Epilepsy Education: Recent Advances and Future Directions.

PURPOSE OF REVIEW: The goal of this review is to survey the current literature on education in epilepsy and provide the most up-to-date information for physicians involved in the training of future doctors on this topic. We intended to review what opportunities exist to enhance our current teaching practices that may not be well-known or widely used, but may be adapted to a broader audience. RECENT FINDINGS: Many new techniques adopting principles of education (e.g., retrieval practice and spaced learning) or new technologies (e.g., pre-recorded lectures, computer-enhanced modules, and simulation practice) have been trialled to enhance medical education in epilepsy with some success. Many of these techniques are currently adaptable to a wider audience or may soon be available. The use of these opportunities more broadly may allow expansion of educational research opportunities as well as enhancing our ability to pass on information. As the knowledge base in epilepsy continues to dramatically expand, we need to keep evaluating our teaching techniques to ensure we are able to pass along this knowledge to our future providers.

Chronic herpes simplex type-1 encephalitis with intractable epilepsy in an immunosuppressed patient.

BACKGROUND: Chronic herpes simplex virus type-1 encephalitis (HSE-1) is uncommon. Past reports focused on its association with prior documented acute infection. Here, we describe a patient with increasingly intractable epilepsy from chronic HSE-1 reactivation without history of acute central nervous system infection. CASE PRESENTATION: A 49-year-old liver transplant patient with 4-year history of epilepsy after initiation of cyclosporine developed increasingly frequent seizures over 3 months. Serial brain magnetic resonance imaging showed left temporoparietal cortical edema that gradually improved despite clinical decline. Herpes simplex virus type-1 (HSV-1) DNA was detected in cerebrospinal fluid by polymerase chain reaction. Cerebrospinal fluid HSV-1&2 IgM was negative. Seizures were controlled after acyclovir treatment, and the patient remained seizure free at 1-year follow-up. CONCLUSION: Chronic HSE is a cause of intractable epilepsy, can occur without a recognized preceding acute phase, and the clinical course of infection may not directly correlate with neuroimaging changes.

Crosstalk between TGF-ß1 and complement activation augments epithelial injury in pulmonary fibrosis.

The epithelial complement inhibitory proteins (CIPs) cluster of differentiation 46 and 55 (CD46 and CD55) regulate circulating immune complex-mediated complement activation in idiopathic pulmonary fibrosis (IPF). Our previous studies demonstrated that IL-17A mediates epithelial injury via transforming growth factor ß1 (TGF-ß1) and down-regulates CIPs. In the current study, we examined the mechanistic role of TGF-ß1 in complement activation-mediated airway epithelial injury in IPF pathogenesis. We observed lower epithelial CIP expression in IPF lungs compared to normal lungs, associated with elevated levels of complement component 3a and 5a (C3a and C5a), locally and systemically. In normal primary human small airway epithelial cells (SAECs) treated with TGF-ß1 (10 ng/ml), C3a, or C5a (100 nM), we observed loss of CIPs and increased poly(ADP-ribose) polymerase (PARP) activation [also observed with RNA interference (RNAi) of CD46/CD55]. TGF-ß1-mediated loss of CIPs and Snail induction [SNAI1; a transcriptional repressor of E-cadherin (E-CAD)] was blocked by inhibiting mitogen-activated protein kinase (p38MAPK; SB203580) and RNAi silencing of SNAI1. C3a- and C5a-mediated loss of CIPs was also blocked by p38MAPK inhibition. While C3a upregulated TGFb transcripts, both C3a and C5a down-regulated SMAD7 (negative regulator of TGF-ß), and whereas TGF-ß1 induced C3a/C5a receptor (C3aR/C5aR) expression, pharmacologic C3aR/C5aR inhibition protected against C3a-/C5a-mediated loss of CIPs. Taken together, our results suggest that epithelial injury in IPF can be collectively amplified as a result of TGF-ß1-induced loss of CIPs leading to complement activation that down-regulates CIPs and induces TGF-ß1 expression

Role of complement activation in obliterative bronchiolitis post-lung transplantation.

Obliterative bronchiolitis (OB) post-lung transplantation involves IL-17-regulated autoimmunity to type V collagen and alloimmunity, which could be enhanced by complement activation. However, the specific role of complement activation in lung allograft pathology, IL-17 production, and OB is unknown. The current study examines the role of complement activation in OB. Complement-regulatory protein (CRP) (CD55, CD46, complement receptor 1-related protein y/CD46) expression was downregulated in human and murine OB; and C3a, a marker of complement activation, was upregulated locally. IL-17 differentially suppressed complement receptor 1-related protein y expression in airway epithelial cells in vitro. Neutralizing IL-17 recovered CRP expression in murine lung allografts and decreased local C3a production. Exogenous C3a enhanced IL-17 production from alloantigen- or autoantigen (type V collagen)-reactive lymphocytes. Systemically neutralizing C5 abrogated the development of OB, reduced acute rejection severity, lowered systemic and local levels of C3a and C5a, recovered CRP expression, and diminished systemic IL-17 and IL-6 levels. These data indicated that OB induction is in part complement dependent due to IL-17-mediated downregulation of CRPs on airway epithelium. C3a and IL-17 are part of a feed-forward loop that may enhance CRP downregulation, suggesting that complement blockade could be a therapeutic strategy for OB.

Recipient body mass index and age interact to impact survival after heart transplantation.

Although recipient body mass index (BMI) and age are known risk factors for mortality after heart transplantation, how they interact to influence survival is unknown. Our study utilized the UNOS registry from 1997 to 2012 to define the interaction between BMI and age and its impact on survival after heart transplantation. Recipients were stratified by BMI: underweight (<18.5), normal weight (18.5-24.99), overweight (25-29.99), and either moderate (30-34.99), severe (35-39.99), or very severe (≥40) obesity. Recipients were secondarily stratified based on age: 18-40 (younger recipients), 40-65 (reference group), and ≥65 (advanced age recipients). Among younger recipients, being underweight was associated with improved adjusted survival (HR 0.902; p = 0.010) while higher mortality was seen in younger overweight recipients (HR 1.260; p = 0.005). However, no differences in adjusted survival were appreciated in underweight and overweight advanced age recipients. Obesity (BMI ≥ 30) was associated with increased adjusted mortality in normal age recipients (HR 1.152; p = 0.021) and even more so with young (HR 1.576; p < 0.001) and advanced age recipients (HR 1.292; p = 0.001). These results demonstrate that BMI and age interact to impact survival as age modifies BMI-mortality curves, particularly with younger and advanced age recipients.

Impact of donor age on survival after heart transplantation: an analysis of the United Network for Organ Sharing (UNOS) registry.

BACKGROUND: Data are limited regarding the influence of donor age on outcomes after heart transplantation. We sought to determine if advanced donor age is associated with differences in survival after heart transplantation and how this compares to waitlist survival. METHODS: All adult heart transplants from 2000 to 2012 were identified using the United Network for Organ Sharing database. Donors were stratified into four age groups: 18-39 (reference group), 40-49, 50-54, and 55 and above. Propensity scoring was used to compare status IA waitlist patients who did not undergo transplantation with IA recipients who received hearts from advanced age donors. The primary outcome of interest was recipient survival and this was analyzed with multivariate Cox regression analysis and the Kaplan-Meier method. RESULTS: A total of 22,960 adult heart transplant recipients were identified. Recipients of hearts from all three older donor groups had significantly increased risk of mortality (HR, 1.187-1.426, all p < 0.001) compared to recipients from donors age 18 to 39. Additionally, propensity-matched status IA patients managed medically without transplantation had significantly worse adjusted survival than status IA recipients who received hearts from older donors age ≥55 (HR, 1.362, p < 0.001). CONCLUSIONS: Compared to donors aged 18-39, age 40 and above is associated with worse adjusted recipient survival in heart transplantation. This survival difference becomes more pronounced as age increases to above 55. However, the survival rate among status IA patients who receive hearts from advanced age donors (≥55) is significantly better compared to similar status IA patients who are managed without transplantation.

The role of autoimmunity in obliterative bronchiolitis after lung transplantation.

First performed in the 1960s with long-term successes achieved in the 1980s, lung transplantation remains the only definitive treatment option for end-stage lung disease. Chronic lung rejection, pathologically classified as obliterative bronchiolitis (OB) with its clinical correlate referred to as bronchiolitis obliterans syndrome, is the limiting factor than keeps 5-yr survival rates for lung transplant significantly worse than for other solid organ transplants. Initially, OB was largely attributed to immune responses to donor antigens, alloimmunity. However, more recent work has demonstrated the role of autoimmunity in the process of lung transplant rejection. IL-17 and autoantigens such as collagen type V and K-α1 tubulin have been implicated in the development of chronic rejection. Ultimately, this translational review discusses the role that autoimmunity plays in the development of OB and lung transplant rejection and then discusses options for therapeutic intervention.

Intercostal Nerve Cryoanalgesia Versus Thoracic Epidural Analgesia in Lung Transplantation: A Retrospective Single-Center Study.

INTRODUCTION: The optimal pain management strategy after lung transplantation is unknown. This study compared analgesic outcomes of intercostal nerve blockade by cryoanalgesia (Cryo) versus thoracic epidural analgesia (TEA). METHODS: Seventy-two patients who underwent bilateral lung transplantation via clamshell incision at our center from 2016 to 2018 were managed with TEA (N = 43) or Cryo (N = 29). We evaluated analgesic-specific complications, opioid use in oral morphine equivalents (OME), and pain scores (0-10) through postoperative day 7. Adjusted linear regression was used to assess for non-inferiority of Cryo to TEA. RESULTS: The overall mean pain scores (Cryo 3.2 vs TEA 3.8, P = 0.21), maximum mean pain scores (Cryo 4.7 vs TEA 5.5, P = 0.16), and the total opioid use (Cryo 484 vs TEA 705 OME, P = 0.12) were similar in both groups, while the utilization of postoperative opioid-sparing analgesia, measured as use of lidocaine patches, was lower in the Cryo group (Cryo 21% vs TEA 84%, P < 0.001). Analgesic outcomes remained similar between the cohorts after adjustment for pertinent patient and analgesic characteristics (P = 0.26), as well as after exclusion of Cryo patients requiring rescue TEA (P = 0.32). There were no Cryo complications, with four patients requiring subsequent TEA for pain control. Two TEA patients experienced hemodynamic instability following a test TEA bolus requiring code measures. Additionally, TEA placement was delayed beyond postoperative day 1 in 33% owing to need for anticoagulation or clinical instability. CONCLUSIONS: In lung transplantation, Cryo was found to be safe with analgesic effectiveness similar to TEA. Cryo may be advantageous in this complex patient population, as it can be used in all clinical scenarios and eliminates risks and delays associated with TEA.

A review of available prosthetics for ventral hernia repair.

OBJECTIVE: To review mesh products currently available for ventral hernia repair and to evaluate their efficacy in complex repair, including contaminated and reoperative fields. BACKGROUND: Although commonly referenced, the concept of the ideal prosthetic has never been fully realized. With the development of newer prosthetics and approaches to the ventral hernia repair, many surgeons do not fully understand the properties of the available prosthetics or the circumstances that warrant the use of a specific mesh. METHODS: A systematic review of published literature from 1951 to June of 2009 was conducted to identify articles relating to ventral hernia repairs and the use of prosthetics in herniorrhaphy. RESULTS: Important differences exist between the synthetics, composites, and biologic prosthetics used for ventral hernia repair in terms of mechanics, cost, and the ideal situation in which each should be used. CONCLUSIONS: The use of synthetic mesh remains an appropriate solution for most ventral hernia repairs. Laparoscopic ventral hernia repair has created a niche for both expanded polytetrafluoroethylene and composite mesh, as they are suited to intraperitoneal placement. Preliminary studies have demonstrated that the newer biologic prosthetics are reasonable options for hernia repair in contaminated fields and for large abdominal wall defects; however, more studies need to be done before advocating the use of these biologics in other settings.

Racial odds for amputation ratio in traumatic lower extremity fractures.

BACKGROUND: Recent studies have demonstrated that black patients receive substandard care compared with white patients across healthcare settings. The purpose of this study was to evaluate the association of race on the management (salvage vs. amputation) of traumatic lower extremity open fractures. METHODS: Data analysis was conducted using the American College of Surgeon's National Trauma Data Bank. Open tibial and fibular (OTFF) and open femoral (OFF) fractures among adults above the age of 18 were identified by International Classification of Diseases, 9th Revision codes. Injuries were identified as amputated based on the presence of one of three types of knee amputations. Statistical analysis included logistic regression stratified for sex, age, race, mechanism of injury, severity, and insurance type. RESULTS: From the National Trauma Data Bank, 10,082 OFF and 22,479 OTFF were identified. Amputation rates were 3.1% for OFF and 4.2% for OTFF. With age stratification, the ratio of amputation odds for blacks to amputation odds for whites (i.e., the Racial Odds for Amputation Ratio [ROAR]) demonstrated a significant interaction between black and age in both the OFF (p = 0.028) and OTFF (p = 0.008) groups. In younger patients, a lower ROAR (p = 0.016) favored salvage in blacks, while the ROAR in older patients favored amputation in blacks (p = 0.013). The higher prevalence of penetrating injuries in blacks only accounted for 12.7% of the lower ROAR among younger adults. CONCLUSIONS: There exists a racial disparity in the management of lower extremity open fractures. Older blacks have greater odds of amputation that is not explained by mechanism. In contrast, younger blacks have lower odds for amputation that is only partially explained by mechanism of injury.

The effectiveness of neurology resident EEG training for seizure recognition in critically ill patients.

EEG monitoring in the ICU is essential for diagnosing seizures in critically ill patients. Neurology residents are the frontline for rapid diagnosis of seizures. Residents received EEG training through didactic lectures and their epilepsy rotations. We hypothesized that seizure recognition was dependent on epilepsy rotation, not the seniority of the residency. Residents were taught ACNS Standardized Critical Care EEG Terminology, unified EEG terminology and criteria for non-convulsive status epilepticus. EEG segments were given to residents for seizure recognition, and explanations provided to residents after each test. Anonymous results with the postgraduate training year (PGY) and time spent in epilepsy rotation were collected. These tests were conducted 3 times, with total of 48 EEG segments, between October, 2017 and May, 2019. There were 43 participates, including 4 PGY-1 (9.3%), 20 PGY-2 (46.5%), 12 PGY-3 (27.9%), and 7 PGY-4 (16.3%) residents. The mean rate of seizure recognition was 57.1% in PGY-1, 63.8% in PGY-2, 58.4% in PGY-3, and 70.1% in PGY-4. Comparing the duration of epilepsy rotations, the mean correct scores of seizure recognition were 58.6%, 64.6%, 64.4%, and 67.3% for duration at 0, 0.5, 1, and 2 months respectively. There was no significant difference regarding the PGY or the time of epilepsy rotation statistically by ANOVA (p = 0.37). Seizure recognition in the EEG of a critically ill patient is not solely dependent time spent in epilepsy rotation or stage of residency training. EEG interpretation skill may require an alternate approach, and continuous training.

Training in Neurology: Rapid implementation of cross-institutional neurology resident education in the time of COVID-19.

In-person resident didactics are traditionally limited to the faculty within a single institution. Tele-education efforts have been implemented in neurology to various degrees historically, but the coronavirus disease 2019 (COVID-19) pandemic has necessitated a broad and immediate overhaul in neurology didactic training. To respond to the immediate need for resident didactics, we created a rapid onset, volunteer tele-education didactic series publicized on online forums to the American Academy of Neurology A.B. Baker Section via Synapse and the Women Neurologists Group via Facebook. We describe how, with just 1 week of lead time, we created an ongoing neurology lecture series featuring faculty from across the country lecturing on a diverse range of neurology topics. The series is ongoing and draws upwards of 120 residents per lecture. Tele-education offers unique benefits to enhance the education of all neurology trainees everywhere.

Does the Microbiology of Bactibilia Drive Postoperative Complications After Pancreatoduodenectomy?

BACKGROUND: The influence of bile microflora, particularly with broad antimicrobial resistance patterns, on postoperative outcomes after pancreatoduodenectomy (PD), is poorly understood. The aim of this study was to determine the influence of the microbiology of bactibilia on postoperative outcomes following PD. METHODS: Intraoperative bile cultures were obtained in 162 patients undergoing PD between 2015 and 2017. Intraoperative bile cultures were analyzed and correlated with short-term outcomes after PD. Independent groups t test, Pearson's correlation, or Fisher's exact tests were performed. Hazard ratios (HR) are reported with 95% confidence intervals (CI). Statistical significance was defined as P value of < 0.05. RESULTS: Intraoperative bile cultures were positive in 89/162 patients (55%). The most common bacteria were Enterococcus spp. (n = 48, 54%), Klebsiella spp. (n = 24, 27%), and Enterobacter spp. (n = 17, 19%). Bactibilia was not associated with increased infectious complications, postoperative pancreatic fistula (POPF), or mortality. Enterococcus and Enterobacter were associated with higher rates of incisional (HR, 6.5; 95% CI, 1.2-34.8; P = 0.03) and organ-space surgical site infection (HR, 4.9; 95% CI, 1.1-22.0; P = 0.03), respectively. No single bacterium was associated with POPF, bile leak, cholangitis, 30- or 90-day mortality. CONCLUSION: Bactibilia, in general, does not increase the risk of developing a postoperative complication following pancreatoduodenectomy; however, Enterococcus and Enterobacter increase the likelihood of developing incisional and organ-space surgical infections, respectively.

Repair of Enlarging Left Ventricular Pseudoaneurysm Two Months After Coronary Artery Bypass Grafting.

Enlarging left ventricular pseudoaneurysms are a rare complication (especially after surgical revascularization) and require tailored surgical decision making and techniques for repair. We present a challenging patient with a rapidly enlarging left ventricular pseudoaneurysm 4 weeks after coronary bypass. The repair was approached through a left thoracotomy using circulatory arrest with selective antegrade cerebral perfusion.

The Utility of ECMO After Liver Transplantation: Experience at a High-volume Transplant Center and Review of the Literature.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) artificially supports respiratory and cardiac function when conventional techniques fail. ECMO has been described as a treatment modality for acute pulmonary and cardiac failure following orthotopic liver transplantation (OLT). Here, we present a series of adult OLT recipients placed on ECMO after transplantation for both respiratory and cardiac indications and review the literature on the role of ECMO in the setting of OLT. METHODS: For the patient series, we cross-referenced all patients who underwent OLT at our institution between 2007 and 2018 with the ECMO database of our institution and described these cases. For the literature review, we identified cases and series that described the use of ECMO after liver transplantation in adult recipients. RESULTS: A total of 1792 patients underwent OLT. Eight patients were placed on ECMO (0.4%), 5 men and 3 women aged 28 to 68 years (4 venovenous and 4 venoarterial). Three of (38%) 8 patients survived to discharge and are alive today. In the literature, we identified 3 series and 12 case reports of ECMO following OLT, with the majority of the literature derived from the Asian OLT experience. CONCLUSIONS: ECMO following liver transplantation should be considered as a viable rescue strategy in patients with severe cardiopulmonary failure. ECMO is particularly effective if the cause of cardiopulmonary failure is recognized promptly and is thought to be transient. This is the largest series in the United States and demonstrates a 38% survival rate, which is comparable to other reports in the literature from Asia.

Antibiotic irrigation during pancreatoduodenectomy to prevent infection and pancreatic fistula: A randomized controlled clinical trial.

BACKGROUND: Surgical site infection affects 25% of patients undergoing pancreatoduodenectomy. This double-blind, randomized controlled trial tested the efficacy of intraperitoneal antibiotic irrigation in decreasing infection and pancreatic fistula after pancreatoduodenectomy. METHODS: Patients undergoing pancreatoduodenectomy were randomized (1:1 ratio) to intraperitoneal antibiotic (polymyxin B, 500,000 units/L) irrigation or 0.9% NaCl irrigation. All patients received 1 dose of standard parenteral antibiotics within 1 hour of incision. The trial was powered to detect a 15% difference in any surgical site infection (primary endpoint) within 30 days after pancreatoduodenectomy. RESULTS: One hundred ninety patients undergoing pancreatoduodenectomy were randomized: 95 to antibiotic irrigation and 95 to saline irrigation. Groups were well matched regarding demographics, diagnosis, preoperative biliary stenting, bactibilia, texture of the pancreatic parenchyma, pancreatic and bile duct size, portal vein resection, and anastomotic technique. Overall, 30-day surgical site infection was observed in 24 (13%) patients: antibiotic irrigation in 10 (11%) versus saline in 14 (15%) (P = .62). Superficial (n = 9, 5%) and organ-space (n = 15, 8%) surgical site infection rates were 3% and 7% (antibiotic) and 6% and 8% (saline), respectively (P > .31). Clinically relevant postoperative pancreatic fistula occurred in 11 (12%) patients in the antibiotic arm and 10 (11%) in saline controls (P > .95). CONCLUSION: The addition of antibiotic solution to intraperitoneal irrigation does not decrease the incidence of postoperative infectious complications or pancreatic fistula after pancreatoduodenectomy.

Education Research: The current state of neurophysiology education in selected neurology residency programs.

OBJECTIVE: Prior research has illustrated there is a knowledge gap in neurology residents' neurophysiology education (EEG and EMG), and we sought to understand whether this is still an issue and to recognize the barriers in order to create solutions and improve education. METHODS: Surveys were developed for adult neurology residents and one for program directors asking about confidence in neurophysiology knowledge, percent of graduates reaching level 4 ACGME (American Council of Graduate Medical Education) milestones in EEG and EMG, methods of learning used, interest in the subjects, and suggestions for improvements. RESULTS: Twenty-six program directors (19% responder rate) and 55 residents (from at least 16 different programs) completed the survey. Program directors thought that 85% of graduating residents met level 4 milestones in EEG and only 75% in EMG. Structured rotations and more time allocated to education of these topics were frequent barriers mentioned. Postgraduate year 4 residents were 60% and 67% confident in EEG and 64%, 59%, and 62.3% in EMG level 4 milestones. Learning to read EEGs was considered important throughout residents' training; however, this interest and value decreased over time with EMG. CONCLUSION: In our study, program directors suspect up to a quarter of residents may graduate not meeting level 4 ACGME milestones, and residents expressed lack of confidence in these areas. The educational methods used to instruct residents in EEG and EMG were similar as were the barriers they face across programs. This information hopefully will help fuel curriculum design and interest in these important neurology techniques.

Preventing Postoperative Delirium After Major Noncardiac Thoracic Surgery-A Randomized Clinical Trial.

OBJECTIVES: To assess the efficacy of haloperidol in reducing postoperative delirium in individuals undergoing thoracic surgery. DESIGN: Randomized double-blind placebo-controlled trial. SETTING: Surgical intensive care unit (ICU) of tertiary care center. PARTICIPANTS: Individuals undergoing thoracic surgery (N=135). INTERVENTION: Low-dose intravenous haloperidol (0.5 mg three times daily for a total of 11 doses) administered postoperatively. MEASUREMENTS: The primary outcome was delirium incidence during hospitalization. Secondary outcomes were time to delirium, delirium duration, delirium severity, and ICU and hospital length of stay. Delirium was assessed using the Confusion Assessment Method for the ICU and delirium severity using the Delirium Rating Scale-Revised. RESULTS: Sixty-eight participants were randomized to receive haloperidol and 67 placebo. No significant differences were observed between those receiving haloperidol and those receiving placebo in incident delirium (n=15 (22.1%) vs n=19 (28.4%); p = .43), time to delirium (p = .43), delirium duration (median 1 day, interquartile range (IQR) 1-2 days vs median 1 day, IQR 1-2 days; p = .71), delirium severity, ICU length of stay (median 2.2 days, IQR 1-3.3 days vs median 2.3 days, IQR 1-4 days; p = .29), or hospital length of stay (median 10 days, IQR 8-11.5 days vs median 10 days, IQR 8-12 days; p = .41). In the esophagectomy subgroup (n = 84), the haloperidol group was less likely to experience incident delirium (n=10 (23.8%) vs n=17 (40.5%); p = .16). There were no differences in time to delirium (p = .14), delirium duration (median 1 day, IQR 1-2 days vs median 1 day, IQR 1-2 days; p = .71), delirium severity, or hospital length of stay (median 11 days, IQR 10-12 days vs median days 11, IQR 10-15 days; p = .26). ICU length of stay was significantly shorter in the haloperidol group (median 2.8 days, IQR 1.1-3.8 days vs median 3.1 days, IQR 2.1-5.1 days; p = .03). Safety events were comparable between the groups. CONCLUSION: Low-dose postoperative haloperidol did not reduce delirium in individuals undergoing thoracic surgery but may be efficacious in those undergoing esophagectomy. J Am Geriatr Soc 66:2289-2297, 2018.

Academic versus Clinical Productivity of Cardiac Surgeons in the State of New York: Who Publishes More and Who Operates More.

We investigated whether/how cardiac surgeons can be productive both academically and clinically. Using online resources (New York State Adult Cardiac Surgery database, SCOPUS), we collected individual clinical volumes (operations performed/year), academic metrics (ongoing publications, role as author), practice setting, and seniority for all cardiac surgeons in the State of New York from 1994 to 2011. Over time, individual clinical volumes decreased (median operations/year: 193 in 1995 vs 126 in 2010; P < 0.001), whereas academic productivity remained unchanged (median publications/year: 0.7 vs 0.3; P = 0.55). There was no correlation (Spearman's correlation coefficient: -0.061; P = 0.08) between the number of new publications and operations/year for the whole population. More operations/year (median: 155 vs 144; P = 0.03) were performed by surgeons without versus with publications during that same year. Who published more worked at hospitals with higher clinical volumes (Spearman's correlation coefficient: 0.16; P < 0.001) and was more likely affiliated with thoracic surgery fellowship programs (median publications/year: 1.7 for affiliated vs 0 for nonaffiliated surgeons; P < 0.001). Cardiac surgeons could be classified into four categories: ∼40 per cent clinically busy, but not publishing at all; ∼45 per cent operating less, but publishing a little; ∼15 per cent clinically very productive (operating as much as the nonpublishers) and publishing a lot; and ∼1 per cent operating the least, but publishing the most.