United States

Background
The July Effect refers to the proposed phenomenon in which the quality and safety of patient care in teaching hospitals may decline in July, coinciding with the annual turnover and advancement of medical trainees. Several studies have investigated this effect, with some reporting a transient increase in adverse events, while others have found minimal or no impact. Acute decompensated heart failure (ADHF) represents a high-risk condition where quality of care may be particularly sensitive to such transitions.

Methods
We analyzed the 2018–2022 National Inpatient Sample (NIS) to identify adults hospitalized with ADHF. We compared July and May admissions to isolate seasonal effects unrelated to the trainee transition. Hospitals were classified as teaching or non-teaching. We performed survey-weighted difference-in-differences (DiD) analyses to evaluate the impact of July admissions on mortality, length of stay (LOS), and total hospital charges across hospital types. Models were adjusted for demographics, socioeconomic indicators, Charlson comorbidity index, hospital region, bed size, and payer.

Results
The adjusted DiD analysis demonstrated a statistically significant interaction indicating that the relative increase in mortality associated with July admissions was smaller in teaching hospitals than in non-teaching hospitals (adjusted odds ratio 0.95, 95% confidence interval 0.92–0.99, p=0.009). However, within teaching hospitals, the adjusted mortality rate was slightly higher in July (1.40%) compared to May (1.35%). In non-teaching hospitals, the adjusted mortality rate increased from 1.12% in May to 1.22% in July, although this change was not significant in the interaction analysis.

For LOS and total hospital charges, the adjusted DiD interaction terms were not significant (p=0.197 and p=0.292, respectively), indicating no appreciable change between May and July in teaching hospitals relative to non-teaching hospitals. Each subgroup analyzed represented more than two million weighted hospitalizations, ensuring robust estimates.

Conclusion
Although adjusted mortality rates were slightly higher in July versus May within teaching hospitals, the difference-in-differences analysis indicated that the relative increase in mortality associated with July admissions was smaller in teaching hospitals than in non-teaching hospitals. These findings suggest no evidence of a detrimental July effect for ADHF, and instead point to stable outcomes during the trainee transition period. Length of stay and hospital charges were unaffected, underscoring that modern teaching hospitals may maintain consistent care quality for high-risk conditions like ADHF despite resident turnover.

AMA Research Challenge 2025 

Impact of July Effect on Outcomes in Acute Decompensated Heart Failure: A Difference-in-Differences Analysis Using the National Inpatient Sample

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poster

Abstract Title
Virtual PAS Stain from Frozen Section H&E Kidney Biopsy Slides
Background
Chronic Kidney Disease (CKD) affects approximately 14% of the US adult population and is a leading cause of End-Stage Renal Disease (ESRD), requiring dialysis or kidney transplantation. Retrospective analysis shows that about 20% of viable kidneys are discarded due to the on-call pathologists' evaluations of frozen section biopsies. Frozen section Hematoxylin & Eosin (H&E) biopsies are the current standard for pre-transplant assessment but are often reviewed by pathologists with limited renal specialization and are difficult to interpret due to freezing artifacts. To address these limitations, we have developed DUal-mode Emission and Transmission (DUET), a novel microscopy technique that enables the creation of virtual Periodic Acid-Schiff (vPAS) images without additional slides or advanced optical methods. 
Methods
DUET images are generated by scanning pixel-registered brightfield and fluorescence images from 29 frozen H&E-stained kidney biopsy slides. Collagen masks were extracted using a NeuralNet training model and were digitally overlaid to generate a vPAS stain. 
Four renal pathologists and three general pathologists scored the following features: percent sclerotic glomeruli, interstitial fibrosis, tubular atrophy (IF/TA), inflammation, arteriosclerosis, and arteriolar hyalinosis. The pathologists first assessed only the H&E WSIs; following a two-week washout period, reviewed the cases with both H&E and vPAS WSIs. Inter-pathologist agreement was analyzed separately for renal and general pathologists by two-way intraclass correlation coefficient (ICC) to identify any group differences. 
Results
Among general pathologists’ evaluations, ICC scores from the H&E to virtual PAS stain increased for IF/TA percentage (0.103 to 0.722), inflammation percentage (0.208 to 0.310), and arteriosclerosis number (0.033 to 0.428). For renal pathologists’ evaluations, ICC scores from the H&E to virtual PAS stain increased for percent sclerotic glomeruli (0.794 to 0.877), IF/TA percentage (0.201 to 0.435), inflammation percentage (0.031 to 0.343), and arteriosclerosis number (0.581 to 0.615). No improvement in ICC score was observed for arteriolar hyalinosis in either pathologists’ group.
Conclusion
We have demonstrated that a frozen virtual PAS stain shows higher consistency among pathologist evaluations when compared to a frozen H&E stain for various metrics used to assess donor kidney viability. This virtual stain allows for easier visualization of IF/TA, inflammation, and arteriosclerosis, as ICC scores for general and renal pathologists increased when comparing the virtual stain to a standard H&E stain for frozen kidney biopsies. DUET-generated vPAS stains offer a rapid, cost-effective solution for enhancing renal pathology assessments from frozen section H&E biopsies. This approach has the potential to reduce diagnostic variability, improve transplant decision-making, and optimize donor kidney utilization.

Virtual PAS Stain from Frozen Section H&E Kidney Slides

Kidney transplantation remains the preferred treatment for pediatric and adolescent patients with end-stage kidney disease, offering improved growth, pubertal development, survival, and quality of life. Using data from the United States Renal Data System (USRDS), this study compared demographics and outcomes between adolescent (14–18 years) and young adult (19–25 years) kidney transplant recipients whose first transplant occurred in 2000 or later. Statistical analyses assessed differences in donor type, graft survival, transplant failure, and mortality between groups.

Among 13,135 total patients, adolescents were more likely than young adults to be wait-listed (60.8% vs. 39.4%; p<0.0001) and receive a transplant (71.8% vs. 33.3%; p<0.0001). However, adolescents had higher rates of first transplant failure (26.5% vs. 20.6%; p<0.0001) and a younger mean age at failure (23.3 vs. 28.8 years; p<0.0001). Graft and transplant survival rates were high in both groups, exceeding 97% at one year and 84–89% at five years, with slightly better outcomes in living donor transplants. Adjusted one- and five-year graft survival among adolescents and young adults surpassed that of adults for both living and deceased donor recipients. Despite these favorable graft survival trends, overall mortality and post-failure survival times were comparable between adolescents and young adults.

These findings highlight the persistent vulnerability of adolescent kidney transplant recipients to early graft loss, emphasizing the importance of enhanced transition support, adherence interventions, and donor-specific management strategies. Efforts to address psychosocial and systemic barriers may further improve long-term outcomes in this high-risk population

A Comparison of Demographics and Outcomes in Adolescents and Young Adults with Kidney Transplants: A USRDS Registry Study

Background: 
Total Knee Arthroplasty (TKA) is one of the most commonly performed orthopaedic surgeries in the United States, particularly among older adults with comorbid conditions. Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia globally and is frequently observed in patients undergoing TKA. It is known to complicate postoperative outcomes; however, the long-term impact of pre-existing AF on surgical outcomes after TKA remains underexplored. Thus, this study aimed to evaluate 2-, 5-, and 10-year risk and indications for revision among patients with AF undergoing TKA.
Methods: 
The TriNetX database was utilized for this retrospective cohort study. The primary outcome was the 2-, 5-, and 10-year risk of revision following primary TKA among patients with and without pre-existing AF. The AF and control cohorts were 1:1 propensity matched by age, sex, clinical comorbidities and anticoagulant use. Cox proportional hazards models were used to assess the risk of all-cause revision as well as specific complications. Results were reported as hazard ratios (HRs) and confidence intervals (CI). A p-value of 0.05 was deemed to be the level of significance. 
Results: 
Patients with pre-existing AF (n=22,510) had a significantly higher risk of all-cause revision at 2 years (HR 1.3, 95% CI 1.1–1.5, p<0.001), 5 years (HR 1.2, 95% CI 1.1–1.3, p<0.001), and 10 years (HR 1.2, 95% CI 1.1–1.3, p<0.001) post-TKA compared to matched controls (n=22,510). The AF cohort demonstrated increased risk of periprosthetic joint infection (PJI) (HR 1.5, 95% CI 1.4-1.7, p<0.001) and hematoma (HR 1.8, 95% CI 1.6-2, p<0.001) while showing decreased incidence of arthrofibrosis (HR 0.9, 95% CI 0.8-0.9, p=0.003). No significant difference in periprosthetic fracture rates was observed.
Conclusion: 
Pre-existing AF is associated with increased long-term risk of revision following TKA. These findings suggest the need for enhanced longitudinal monitoring and multidisciplinary perioperative management, including a lower clinical threshold for PJI evaluation and vigilant supervision of anticoagulation therapy.


Impact of Pre-existing Atrial Fibrillation on Long-Term Outcomes Following Total Knee Arthroplasty

Background:

Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based perioperative care protocol designed to reduce surgical stress, improve postoperative recovery, and minimize hospital stay and complications. Since its development in the early 2000s by the ERAS Society, this protocol has shown consistent success across various surgical specialties. Anesthesiologists play a pivotal role in the planning and execution of ERAS pathways, influencing outcomes across the preoperative, intraoperative, and postoperative phases.

Aims:

The aim is to evaluate whether or not ERAS implementation leads to shorter hospital stays, reduced postoperative pain and opioid use, faster return of bowel function, decreased complications and readmissions, and greater patient satisfaction.

Methods:

Following PRISMA guidelines, a systematic search of PubMed was conducted for English-language studies from January 2015 to June 2025. A systematic review was performed that highlights the role of anesthesia within the ERAS framework using literature sourced from peer-reviewed publications and ERAS Society guidelines. The protocol elements were categorized into three phases: preoperative, intraoperative, and postoperative. Special attention was given to pharmacologic interventions, anesthetic regimens, and perioperative fluid and pain management, aligning with the responsibilities of anesthesiologists. Key preoperative components include patient education, optimization of comorbidities, one-month abstinence from smoking and alcohol, premedication with NSAIDs/PCM, and carbohydrate loading. Intraoperative strategies include using balanced fluid therapy,
short-acting anesthetics, a mix of pain relief methods, and laparoscopic techniques when possible. Postoperative care emphasizes early mobilization, hydration, nausea control, and techniques such as chewing gum to reduce ileus.

Results:

Preoperative Components: Key elements include thorough risk assessment, patient education, smoking and alcohol abstinence for at least one month, deep vein thrombosis (DVT) prophylaxis, premedication with NSAIDs or dexamethasone, and carbohydrate loading. Mechanical bowel preparation and minimized fasting (solid food up to 6 hours, clear carbohydrate-rich liquids up to 2 hours before
surgery) are also essential.Intraoperative Components: A single antibiotic dose is recommended. Fluid management involves zero-balance therapy for low-risk patients and goal-directed fluid therapy for high-risk surgeries to avoid both hypovolemia and fluid overload. Minimally invasive techniques like laparoscopy are preferred. Anaesthetic strategies favor short-acting agents and regional anesthesia. Vigilant prevention of hypothermia and avoidance of nasogastric tubes and drains are encouraged. Postoperative Components: Early ambulation, prompt catheter removal, hydration, and non-pharmacologic interventions like chewing gum help minimize ileus and speed recovery. Implementation of ERAS protocols, particularly when guided by anesthesiologists, has demonstrated significant benefits:
● Reduced postoperative pain and opioid requirement
● Earlier return of bowel function
● Decreased complication and readmission rates
● Shorter hospital stay and improved patient satisfaction

Conclusion:

ERAS protocols represent a paradigm shift in perioperative care, reducing postoperative morbidity and length of stay. Anaesthesiologists play a central role across all ERAS phases—from risk stratification and fasting minimization to optimized anaesthesia, multimodal analgesia, and early recovery facilitation. This structured review highlights the multidisciplinary nature of ERAS and reinforces the anaesthesiologist’s role as a key driver of successful outcomes.

Enhanced Recovery After Surgery (ERAS): An Anesthesiologist’s Perspective

Introduction:
Left ventricular free-wall rupture (LVFWR) is a rare but catastrophic complication of acute myocardial infarction (AMI), occurring in only ~0.01% of ST-segment elevation AMI cases and carrying an in-hospital mortality approaching 80%, even with surgery. Prompt recognition and rapid multidisciplinary management are crucial, with anesthesiologists playing a central role in stabilization, transfusion, and coordination of care.

Case Presentation:
A 79-year-old male with no prior cardiac history presented with nausea, vomiting, and hypotension. ECG revealed diffuse ST-segment elevations with PR depression, and laboratory evaluation showed markedly elevated troponins (>20,000 ng/L). Bedside echocardiography demonstrated regional wall motion abnormalities and a moderate pericardial effusion. Cardiac catheterization confirmed acute circumflex thrombosis complicated by LVFWR. During catheterization, the patient suffered cardiac arrest requiring 25 minutes of advanced cardiac life support before extracorporeal membrane oxygenation (ECMO) was initiated.

In the operating room, intraoperative transesophageal echocardiography (TEE) revealed biventricular tamponade. Emergent sternotomy evacuated the pericardial effusion, revealing a 5 cm lateral wall rupture. Attempts at repair with sutures, pledgets, BioGlue, and Nu-Knit were complicated by poor tissue integrity and recurrent rupture. After ~100 minutes of cardiopulmonary bypass, the patient was transitioned to VA-ECMO with left ventricular venting. Despite massive transfusion, vasopressor support, and open chest management, the patient remained profoundly unstable and expired in the CICU shortly after surgery.

Conclusion:
This case underscores the anesthetic challenges of LVFWR, particularly rapid hemodynamic collapse, need for massive transfusion, and coordination with surgical teams. Early suspicion, expedited imaging, and immediate anesthetic intervention—including invasive monitoring, pharmacologic optimization, and ECMO initiation—are critical to survival, though tissue friability and recurrent rupture often limit outcomes. Proactive multidisciplinary strategies remain essential in managing this rare but devastating complication.

Medically Challenging Case: Anesthetic Management of Post-Infarction Left Ventricular Free-Wall Rupture

Background:
Gastric antral vascular ectasia (GAVE), also known as watermelon stomach, accounts for up to 4% of non-variceal upper gastrointestinal bleeding. It is often associated with cirrhosis and autoimmune disorders but rarely occurs in patients with alpha-1 antitrypsin deficiency (AATD), particularly in the absence of cirrhosis. Accurate diagnosis is crucial, as GAVE does not respond to therapies for portal hypertension.
Case Presentation:
A 64-year-old Caucasian woman with a history of AATD-related emphysema and chronic anemia presented with worsening fatigue and exertional dyspnea. She also reported diffuse abdominal pain with intermittent nausea and vomiting, but no hematemesis. Laboratory studies revealed normocytic anemia (hemoglobin 8.8 g/dL) and biochemical markers consistent with iron deficiency (ferritin 26 ng/mL, transferrin saturation 10%), with normal B12 and folate levels. Liver enzymes were mildly elevated. Liver biopsy showed severe steatosis, steatohepatitis (grade 2), stage 2 fibrosis (Brunt classification), and PAS-positive periportal globules consistent with AATD, but no evidence of cirrhosis. Upper endoscopy revealed moderate gastric antral vascular ectasia with bleeding in the gastric antrum. Argon plasma coagulation (APC) was performed with successful hemostasis.
Discussion:
Although GAVE is most commonly associated with cirrhosis, its occurrence in non-cirrhotic patients with systemic or autoimmune conditions suggests alternative pathogenic pathways. This case highlights a rare association between GAVE and alpha-1 antitrypsin deficiency (AATD) in the absence of cirrhosis. AATD causes systemic inflammation and accumulation of misfolded proteins in the liver, which may trigger immune-mediated processes that lead to vascular ectasia. Recognition of GAVE in such patients is critical, as it often presents with chronic iron-deficiency anemia and may be misattributed to more common causes. Clinical manifestations vary significantly, ranging from asymptomatic occult blood loss to overt gastrointestinal bleeding.
Due to the similar clinical presentation—and the fact that GAVE does not respond to therapies aimed at reducing portal venous pressure—it is imperative to distinguish it from portal hypertensive gastropathy via endoscopic evaluation. Endoscopic therapy, particularly APC, remains the primary treatment and is effective for bleeding control. Clinicians should maintain a high index of suspicion for GAVE in patients with unexplained anemia and systemic conditions like AATD. Early diagnosis and targeted intervention can prevent ongoing blood loss and improve patient outcomes.


Watermelon Stomach in Non-Cirrhotic Alpha-1 Antitrypsin Deficiency: A Rare Cause of Chronic Anemia

Abstract 

Background and Objective: Traditional clinical skills education faces critical challenges including resource scarcity, quality gaps, and scalability limitations, with 55% of final-year medical students failing to reach competency in three or more essential skills. This comprehensive analysis evaluated the effectiveness, implementation challenges, and future potential of artificial intelligence (AI)-assisted learning in clinical skills education to address these systemic deficiencies. 

Methods: A systematic review and analysis of current AI applications in medical education was conducted, examining peer-reviewed literature from 2023-2025. The analysis included quantitative performance metrics from controlled studies, student satisfaction data, cost-effectiveness analyses, and implementation barriers. Key studies included randomized controlled trials, pilot programs, and multi-center implementations across diverse educational settings. Assessment tools included standardized clinical skills evaluations, SOAP note quality scores, and validated educational satisfaction instruments. 

Results: AI-assisted clinical skills training demonstrated significant measurable improvements over traditional methods. In controlled studies, AI intervention groups achieved statistically significant higher scores on standardized medical interviews (28.1 ± 1.6 vs 27.1 ± 2.2; P=.01). AI systems achieved 92.8% performance rates in specialized applications such as clinical feedback processing. Student satisfaction consistently exceeded 7.9/10 across multiple AI platforms, with 87% of medical students frequently utilizing AI tools for academic tasks. AI-powered documentation systems reduced clinical note preparation time by up to 95%, generating customized notes in under 60 seconds with healthcare professionals reporting 2-4 hour daily time savings. Cost-effectiveness analysis revealed potential savings of at least 30% per student trained compared to traditional simulation-based methods, with 74% of healthcare organizations using generative AI reporting positive return on investment within 12 months. 

Conclusions: AI-assisted clinical skills education represents a transformative opportunity to address fundamental challenges in medical training through enhanced scalability, personalized feedback, and standardized high-quality experiences. The evidence demonstrates superior learning outcomes, high student satisfaction, and significant cost-effectiveness compared to traditional methods. However, successful implementation requires systematic addressing of technical limitations, faculty preparation gaps, ethical considerations including algorithmic bias and data privacy, and institutional readiness challenges. Future success depends on maintaining human-centered medical education focus while leveraging AI capabilities to augment rather than replace fundamental clinical skills, ethical reasoning, and compassionate patient care. Coordinated multi-stakeholder approaches involving medical educators, AI researchers, policymakers, and healthcare institutions are essential for widespread effective implementation.

Enhancing Clinical Skills Education Through AI-Assisted Learning: A Comprehensive Scientific Analysis

Abstract Title
Holding Calm in Crisis: Emotional Regulation as a Clinical Skill in Psychiatry

Background

Medical students often enter psychiatry rotations uncertain about how to contribute during acute or emotionally charged patient encounters. When patients express suicidality, panic, or rage, the instinct is often to intervene quickly or say the “right” thing. This project reframes such moments as opportunities to build a foundational skill: regulating one’s own emotional tone and presence to support patient stability.

Methods

We explored the concept of co-regulation: how clinicians can influence the affective tone of an encounter through deliberate control of their own breathing, posture, voice, and facial expression. Using illustrative examples from consultation-liaison, inpatient, and emergency psychiatry, we outlined how students can learn to create therapeutic space nonverbally, even in the absence of clear diagnostic understanding or verbal certainty.

Results

We identified key teachable components of emotional self-regulation: recognizing physiological signs of internal escalation (e.g., elevated heart rate, voice pitch), slowing cadence, and anchoring affective presence through stillness and containment. These strategies can help stabilize patients in acute distress, model calm, and create conditions of psychological safety. Importantly, this framework helps reconceptualize student “not knowing” as a moment for embodied clinical practice.

Conclusion

Emotional self-regulation is not a soft skill peripheral to psychiatry; it is central to it. Cultivating this capacity enables clinical reasoning, risk assessment, and therapeutic engagement under pressure. By practicing co-regulation, medical students can contribute meaningfully to care even in" early stages of training, and begin internalizing the calm, steady presence essential to psychiatric practice.


Holding Calm in Crisis: Emotional Regulation as Insight into Clinical Presence Across Medical Practice

Background: Hospital readmissions are widely recognized as a critical indicator of the quality of inpatient care and the effectiveness of post-discharge support, with many deemed preventable. Patients with Limited English Proficiency (LEP) face well-documented disparities in health outcomes, often stemming from language barriers that heighten the risk of medical errors, complications, and adverse events. Ensuring effective communication in a patient’s preferred language is essential not only for improving clinical outcomes and patient safety but also for building trust, which is key to reducing preventable readmissions.

Methods: The goal of this systematic review is to examine the relationship between state-level mandates or Medicaid reimbursement for interpreter services and 30-day hospital readmission rates among patients with LEP in California. It draws on a natural experiment conducted at a California academic hospital, comprehensive summaries of state laws, and broader analyses of how language barriers impact healthcare quality and safety. While national readmission databases offer useful contextual data, they do not provide language-specific metrics at the state level.

Results: A natural experiment at a California academic hospital showed that convenient access to professional interpreters significantly reduced 30-day readmission rates for patients with Limited English Proficiency (LEP), dropping from 17.8% to 13.4% during an 8-month period when dual-handset interpreter phones were placed at every bedside. This improvement was not sustained once access declined, and readmissions for English-proficient patients increased during the same timeframe. The intervention was associated with monthly hospital savings of $161,404.
California leads the nation in language access laws, with 257 provisions requiring interpreter availability, training, and documentation. Medi-Cal mandates similar services, supported by both state and federal regulations. However, despite these robust policies, interpreter use remains limited nationwide, with only 10-30% of LEP patients receiving professional services. Language barriers are consistently linked to higher risks of readmission and adverse events, though their relationship with in-hospital mortality remains unclear.

Conclusion: This study highlights the measurable impact of accessible, high-quality interpreter services in reducing 30-day hospital readmissions among patients with Limited English Proficiency (LEP). Despite California’s robust legal framework mandating language access, gaps in implementation limit its effectiveness. The observed reduction in readmissions and associated cost savings underscore the dual clinical and economic value of investing in professional interpreter services. To meaningfully reduce health disparities, language access policies must be matched by consistent enforcement, adequate funding, and institutional commitment, offering a scalable model for advancing equity and quality across healthcare systems.

The Impact of California Interpreter Services Mandates on Hospital Readmission Rates in Patients with Limited English Proficiency

Background: As bariatric surgery becomes increasingly prevalent among women of reproductive age, obstetric care providers are more frequently encountering the unique complications these procedures pose during pregnancy. Roux-en-Y gastric bypass, one of the most common bariatric surgeries, can lead to serious intrapartum complications such as internal herniation and bowel ischemia, which are often difficult to diagnose due to symptoms similar to routine pregnancy related complications, other nonspecific symptoms, and physician hesitance to using imaging modalities with potential X-Ray exposure to the unborn fetus. Finally, laboratory data as well as imaging results are often inconclusive in the pregnant state.
Case Presentation: We present the case of a 30-year-old gravida 6 para 1031 at 25 weeks and 4 days gestation, with a remote history of Roux-en-Y gastric bypass, who presented twice to the hospital for epigastric abdominal pain. In her first hospital evaluation she had an unclear diagnostic picture and was sent home to follow up with routine obstetrical care and gastroenterology related issues. She then returned to the hospital almost two months later with acute worsening of her abdominal pain and ultimately required an emergent Cesarean delivery due to signs of fetal distress. Intraoperative findings revealed extensive small bowel volvulus and internal hernia with necrotic bowel requiring resection and gastric bypass reversal. Despite initial benign imaging and stable examinations, the patient ultimately still ended up developing septic shock and required multiple surgical interventions.
Conclusion: This case highlights the potentially fatal complications of Roux-en-Y gastric bypass during pregnancy and the diagnostic challenges they pose. It underscores the importance of maintaining a high index of suspicion in pregnant patients with a history of bariatric surgery who present with abdominal pain. Prompt recognition, early surgical consultation, and a multidisciplinary approach are critical to reducing maternal and fetal morbidity and mortality.

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