United States

Optimizing the Value of Knee Injections: Comparative Analysis of Hyaluronic Acid and Corticosteroids 

Background:
In the U.S., approximately half the total population will develop knee osteoarthritis. Among them, nearly 50% of patients pursue intra-articular injections prior to total knee arthroplasty. Despite widespread use, the comparative value between corticosteroids (CS) and high molecular weight hyaluronic acid (HMW-HA) injections remains uncertain. This study evaluates each through cost analysis and prospective patient-reported outcomes. We hypothesize that CS injections will demonstrate superior value compared to HMW-HA. 

Methods:
Patients receiving CS or HMW-HA injections were recruited. Time-driven activity-based costing categorized total costs into direct variable labor (DVL), direct variable supply (DVS), direct fixed (DF), and indirect. Patient-reported outcomes were assessed using PROMIS Pain Interference (PROMIS-PI), PROMIS Physical Function (PROMIS-PF), and KOOS-JR at baseline, 3, and 6 months. Score changes from baseline to 3 months were multiplied by average duration of benefit to estimate quality-adjusted life years (QALYPI, QALYPF, QALYK). Total cost was divided by each QALY to determine Value. Lower cost per QALY indicates greater cost-effectiveness. 



Results:
Twelve patients received CS, 11 received HMW-HA. Average total cost was significantly lower for CS ($124.58) than HMW-HA ($604.19, p &lt; 0.001). DVL costs were similar (CS: $13.41; HMW-HA: $13.06, p = 0.84). DVS costs differed significantly (CS: $10.61; HMW-HA: $367.14, p &lt; 0.001). DF (CS: $33.52; HMW-HA: $74.66, p = 0.09) and indirect costs (CS: $67.04; HMW-HA: $149.32, p = 0.009) were higher for HMW-HA. 

QALYs were not significantly different: QALYPI (CS: 0.60; HMW-HA: 0.59), QALYPF (CS: 1; HMW-HA: 0.36), QALYK (CS: 2.59; HMW-HA: 1.77). 

Value measures favored CS: 
ValuePI: CS $206.21 vs. HMW-HA $1,022.47 
ValuePF: CS $124.58 vs. HMW-HA $1,661.51 
ValueKOOS: CS $48.09 vs. HMW-HA $348.46 

Conclusion:
CS injections were significantly less costly, mainly due to lower supply costs, and showed similar clinical benefit to HMW-HA at 3 months. CS demonstrated greater cost-effectiveness across all PROMs. 

A limitation is short follow-up, though both injections typically provide around 3 months of benefit. Some evidence suggests effects may last longer. Continued follow-up may be valuable. 

These findings highlight the importance of evaluating both outcomes and cost to determine treatment value.

AMA Research Challenge 2025 

Optimizing the Value of Knee Injections: Comparative Analysis of Hyaluronic Acid and Corticosteroids​

Optimizing the Value of Knee Injections: Comparative Analysis of Hyaluronic Acid and Corticosteroids 

Background:
In the U.S., approximately half the total population will develop knee osteoarthritis. Among them, nearly 50% of patients pursue intra-articular injections prior to total knee arthroplasty. Despite widespread use, the comparative value between corticosteroids (CS) and high molecular weight hyaluronic acid (HMW-HA) injections remains uncertain. This study evaluates each through cost analysis and prospective patient-reported outcomes. We hypothesize that CS injections will demonstrate superior value compared to HMW-HA. 

Methods:
Patients receiving CS or HMW-HA injections were recruited. Time-driven activity-based costing categorized total costs into direct variable labor (DVL), direct variable supply (DVS), direct fixed (DF), and indirect. Patient-reported outcomes were assessed using PROMIS Pain Interference (PROMIS-PI), PROMIS Physical Function (PROMIS-PF), and KOOS-JR at baseline, 3, and 6 months. Score changes from baseline to 3 months were multiplied by average duration of benefit to estimate quality-adjusted life years (QALYPI, QALYPF, QALYK). Total cost was divided by each QALY to determine Value. Lower cost per QALY indicates greater cost-effectiveness. 



Results:
Twelve patients received CS, 11 received HMW-HA. Average total cost was significantly lower for CS ($124.58) than HMW-HA ($604.19, p < 0.001). DVL costs were similar (CS: $13.41; HMW-HA: $13.06, p = 0.84). DVS costs differed significantly (CS: $10.61; HMW-HA: $367.14, p < 0.001). DF (CS: $33.52; HMW-HA: $74.66, p = 0.09) and indirect costs (CS: $67.04; HMW-HA: $149.32, p = 0.009) were higher for HMW-HA. 

QALYs were not significantly different: QALYPI (CS: 0.60; HMW-HA: 0.59), QALYPF (CS: 1; HMW-HA: 0.36), QALYK (CS: 2.59; HMW-HA: 1.77). 

Value measures favored CS: 
ValuePI: CS $206.21 vs. HMW-HA $1,022.47 
ValuePF: CS $124.58 vs. HMW-HA $1,661.51 
ValueKOOS: CS $48.09 vs. HMW-HA $348.46 

Conclusion:
CS injections were significantly less costly, mainly due to lower supply costs, and showed similar clinical benefit to HMW-HA at 3 months. CS demonstrated greater cost-effectiveness across all PROMs. 

A limitation is short follow-up, though both injections typically provide around 3 months of benefit. Some evidence suggests effects may last longer. Continued follow-up may be valuable. 

These findings highlight the importance of evaluating both outcomes and cost to determine treatment value.

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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

Background: 
Placenta Accreta Spectrum (PAS) is a pregnancy complication in which the placenta abnormally adheres to the uterine wall. Complications include damage to nearby structures, infant prematurity, and potentially life-threatening maternal hemorrhage during delivery, often necessitating hysterectomy. Thus, careful considerations should be given to adequate planning to minimize morbidity and mortality. This case provides an example of a high-risk obstetric presentation with a focus on anesthetic strategies utilized for intraoperative coordination within a multidisciplinary team to achieve a favorable maternal and fetal outcome. 

Case Presentation:
32-year-old G4P2012 at 32w4d with a medical history of gestational diabetes requiring insulin, two prior cesarean deliveries, obesity, and suspected chronic hypertension presents for a scheduled cesarean section hysterectomy for PAS with placenta previa in the third trimester. Prior imaging showed the findings above in addition to loss of uterovesical interface suggesting invasion. The patient was subsequently admitted to the antepartum unit at 24w3d for inpatient management in preparation for planned surgery.

Discussion: 
Several anesthesia-specific considerations including airway access, hemodynamic stability, and pain control were essential to the effective pre-, intra- and post-operative management of this patient. Moreover, coordination within the various procedural segments remained an integral component to optimizing efficiency and minimizing adverse risks. 

In approaching airway management, the patient was assessed pre-operatively utilizing the Mallampati score. She was determined to be class III, and thus video laryngoscopy was deemed the preferred technique for endotracheal intubation. Furthermore, due to the high risk of bleeding, her current hemodynamic state was evaluated and blood products were acquired in preparation. Prior to surgery, most recent hemoglobin and platelet count were 13.0 and 220, respectively. Two 18-gauge IVs were placed for access. Patient monitoring was performed using blood pressure and continuous pulse oximetry.

In regard to analgesic therapy, the patient was given a combination spinal/ epidural for primary intraoperative anesthetic and post-operative pain management. Spinal anesthesia was induced prior to the initial interventions of urology and interventional radiology. Following which, the epidural was dosed and upon being deemed adequate, general anesthesia was inducted; subsequently allowing for hysterotomy, fetal delivery, and hysterectomy with bilateral salpingectomy performed by the obstetric team. The patient remained hemodynamically stable throughout the remaining surgical interventions, and post-operatively recovered from anesthesia with adequate pain management. 

Thus, this case underscores the importance of anesthetic considerations within the coordination of multidisciplinary approaches, highlighting anesthesia’s role in optimizing the patient pre-, intra-, and post-operatively for complex cases to reduce adverse events.


Approaching Placenta Accreta Spectrum: An Anesthesia-Centered Perspective Within a Multidisciplinary Framework

Background
Abdominal aortic aneurysms (AAA) have a global prevalence of about 1% and account for 150,000-200,000 deaths annually. When identified, a patient may undergo endovascular aortic repair (EVAR) to prevent further aneurysmal dilation. These grafts may present with an endoleak requiring an additional EVAR. Grafts can obstruct blood flow to branching vessels comprising supply to structures including the spinal cord. To prevent spinal cord ischemia (SCI) in high-risk cases, spinal drains (SD) are placed. SD placement can present with its own complications that warrant further research as highlighted in the case presented.
Case Presentation
An 85-year-old man with a complicated medical history associated with AAA management presented to the emergency department (ED) with persistent back pain radiating to the left lateral thigh and left leg weakness. Eleven days prior, apixaban use was stopped for SD placement after a type 1 endoleak was identified. The SD was unsuccessful. MRI showed a subdural hematoma spanning T12 to the left lateral aspect of L1. Excavation without further injury was deemed difficult due to proximity to the cauda equina and thrombus adhesion leading to support for watchful waiting. A few days later, imaging showed aneurysmal enlargement and intervention became imperative. Upon second attempt at SD placement, pink-tinged aspirate was evident, so the drain was removed. A third attempt at SD placement was made. Due to lack of CSF return and new onset lower extremity weakness, the drain was removed. A fenestrated EVAR was performed. Post-operative, the patient was diagnosed with incomplete paraplegia and was evaluated for rehabilitation.
Discussion
EVAR is the recommended treatment for a type 1 endoleak, but it has a risk of SCI. A 2018 study demonstrated the risk of paralysis during EVAR drops from 20% to 2.3% after a SD is placed. The risk of subdural hematoma with SD placement may have increased due to prior use of the anticoagulant Apixaban (an associated side effect) combined with repeated spinal procedures. Although the patient was not taking Apixaban at the time of drain placement, further research is required to determine if the drug may have an effect after stopping its use. Furthermore, the risk of paralysis associated with SD placement increases from 3% at first placement to 12% at second placement. This case demonstrates that risks for SD complications in patients undergoing EVAR should be further studied.

Complication Risk Related to Spinal Drain Placement for Endovascular Aortic Repair

Background 
Lennox-Gastaut syndrome (LGS) is a rare neurologic disorder characterized by drug-resistant seizures, intellectual disability, and motor dysfunction, typically presenting between ages three and five. This case highlights a unique presentation of early onset type 2 diabetes mellitus (T2DM) in a medically complex 18-year-old male patient with LGS - a combination that, to our knowledge, has sparsely been reported. 

Case Presentation 
Like many patients with LGS, this patient suffered extensive seizures requiring multiple seizure medications: clobazam, diazepam, levetiracetam, and methsuximide. His history also included neuromuscular disease, cerebral palsy, microcephaly, global delay, and ventricular arrhythmias managed with atenolol. His biological mother had schizophrenia, and he was adopted shortly after birth, with no other family medical history available. 

At age 10, the patient was noted to have acanthosis nigricans and a five pound weight loss over the past year while on a regular diet. Progressive dysphagia due to sensorimotor deficits developed over the next two years, requiring a pureed and thin-liquid diet. Some of his seizures, described as subtle head drops, often occurred during meals. Between the ages of 12 and 13, he was placed in a special care facility with monitored feeding. 

At age 16, the patient acutely developed decreased responsiveness for 24 hours, without fever, emesis, diarrhea, rash, or respiratory distress. Laboratory workup revealed ketosis (beta hydroxybutyrate=9.1), acidosis (pH=7.30), hemoglobin A1c 8.2%, glucose=840 mg/dL, bicarbonate=16, and H/H=18.7/58, with normal procalcitonin and lactate. Blood glucose was promptly managed with daily Lantus and Humalog corrections every four hours, while an endocrinology consultation and diabetes antibody workup suggested a T2DM presentation. 

Discussion 
Diabetes mellitus is not typically associated with LGS, however, several risk factors are present in this case. The association of seizures with feeding difficulties and metabolic stress have reciprocal effects on brain function, and furthermore, can complicate glycemic control in a chronically ill patient with LGS. Medications such as benzodiazepines and levetiracetam can also affect glycemic control, though their effects on the LGS population are not well understood. Finally, this patient’s LGS was attributed to a RHOBTB2 gene mutation, which has links to glucose metabolism as well. Nevertheless, while insulin resistance is often associated with obesity and metabolic syndrome, this patient's presentation was preceded by a healthy BMI, 
progressive dysphagia, and a regimented diet. These factors cumulatively emphasize the need for heightened vigilance in screening for metabolic complications in this vulnerable population, even in the absence of typical risk factors.


A Surprising Case of Type 2 Diabetes Mellitus in a Diet Restricted Lennox Gastaut Adolescent

BACKGROUND
Pulmonary mucormycosis is a rare but life-threatening fungal lung infection, most commonly seen in immunocompromised patients. The causative fungi belong to the order Mucorales, with Rhizopus species being most common. Growing on decaying food, soil, and animal excrement, patients usually become infected via spore inhalation. Risk factors include diabetes mellitus (particularly diabetic ketoacidosis), hematologic malignancy, and solid organ or stem cell transplant.

CASE PRESENTATION
A 47-year-old female with newly diagnosed, unmedicated Type 2 diabetes and a recent DKA hospitalization presented with a 3-month cough and 5 days of worsening hemoptysis. She denied systemic or respiratory symptoms, smoking, or drug use. She had recently emigrated from El Salvador and had a prior admission for community-acquired pneumonia revealing a cavitary lesion concerning for prior Tuberculosis (TB), though Quantiferon Gold was negative. Interval imaging was planned to rule out malignancy.
On this admission, CT chest showed increased left hilar soft tissue encasing a dilated left pulmonary artery (PA), concerning for pseudoaneurysm (PSA). Bronchoscopy revealed bleeding in the left upper lobe; endobronchial ultrasound showed invasion and thinning of the PA wall. Due to high rupture risk, Interventional radiology was consulted, but embolization was contraindicated due to lesion proximity. Biopsy was deferred given risk, and after multidisciplinary discussion, the patient underwent a left thoracotomy and pneumonectomy.
Post-operative recovery was uneventful. Infectious disease initiated RIPE (Rifampin, Isoniazid, Pyrazinamide, Ethambutol) therapy due to TB concern. However, final pathology revealed pulmonary mucormycosis. RIPE was discontinued, and she was transitioned to AmBisome and Cresemba for 12 weeks, with follow-up imaging planned.

DISCUSSION
Pulmonary mucormycosis is a rare infection with a high mortality rate. Estimated burden in the U.S. is 3.0 cases per million people annually, with mortality rates greater than 50%. A high index of suspicion is essential, particularly in patients with non-resolving pneumonia despite antibiotic therapy, presence of cavitary lesions on imaging, diabetes mellitus, or history of solid organ/stem cell transplant. In diabetes, tuberculosis is a more common consideration which may delay diagnosis. Diagnosis typically involves bronchoalveolar lavage and histopathological sampling. The gold standard for diagnosis is via endobronchial biopsy showing Mucorales hyphae with tissue invasion. Imaging may show upper lobe predominance on CXR and reverse halo sign on CT. Management requires aggressive treatment, often combining antifungal therapy and surgery. FDA-approved treatments include liposomal Amphotericin B and Isavuconazole with Posaconazole as an alternative. Surgical options, such as lesion excision or pneumonectomy, may be necessary in advanced cases.

The Great Mimicker: A Case of Pulmonary Mucormycosis Leading to Left Pulmonary Artery Pseudoaneurysm and Subsequent Pneumonectomy in a Diabetic Middle-Aged Female from El Salvador with Tuberculosis Symptoms

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.

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

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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