados: Se incluyeron 54 pacientes, (54 ± 12 años). El 36,5% presentó miocardiopatía isquémica, y el 23,1% enfermedad valvular significativa. Las indicaciones para ECMO VA fueron: poscardiotomía (43,4%), SC refractario (28,3%), y falla primaria del injerto (20,8%). La reanimación cardiopulmonar previa a la ECMO VA se realizó en el 18,5%. La canulación fue periférica en el 81,5%, el 83,3% se asistió en INTERMACS 1, y el 87% presentaba balón de contrapulsación intraaórtico. La duración de asistencia en ECMO VA fue de 5,5 días (RIC 2,8-10). La tasa de supervivencia en ECMO VA fue del 63% (37% puente a trasplante cardíaco, y 26% recuperación), y al alta del 42,6%. Las complicaciones más frecuentes fueron: sangrado (61,1%), infección (51,9%), y complicaciones tromboembólicas (46,3%). Conclusión: La ECMO VA como tratamiento del SC o PCR refractarios en nuestro centro presentó una sobrevida aceptable al alta hospitalaria. La ECMO VA es un tratamiento efectivo cuando las terapias convencionales fallan, siendo aparentemente útil y aplicable en un país donde existe acceso limitado a los dispositivos de asistencia ventricular compleja.

ABSTRACT Background: Venoarterial extra corporeal membrane oxygenation (VA-ECMO) is a rescue intervention used in patients with cardiogenic shock (CS) or cardiac arrest (CA) refractory to conventional medical therapies. Objective: The aim of the present study is to describe the characteristics and summarize our 7-year experience in patients with CS or CA supported with VA-ECMO. Methods: We conducted a single-center retrospective study analyzing consecutive adult patients requiring VA-ECMO due to refractory CS or CA at ICBA, Instituto Cardiovascular between January 2014 and December 2020. Results: A total age 54 patients were included (54 ± 12 years), 36.5% presented ischemic cardiomyopathy and 23.1% significant valvular heart disease. The indications for VA-ECMO implantation were post-cardiotomy (43.4%), refractory CS (28.3%) and primary graft dysfunction (20.8%). Cardiopulmonary resuscitation before VA-ECMO occurred in 18.5% of the cases. Peripheral cannulation was performed in 81.5% of the cases, 83.3% had INTERMACS profile 1 and 87% were on intraaortic balloon pump. Duration of ventricular assistance on VA- ECMO was 5.5 days (IQR 2.8-10). Survival rate on ECMO VA was 63% (37% as a bridge to cardiac transplantation and 26% as a bridge to recovery) and survival to discharge was 42.6%. The most common complications were hemorrhage (61.1%), infections (51.9%), and thromboembolic complications (46.3%). Conclusion: In our center, VA-ECMO as a treatment for refractory CS or CA showed acceptable survival during ventricular support and on hospital discharge. It is an effective life support treatment to rescue critically ill patients when conventional therapies fail, is apparently useful and can be implemented in a country with limited resources and access to complex ventricular assist devices.

Prognostic Value of the Leuko-Glycaemic Index in the Postoperative Period of Coronary Artery Bypass Grafting

Abstract Introduction: High leuko-glycaemic index (LGI) (> 2000) has been associated with poor prognosis in many critical care settings. However, there is no evidence of LGI's prognostic value in the postoperative period of coronary artery bypass grafting (CABG). This study aims to analyze the prognostic value of LGI in the postoperative period of CABG. Methods: Single-center retrospective analysis of prospectively collected data was performed. Consecutive adult patients undergoing CABG between 2007 and 2019 were included. Blood glucose levels and white blood cells count were evaluated in the immediate postoperative period. LGI was calculated by multiplying both values and dividing them by 1,000 and analyzed in quartiles. Receiver operating characteristic curve was used to determine the best cutoff value. The primary combined endpoint was in-hospital mortality, low cardiac output (LCO), or acute kidney injury (AKI). Secondary endpoints included in-hospital death, AKI, atrial fibrillation, and LCO. Results: The study evaluated 3,813 patients undergoing CABG (88.5% male, 89.8% off-pump surgery, aged 64.6 years [standard deviation 9.6]). The median of LGI was 2,035. Presence of primary endpoint significantly increased per LGI quartile (9.2%, 9.7%, 11.8%, and 15%; P<0.001). High LGI was associated with increased occurrence of in-hospital mortality, LCO, AKI, and atrial fibrillation. The best prognostic cutoff value for primary endpoint was 2,000. In a multivariate logistic regression model, high LGI was independently associated with in-hospital death, LCO, or AKI. Conclusion: High LGI was an independent predictor of in-hospital mortality, LCO, or AKI in postoperative period of CABG. It was also associated with higher in-hospital death.

Distributed leadership in healthcare: leadership dyads and the promise of improved hospital outcomes.

PURPOSE: This paper aims to extend the consideration of distributed leadership in health-care settings. Leadership is typically studied from the classical notion of the place of single leaders and continues to examine distributed leadership within small teams or horizontally. The purpose is to develop a practical understanding of how distributed leadership may occur vertically, between different layers of the health-care leadership hierarchy, examining its influence on health-care outcomes across two hospitals. DESIGN/METHODOLOGY/APPROACH: Using semi-structured interviews, data were collected from 107 hospital employees (including executive leadership, clinical management and clinicians) from two hospitals in Australia and the USA. Using thematic content analysis, an iterative process was adopted characterized by alternating between social identity and distributed leadership literature and empirical themes to answer the question of how the practice of distributed leadership influences performance outcomes in hospitals? FINDINGS: The perceived social identities of leadership groups shaped communication and performance both positively and negatively. In one hospital a moderating structure emerged as a leadership dyad, where leadership was distributed vertically between hospital hierarchal layers, observed to overcome communication limitations. Findings suggest dyad creation is an effective mechanism to overcome hospital hierarchy-based communication issues and ameliorate health-care outcomes. ORIGINALITY/VALUE: The study demonstrates how current leadership development practices that focus on leadership relational and social competencies can benefit from a structural approach to include leadership dyads that can foster these same competencies. This approach could help develop future hospital leaders and in doing so, improve hospital outcomes.

Personality, Resilience, and Calling in Students Undertaking a Medical Degree Across Two Continents: Disparate Pathways to the Healing Profession.

Background: An educational partnership between The University of Queensland (UQ) in Australia and Ochsner Health in the United States developed the UQ-Ochsner medical program that trains American citizens to practice medicine in the United States. This program provides the opportunity to explore and compare the personal characteristics of UQ-Ochsner students with their domestic (Australian citizen) and international classmates not enrolled in the Ochsner program. Findings may offer some insights into the types of students who choose to study medicine across multiple countries. Methods: We used a quantitative cross-sectional design for our study. A first-year cohort of domestic, international, and UQ-Ochsner students completed a survey comprising demographic questions and measures of temperament and character personality, resilience, and calling to medicine. Univariate statistics were used to compare groups for all variables. Results: The whole sample response rate was 72.1% (375/520). Domestic students represented the greatest proportion of students <25 years, and UQ-Ochsner students represented the greatest proportion of students of ≥26 years. Gender did not differ significantly between groups. The majority first degree for all students was science, although 23% of UQ-Ochsner students reported arts/law/humanities degrees. In comparison to all other students (domestic and international combined), UQ-Ochsner students scored significantly lower in levels of harm avoidance (P=0.039) and higher in self-directedness and self-transcendence, resilience, and calling with medium to strong effect sizes (d>0.3). Conclusion: UQ-Ochsner students have a personality profile similar to their classmates but with levels of certain traits-higher self-directedness and lower harm avoidance-that in combination contribute to higher resilience and a strong sense of calling to medicine. Being slightly older may allow for more development of self-directedness, but low harm avoidance suggests an innate degree of confidence in and acceptance of risk to achieving goals.

Prognostic Value of the Leuko-Glycaemic Index in the Postoperative Period of Coronary Artery Bypass Grafting.

INTRODUCTION: High leuko-glycaemic index (LGI) (> 2000) has been associated with poor prognosis in many critical care settings. However, there is no evidence of LGI's prognostic value in the postoperative period of coronary artery bypass grafting (CABG). This study aims to analyze the prognostic value of LGI in the postoperative period of CABG. METHODS: Single-center retrospective analysis of prospectively collected data was performed. Consecutive adult patients undergoing CABG between 2007 and 2019 were included. Blood glucose levels and white blood cells count were evaluated in the immediate postoperative period. LGI was calculated by multiplying both values and dividing them by 1,000 and analyzed in quartiles. Receiver operating characteristic curve was used to determine the best cutoff value. The primary combined endpoint was in-hospital mortality, low cardiac output (LCO), or acute kidney injury (AKI). Secondary endpoints included in-hospital death, AKI, atrial fibrillation, and LCO. RESULTS: The study evaluated 3,813 patients undergoing CABG (88.5% male, 89.8% off-pump surgery, aged 64.6 years [standard deviation 9.6]). The median of LGI was 2,035. Presence of primary endpoint significantly increased per LGI quartile (9.2%, 9.7%, 11.8%, and 15%; P<0.001). High LGI was associated with increased occurrence of in-hospital mortality, LCO, AKI, and atrial fibrillation. The best prognostic cutoff value for primary endpoint was 2,000. In a multivariate logistic regression model, high LGI was independently associated with in-hospital death, LCO, or AKI. CONCLUSION: High LGI was an independent predictor of inhospital mortality, LCO, or AKI in postoperative period of CABG. It was also associated with higher in-hospital death.

Cirugía de preservación valvular como alternativa en enfermedad de la raíz aórtica / Aortic Valve Sparing Surgery as Alternative in Aortic Root Disease

RESUMEN Introducción: Desde 1968, la enfermedad aneurismática de la raíz aórtica ha sido tratada mediante el remplazo con tubo valvulado. En las últimas décadas la cirugía de preservación valvular surgió y evolucionó como una opción al remplazo protésico. Objetivo: Reportar la experiencia institucional en la técnica de preservación valvular y sus resultados a largo plazo. Material y métodos: Revisión de 116 casos consecutivos con criterios de reparabilidad, intervenidos entre 2005 y 2019. Previo ecocardiograma transesofágico (ETE) y angiotomografía (AngioTC), se procedió quirúrgicamente acorde a la clasificación anatomofuncional, con la combinación de técnicas. Se realizó control intraoperatorio y conversión a remplazo según el criterio del cirujano interviniente. Se reportan las variables intraoperatorias, la morbimortalidad intrahospitalaria y la mortalidad, la libertad de insuficiencia valvular significativa y la reoperación en el seguimiento clínico y ecocardiográfico. Resultados: La edad media era 56 ± 15,6 años, varones 73%, 59% asintomáticos, intervenidos por diámetro aórtico (52 ± 11,7 mm) o progresión de valvulopatía. En el posprocedimiento, 4% de los casos resultó con insuficiencia leve o nula y 2 conversiones (1,7%); mortalidad hospitalaria 0,9%. A 10 años de seguimiento, sobrevida actuarial del 88% y libertad de insuficiencia significativa (moderada/grave) 79%. Se reintervinieron 5 casos, a un intervalo promedio de 9,1 años, libertad de reoperación de 90% a 10 años. No se registraron eventos tromboembólicos ni hemorrágicos mayores. Conclusión: las técnicas de preservación valvular aórtica, en contexto de enfermedad de la raíz, resultan una opción factible, segura y estable en el tiempo.

ABSTRACT Background: Since 1968, ascending aorta replacement with a valved conduit has been the standard practice for aortic root aneurysm. By the end of the 20th century, aortic valve sparing operation emerged and evolved as an alternative to aortic valve replacement. Objective: The aim of this study was to report our experience with aortic valve sparing technique and its long -term outcomes. Methods: A total of 116 consecutive cases with criteria of repairability operated on between 2005 and 2019 were analyzed. Preopera- tive transesophageal echocardiography (TEE) and computed tomography angiography (CTA) were used in combination to determine the aortic phenotype based on a previous anatomical and functional classification. Perioperative control was performed and conver- sion to aortic valve replacement was left to the discretion of the attending surgeon. Intraoperative variables, in-hospital morbidity and mortality, freedom from significant aortic regurgitation (AR) and reoperation in the clinical and echocardiographic follow-up were reported. Results: Mean age was 56±15.6 years and 73% were men; 59% were asymptomatic, and the reason for the intervention was the aortic diameter (52±11.7 mm) or progression of AR. After the procedure, 4% of the cases presented mild or trivial AR and 2 patients required conversion to aortic valve replacement (1.7%). In hospital mortality was 0.9%. Actuarial survival was 88% at 10 years, and 79% were free from significant (moderate/severe) AR. Five cases underwent reoperation after a mean interval of 9.1 years and free- dom from reoperation at 10 years was 90%. There were no major thromboembolic or bleeding events. Conclusion: Aortic valve sparing technique in the setting of aortic root disease is a feasible and safe option, and stable over time.

The importance of anosmia, ageusia and age in community presentation of symptomatic and asymptomatic SARS-CoV-2 infection in Louisiana, USA; a cross-sectional prevalence study.

OBJECTIVE: While many seroprevalence studies of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been performed, few are demographically representative. This investigation focused on defining the nature and frequency of symptomatic and asymptomatic SARS-CoV-2 infection in a representative, cross-sectional sample of communities in Louisiana, USA. METHODS: A sample of 4778 adults from New Orleans and Baton Rouge, Louisiana were given a survey of symptoms and co-morbidities, nasopharyngeal swab to test for active infection (PCR), and blood draw to test for past infection (IgG). Odds ratios, cluster analysis, quantification of virus and antibody, and linear modelling were used to understand whether certain symptoms were associated with a positive test, how symptoms grouped together, whether virus or antibody varied by symptom status, and whether being symptomatic was different across the age span. RESULTS: Reported anosmia/ageusia was strongly associated with a positive test; 40.6% (93/229) tested positive versus 4.8% (218/4549) positivity in those who did not report anosmia/ageusia (OR 13.6, 95% CI 10.1-18.3). Of the people who tested positive, 47.3% (147/311) were completely asymptomatic. Symptom presentation clustered into three groups; low/no symptoms (0.4 ± 0.9, mean ± SD), highly symptomatic (7.5 ± 1.9) or moderately symptomatic (4.0 ± 1.5). Quantity of virus was lower in the asymptomatic versus symptomatic group (cycle number 23.3 ± 8.3 versus 17.3 ± 9.0; p < 0.001). Modelling the probability of symptoms showed changes with age; the highest probability of reporting symptoms was 64.6% (95% CI 50.4-76.5) at age 29 years, which decreased to a probability of 49.3% (95% CI 36.6-62.0) at age 60 years and only 25.1% (95% CI 5.0-68.1) at age 80 years. CONCLUSION: Anosmia/ageusia can be used to differentiate SARS-CoV-2 infection from other illnesses, and, given the high ratio of asymptomatic individuals, contact tracing should include those without symptoms. Regular testing in congregant settings of those over age 60 years may help mitigate asymptomatic spread.

Is the Obesity Paradox in Cardiac Surgery Really a Myth? Effect of Body Mass Index on Early and Late Clinical Outcomes.

OBJECTIVE: The present study was conducted to investigate the obesity paradox and assess the effect of body mass index (BMI) on early and late clinical outcomes after cardiac surgery. DESIGN: Cohort study with a retrospective analysis of prospectively collected data. DESIGN: Single-institution cardiology medical center. PARTICIPANTS: The study comprised consecutive patients undergoing cardiac surgery from January 2009 to January 2019. Patients were divided into the following 4 groups defined by BMI: underweight (UW) (≤18.5 kg/m2): 0.5%, n = 27; normal weight (18.5-25 kg/m2): 25.7%, n = 1,393; overweight (OW) (>25-30 kg/m2): 44.7%, n = 2,423; and obese (OB) (≥30 kg/m2): 29.1%, n = 1,576. INTERVENTIONS: No interventions. MEASUREMENTS AND MAIN RESULTS: A multivariate analysis was used to compare clinical outcomes among the different BMI groups. Overall 1-year survival of patients in the BMI categories was determined by the Kaplan-Meier method and compared using the log rank test. The study included 5,419 patients. The BMI groups were significantly different regarding presurgical variables. Mortality according to BMI exhibited a reverse J-shaped relationship: 7.4% in the UW group, 5.2% in the normal weight group, 3.2% in the OW group, and 4.3% in the OB group (p = 0.016). Low- cardiac- output syndrome and bleeding were more frequent in the UW group, whereas mediastinitis and hyperglycemia were more common in the OB group. After adjusting for other risk factors, BMI was not an independent predictor of in-hospital mortality. One-year follow-up was completed in 95% of the patients, and the analysis of long-term mortality did not show a difference among the BMI categories (p log rank = 0.16). CONCLUSION: OW patients had a lower mortality and better outcomes after cardiac surgery. However, when other preoperative variables were taken into account, BMI did not have independent effect on in-hospital and 1-year mortality.